My Graduate Program Case Study Presentation with a focus on pain and compassionate care

1. Case study
End of life nursing care
Renal cell carcinoma

2. Lorna’s story
 77 y. o. retired female
 Lived with her husband and sister in a shared
rental unit
 2 supportive daughters and 2 granddaughters
 Goes to small local chapel nearby
 History of Hypertension, Obesity, Anxiety,
Cholecystectomy (surgical removal of the
gallbladder)

3. Lorna’s story cont.
 Allergic to Hydrochlorothiazide (diuretic drug)
 Presented to GP with intermittent left flank pain,
abdominal pain and increased fatigue and
weakness
 Diagnosed with advanced renal cell carcinoma in
early 2011
 L nephrectomy the same year

4. Lorna’s story con.
Reoccurrence of renal disease in April 2014
 First admission to CHCB for symptom management of
increasing right hip pain and functional decline - not
able to cope at home
 X-ray showed bilateral joint degenerative changes
with subchondral sclerosis and degenerative changes
to lumbar spine
 Ongoing complex, severe pain difficult to manage
 Increasingly depressed, anxious and tearful
 Anaemia requiring transfusion
 MRI in August 2014 – cauda equina compression (T1-
L2)
 Drowsy, urine retention (IDC inserted), faecal
incontinence, severe lower limbs weakness
(secondary to the tumour infiltration)
 Palliative radiotherapy to spine

5. Story cont.
 Readmitted to CHCB for ongoing symptom
management
 Decreased appetite/Minimal oral intake
 Lost at least 20 kg since diagnosis
 Focus on pain & symptom management
 Non-essential medications ceased
 CSCI via syringe driver
 Psychological and spiritual support to patient and
family
 Terminal care
 LCP

6. Metastatic renal cell carcinoma
 RCC or adenocarcinoma – the most common type
of kidney cancer – starts in the lining of small
proximal tubules in the kidney
 Stage 4 – tumour has invaded other organs
 The 10th most frequently seen cancer in Australia
typically discovered when the person is 50-70
 Average survival = 5 years
 Risk factors: cigarette smoking, hypertension,
obesity and genetics
 Most common metastases – lungs, liver and long
bones
 Early warning signs – abdominal discomfort,
fatigue, weight loss.
 Later – haematuria, flank pain, anaemia, palpable
abdominal mass

7. Proximal
Convoluted
Tubule
circulates
water and
reabsorbs
glucose,
amino acids,
metabolites
and
electrolytes
from the
filtrate into
nearby
capillaries.
This is where
the RCC in
most cases
starts from.

8. Cauda Equina syndrome (CES)
 CES affects a bundle of nerve roots called the
cauda equina (Latin for horse's tail) where
something is compressing on the spinal nerve roots
such as a tumour.
 These nerve roots send and receive messages to
and from your legs, feet, and pelvic organs.
Damage to these may result in severe low back
pain, faecal incontinence, urinary retention and
severe lower limb weakness.

9. Anatomy

10. Cauda equina syndrome
www.nlm.nih.gov

11. Medication
 Variable dose medication delivered subcut via
Syringe Driver every 24 hrs - Oxycodone
Injection (40mg) for pain
 Regular prescriptions – Dexamethasone 2mg
PO/SC in the Morning – Indication: Cauda equina
compression Olanzapine 2.5mg PO/Sublingual/SC
Twice Daily – Indication: agitation
 As Required prescriptions – Metoclopramide
10 to 20mg q4 hours PRN, PO/SC up to 80 mg per
24 hours for nausea/vomiting
Midazolam Injection 2.5 to 5mg q1hour PRN, up
to 2 doses per 4 hours, SC – indication: agitation

12. Medication as required con.
 Glycopyrrolate 0.2mg/1mL Injection SC 0.2 to
0.4mg q 4 hours PRN for respiratory secretions
 Pregabalin 75mg capsule, 75 mg q 12 hours PRN,
2nd line for severe pain not responding to
oxycodone
 Haloperidol 0.5 to 1mg q 1 hour PRN, PO/SC up
to 2 doses per 6 hours. For agitation/delirium:
minimum dosage interval = 1 hr. For nausea or
vomiting: minimum dosage interval = 6 hrs
 Oxycodone Injection 5 to 7.5mg q 1 hour, PRN,
SC

13. End Of Life Nursing Care
Symptoms and Interventions
 Skin integrity is maintained – assessment (itch,
sweating, pressure areas) - cleansing,
repositioning, use of special aids (Braden score 10)
 Urinary problems – IDC/use of pads
 Bowel problems – constipation/diarrhoea
 Administration of medications – CSCI/ SC butterfly
 Personal hygiene – skin care, eye care, wash
 Psychological well being – verbal and non-verbal
communication, listening, information and
explanation, use of touch, spiritual/cultural needs

14. Symptoms and Interventions
 Nausea/Vomiting – treatment depends on the area
of stimulation (chemoreceptor trigger zone/CTZ
and the vomiting centre) – often difficult to control
 Agitation/distress/anxiety – consider spiritual
issues, listening, support, open discussion with
patient and family, psychotropic drugs –
benzodiazepines, antidepressants
 Respiratory secretions – ‘death rattle’ – positioning
to allow postural drainage, drugs – anticholinergics
(hyoscine hydrobromide, glycopyrrolate)

15. Pain
 “Pain is whatever the person experiencing it says it
is, existing whenever he says it does.”
 Verbal if Pt conscious
 Non-verbal cues
 Positional change
 PRN / BT analgesia for incident pain/prior
movement

16. Pain
 Psychological and spiritual elements of pain –
anxiety, sadness, anger, frustration
 Pain of loss
 Loss of role
 Loss of independence
 Loss of future
 Nurse being at the bedside, fully present giving a
‘dose’ of herself – respectful verbal and non-verbal
communication, caring touch

17. LCP issues
One –way road to death?
Backdoor form of euthanasia?
OR
Improves care at the end of life?
Results in more “good deaths”?
OR
Travel to Liverpool for treatment (as one husband
misunderstood)
Review the use of LCP in palliative settings – poor
implementation and possible falsification

18. Compassionate care
 Patient satisfaction is closely related to the quality
of kindness, caring, compassion and trust
 Magical moments of healing occur when a profound
connection is made
 The patients emotional and psychological wellbeing
impacts more powerfully on physical health
outcomes than most of the medicines we use
 Work intensity, demands, lack of recourses –
disorganised, pressured reactive pattern of patient
care that focuses on clinical tasks rather than
caring for the whole person
 Very often the human touch is missing
 Hug – form off communication because it can say
things you don’t have words for.

20. Four major shifts to re-humanise
healthcare (Youngson, 2012)
Reductionist focus on
Pathology
Detached care
Focus on sickness,
defects and problems
Health professional
directing care
Focus on whole person
Empathetic, compassionate
care
Focus on wellbeing, strengths
and resilience
Health professional serving
the patient’s goals

21. Think about....recommendations
 “We don’t have time to care”- the first step in finding
time to care is simply to stop/slow down. Give your
patient complete attention – in moments of close
connection, the time stands still – patients feel you
spent much more time with them.
 Tell patients you have time – “Is there anything else I
can do for you before I leave? I have time.”
 Small acts of kindness
 Stop treating patient impersonally, detached – “MND in
room 6” or ‘darling, honey, sweetie’
 Bad moods are contagious
 A ‘good’ nurse doesn’t mind being moved from one job
to another???
 Effective healthcare system needs to inspire and support
compassionate caring and healing relationships –
difficult to achieve in the stressed healthcare institutions
we mostly work in.

22. Tell us a story about a time when
you had an extraordinary
connection with a patient/client

24. References:
 Institute of Medicine (IOM). (2008). Cancer care for the whole patient:
Meeting psychosocial health needs, Washington, DC: The National
Academies Press
 MacLoad, R., Vella-Brincat, J. & Macleod, A. D. (2012). The palliative care
handbook: Guidelines for clinical management and symptom control (6th
ed.). Wellington, New Zealand:Crucial Colour
 NHS Improving Quality. (2013). Liverpool care pathway for the dying
patient. Retrieved from http://www.endoflifecare.nhs.uk/care-pathway/
step-care-in-the-last-days-of-life/liverpool-care-pathway.aspx
 Sachdeva, K., Makhoul, I., Javeed, M., & Curti. Renal cell carcinoma.
Retrieved from www.emedicine,medscape.com/article/38054
 Watson, J., & Woodward, T. K. (2010). Jean Watson’s theory of human
caring. In M. I. Parker, & M. C. Smith (Eds.), Nursing theories & nursing
practice (3rd ed., pp. 351-369). Philadelphia, PA: F. A. Davis Company
 Youngson, R. (2012). Time to care: How to love your patients and your
job. Raglan, New Zealand: Rebelheart Publishers
 Gardner, A., Gardner, E. & Morley, T. (2011). Cauda equina syndrome: a
review of the current clinical and medico-legal position. Eur Spine J
20:690-697