Wendy Ansell, BSc (Hons) (Open), RN, OncNursCert.
Macmillan Urology Nurse Specialist, Medical Oncology Department, St Bartholomew’s Hospital, London
Until 10 to 15 years ago ‘urology’ was not a specialty in its own right. Those practicing urology were general surgeons with an interest in in the field, and patients needing to be admitted for urological operations were cared for in general surgical wards. As technology has progressed, reducing the morbidity of in-patient procedures and enabling many urological interventions to be carried out as outpatient procedures, the specialism of urology has grown and is one of the specialties where multidisciplinary working has become normal practice.
The term multidisciplinary team has been used to encompass any team of professionals working together for the total care of patients. In the Guidance on Commissioning Cancer Services manuals produced to improve outcomes in cancer through the Clinical Outcomes Group (the COG guidelines), such as those for colorectal care (DoH, 1997), core multidisciplinary teams and associate teams for each cancer site are defined. A clinical nurse specialist (CNS) is specified as a core team member along with the surgeon, oncologist, pathologist and radiologist. Team working between urologists and nurses has already become an integral part of urology and it is likely that nurses will be included in the core team for uro-oncology patients in order to provide seamless care for them.
Working in a multidisciplinary team
Moore (1997) has described ways in which different trusts have created multidisciplinary team working for cancer patients. The initial team described in this paper consisted of a medical oncologist, a specialist registrar in oncology and a uro-oncology CNS, who work both in a cancer centre at Oldchurch and Whipps Cross hospitals and in district hospitals. The medical oncologist has been undertaking ‘outreach’ clinics in two district hospitals since 1984. When the Calman-Hine report (1995) was published, the team was expanded in 1996-97 to include the specialist registrar and a uro-oncology CNS. The work has expanded over the past five years with the total number of patient attendances at the outreach clinics rising from 75 in 1996-97 to 663 in 1999-2000 (Farrugia and Ansell, 2000; Ansell in press). Before the publication of the COG guidelines (DoH, 1997) therefore, a framework was already in place in which the medical oncology team undertook clinics alongside the urologists in one hospital and the clinical oncologists in another.
The wider role of the CNS has been described (Kai-Cheung Chuk, 1997; Robb, 2001; Webber, 1996) and is not specifically addressed here.
Many of our patients need to travel substantial distances in order to attend the main cancer centre. One aim of undertaking these clinics alongside colleagues in the district hospitals has been to enable more people to be seen closer to their own homes, and to bring them to the centre to receive treatments only when they cannot be provided elsewhere. The Calman-Hine report (1995) emphasised the importance patients placed on this, and that they should have access to specialists wherever they live. There are many professionals involved in a patient’s cancer journey. Communication between them is vital to ensure that the journey is as smooth as possible and that seamless care is provided, all of which is emphasised in the COG guidelines (DoH, 1997).
The outreach clinics
All the patients seen in the clinics already have a cancer diagnosis. Patients may have undergone treatments with the support of the urologist or may be awaiting their primary treatment and have been referred by the urologist to the oncologist. The outreach clinics are run at the same time as the urologists’ clinics, where practicable. This provides the opportunity for patients to be seen jointly when needed, or for them to be transferred on the day if a change in focus is required. Clinics are held either once or twice a month. The workload at the cancer centre in Oldchurch hospital has increased sufficiently for a second consultant to be working twice a week with another team and with one clinic dedicated to uro-oncology patients weekly. There is a weekly clinic at the centre so, if timing is critical, a patient may come to the centre initially.
New patients and their families and friends are seen by one of the medical team, usually with the CNS present, and a provisional management plan is formed. Ideally, the patient’s condition will have been discussed at a full multidisciplinary team meeting earlier in the day. This meeting provides the histopathologist and radiologist with the opportunity of putting forward their opinions. The provisional plan is then formulated and later refined to incorporate the patient’s views and individual factors. The CNS participates in this initial consultation and then spends time with the patient and family, if they wish, going over the management plan and discussing any potential difficulties.
Patients with urological cancers spend the majority of their illness receiving treatment as outpatients and living with their cancer at home. Men with prostate cancer, for example, spend very little time in hospital other than when they receive radical surgery for localised disease or if they are admitted when they are generally unwell from advanced disease. The CNS provides support for these patients, as shown in Box 1.
Part of the CNS role is enabling patients to have sufficient understanding of their own disease and the expectations of treatment. Patients appreciate having guidance on when and where to seek advice. Patients are given written information to take home, where it is available, and contact numbers for access to patient-support organisations such as CancerBACUP. If they are offered treatment as part of a research study protocol they are given full written information. Patients have a contact number for the CNS, and are encouraged to draw up a ‘shopping list’ of questions to bring to the next consultation.
The presence of a CNS at the clinics means that referral to specialist support such as palliative community care or social services is offered to patients earlier in their disease pathway than it might otherwise have been. This referral may be offered for psychological support, for symptom control or practical help at home. The pivotal role of the GP is emphasised.
Multidisciplinary working at the cancer centre
The team has now expanded and consists of two medical oncology consultants, two senior registrars, the ward senior house officer, the research sister and the CNS. The team meets twice a week to discuss all patients who are receiving chemotherapy to check that their overall management is going to plan. This meeting provides an opportunity to discuss patients who have been seen in clinic and whose management needs are not straightforward, so a cohesive plan can be made. The CNS is able to seek medical advice about patients and the medical team can refer to the CNS any patients whom they feel need particular support.
At ward level there is a weekly multidisciplinary team meeting to discuss any of the medical oncology inpatients who need a comprehensive care plan. These patients may be under the care of any of the oncologists and the people who attend are ward nursing staff, medical staff, the physiotherapist, occupational therapist, social workers, dietitian and the palliative care team as well as the CNS. The CNS involvement may be with patients who have been admitted for chemotherapy or those who have come in for reassessment and symptom control and may be known to the CNS. The CNS can pass on relevant information about the community services that are already in place, and the knowledge the patient and family have about the disease, all of which helps the ward staff to draw up a discharge plan from the day of admission.
The broader network of multidisciplinary care
Patients are referred to the cancer centre for treatment that cannot be delivered at their local hospital. For patients with testicular cancer needing intensive chemotherapy treatments, the geographical referral area is much more extensive. For these patients, the role of the CNS is as a link person for the patient and family. This liaison may involve helping to co-ordinate the patient’s care both at the centre and at the patient’s home, as well as providing a resource for information to the other teams so that they are aware of the treatment aims and potential complications. For most young men with testicular cancer, even those with extensive disease, the aim of treatment is to render them disease free and to enable them to return to a normal life. The CNS provides continuing support after treatment has been completed and during their long-term follow up.
Patients with recurrent or metastatic renal cancer may be referred to the medical oncologist at the centre for biotherapies or experimental chemotherapy when surgery has not elicited a cure or the disease is too advanced for radical surgery. Alpha-interferon has been shown to achieve a better response in these patients than medroxyprogesterone in a randomised controlled trial (Lancet, 1999) and may be offered in the first instance. This treatment is given on an outpatient basis and patients are encouraged to learn to self-inject. The CNS is involved as an educator of patients, families or carers and of the nurses in the community who may not be familiar with the drug. The CNS maintains close contact with the patient to ensure that he is receiving a dose that is right for him as individual tolerance varies.
The patient’s perspective
This department has not yet formally attempted to audit the patients’ feelings about the efficacy of multidisciplinary team working or the CNS role as a part of that team. On an anecdotal level, patients frequently refer to appreciating the continuity of care and seeing ‘the same faces’. Patients have also said they appreciate the collaboration between their different specialists and knowing that the plan of care is individualised. Concerning the CNS role, the most frequent comment made is that patients are reassured to have someone who knows them ‘at the end of the telephone’ whom they can contact for advice. Twomey (2000) found that a lot of work undertaken by the CNS is via the telephone.
Moore (1997) described areas where multidisciplinary working has been expanded and described some of the inherent difficulties - two of which are manpower and funding issues. Working at hospitals other than one’s own base is not always easy. Ordering investigations and accessing results takes longer, and the travelling does occupy time. It can be difficult to organise full communication between team members when patients require time-critical treatment management incorporating surgery and/or chemotherapy and/or radiotherapy because of external constraints such as lack of available beds at the appropriate hospital and time.
This paper has described the clinical aspects of one particular uro-oncology CNS role. There is an increasing number of uro-oncology CNSs nationally. With the setting up of site-specific networks of cancer care, most site-specific oncology CNSs have a role in participating in tumour board meetings where the planned management of urological care throughout the network is discussed between all the appropriate professional representatives.
One criticism of the CNS post is that other professionals can provide all the aspects of the care given by the CNS. This is true in part but it is the co-ordination of that care by the CNS for each individual patient across traditional boundaries that can make a difference to the patient’s cancer journey. The NHS document on cancer nursing (DoH, 2000) suggests that a CNS should supervise a ‘co-ordinated nursing service’.
Future multidisciplinary team working
A multidisciplinary team may consist of all the health professional listed in Box 2.
This paper has concentrated on aspects of multidisciplinary team working for the patient with urological cancer that already existed before the COG guidelines (DoH, 1997) were published. Following the introduction of these national guidelines, there are aspects of the interpretation of multidisciplinary team care that are now being addressed. One technological advancement that may aid full multidisciplinary team meetings is that of tele-video linking. This enables teleconferencing to occur and allows slides and scans to be viewed by staff at different sites. With the COG guidelines for urology expected soon further changes may be needed.
All health-care professionals want to give patients the best care possible and to smooth their journey in such a way that benefits patients and staff alike. To work effectively there must be good communication, collaboration and mutual respect within the multidisciplinary team. The role of the CNS as a part of that team has many challenges but can be very satisfying and is a role that can facilitate change.
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