VOL: 103, ISSUE: 13, PAGE NO: 33-34
Author Karen Harrold, RGN, BSc
Clinical nurse specialist for chemotherapy, Mount Vernon Cancer Centre, Northwood, Middlesex
Abstract Harrold, K. (2007)Offering pre-treatment support for chemotherapy patients. nursingtimes.net
This article outlines a project set up by chemotherapy cancer nurses, who designed innovative pre-treatment assessment clinics in which patients were offered an improved level of support and information. The nurses also expanded their role by running nurse-led clinics for patients with colorectal cancer who were receiving oral chemotherapy.
The concept of innovative pre-chemotherapy treatment assessment clinics was developed by nurses in the cancer unit at Mount Vernon Cancer Centre. These nurses wanted to provide a low-stress setting that helps patients to receive and fully absorb the information they need about their disease and its treatment. At Mount Vernon Cancer Centre the clinics have proved both highly successful and popular with patients.
Patient information is vital in improving patient understanding of the disease and its treatment. However, many medical staff do not have the time to devote to patients in order to provide the detailed information they need. Research shows that patients lack basic knowledge about their cancer and its treatment, and for three out of four patients it will be the doctor or nurse who is the source of new information (Berner et al, 1997).
The impetus for the advent of pre-treatment assessment clinics came from nurses caring for patients who were scheduled to receive oral chemotherapy. The most common of these is capecitabine for the treatment of colorectal and breast cancer. Oral capecitabine is an effective, well-tolerated form of chemotherapy that is self-administered at home, making it convenient for most patients. This also helps to free up capacity in outpatient cancer services, which are under pressure from the growing complexity of treatment and the rising cancer incidence in an ageing population.
Originally, patients taking oral chemotherapy were given information on managing their treatment at the same appointment in which they received their first prescription for the drug. Nursing staff at Mount Vernon were concerned about the impact of the amount of information patients received at the time of their treatment and their ability to absorb this at such a difficult time. Patients were in a stressful situation, primarily focused on the physical process they were undergoing. In addition, the circumstances did not give any opportunity for reflection and questions on important aspects of treatment such as efficacy and side-effect management.
Research has shown that if cancer patients received information before their first appointment for treatment, they were better prepared emotionally for a visit to a cancer unit (Huchcroft et al, 1984). The same study also found that patients were better informed and less confused about the reasons for their appointment.
Since setting up the pre-treatment assessment clinics at Mount Vernon Cancer Centre, patients who have attended have felt supported by it; this has encouraged nurses in the unit to extend it to patients receiving intravenous (IV) therapy. In addition to the information session provided during the clinic, patients on IV therapy are also shown around the chemotherapy suite. Patients often feel nervous about the environment in which they will receive their IV treatment and the tour helps to dispel any negative or preconceived images, as they see the relaxed atmosphere within abright and airy unit.
Pre-treatment assessment clinics are a successful nurse-led innovation with benefits for both patients and nurses. The patients are better informed and prepared for their treatment, while the chemotherapy nurses have expanded their role and gained the opportunity to further develop their communication skills.
The pre-treatment assessment
Patients attend the clinic in the same week they are to start treatment. The pre-treatment appointment lasts for approximately an hour to an hour-and-a-half. Any blood tests and baseline observations (for example, height, weight and blood pressure) that are needed are taken.
The nurse explains what chemotherapy treatment is and how it works in general terms, then gives the patient more specific information about the drugs prescribed, their actions and side-effects. Patients are also told how to manage any side-effects, which can include sickness, diarrhoea, sore mouth or high temperature. These side-effects are extremely manageable and therefore it is important to make patients aware of any signs or symptoms in order to ensure they are effectively dealt with, should they arise.
The nurse will explain how the drugs are made up in the chemotherapy reconstitution unit and why this takes time. This helps patients to understand the length of time they may have to wait before receiving their treatment.
The session also covers whether the patient is taking other medications, making sure they have informed staff of all medicines (including over-the-counter medicines, as well as vitamins and minerals) that they are currently taking.
If a patient is planning to continue working throughout treatment the nurse will discuss how to pace and plan work activities. For those not planning to continue working, a discussion of benefit entitlements may be relevant at this point.
The importance of avoiding people with coughs, colds and obvious infections is discussed, as well as what leisure activities are appropriate during treatment. Patients often want to talk about holidays, abroad or in the UK, and this is a good time to discuss travel insurance and give advice on taking adequate care in the sun.
It is important for patients to maintain a good diet during treatment so nutrition is also discussed. The subject of alcohol is often raised at this point and advice will be given about whether a small glass of wine or beer is safe, depending on the drug regimen. Drinking spirits should be avoided during treatment.
Each patient is different and will therefore have a different range of concerns so the subjects discussed during pre-treatment assessment appointments vary. Other topics commonly raised are prescription charges, whether to be accompanied to appointments as well as sex and fertility issues.
A pre-chemotherapy consultation checklist (Boxes 1 and 2) is completed to ensure an accurate record is kept of what information the patient has received and to document any referrals made to other members of the multidisciplinary team. This, plus a general question and answer session at the end of the consultation, gives patients the opportunity to explore other anxieties or issues not previously raised.
Nurse-led adjuvant oral chemotherapy clinic
Another innovation at Mount Vernon Hospital is the advent of nurse-led clinics for patients with colorectal cancer receiving adjuvant oral chemotherapy, which opened in September 2006.
The pressure of limited resources and lack of capacity has highlighted opportunities for nurses to expand their role and take on some of the work traditionally managed by doctors (Cancer Capacity Coalition, 2005). The recent extension of oral chemotherapy, in the form of capecitabine to patients with primary colorectal cancer, is one example where the role of the chemotherapy nurse has expanded and now includes the overall management of these patients.
Oral chemotherapy has been used as a palliative treatment for patients with metastatic colorectal and breast cancer for some time but, due to the advanced nature of their disease, these patients are seen by the oncologist. However, patients receiving adjuvant oral chemotherapy for primary colorectal cancer are generally well. Since September 2006 these patients have been seen in a nurse-led clinic. They are treated over a six-month period and need to be seen every three weeks for blood tests, assessment and prescription of the next treatment cycle. These patients saw a doctor for their first treatment cycle; thereafter, for the remaining seven cycles, they saw a nurse in the nurse-led clinic.
All patients, whether receiving IV or oral therapies, are assessed for chemotherapy-related toxicities and performance status before each cycle of treatment. This is done with the aid of a multidisciplinary assessment tool, which has been adapted and developed for use from the common toxicity criteria (National Cancer Institute, 2006) and is used in the assessment of patients in clinical trials (Appendix 1). In the nurse-led clinic, it is the nurse’s responsibility to decide if the patient is well enough to continue treatment in accordance with a specifically developed protocol (Appendix 2) or to refer the patient to a doctor in the parallel clinic if a dose adjustment is required.
In addition to the convenience of an oral treatment that patients can take at home, one of the advantages of having a nurse-led clinic alongside the conventional outpatient clinic is that the workload can be divided, thereby reducing the waiting time significantly for them. Patients may have travelled up to 30 miles and as many are working, they do not want to spend any longer than is necessary at the clinic. Another advantage is continuity of care - patients see the same nurse at each clinic visit and are able to contact the nurse between visits to discuss any concerns or questions. Patients attending outpatient clinics often see many different doctors. More time is allocated for giving information and for questions at the nurse-led clinic than in outpatient clinics,which is important as the patient is self-administering and self-monitoring at home.
This clinic provides an important opportunity in the development of cancer nursing services as nurses are responsible for the whole treatment pathway for these patients.
Chemotherapy nurses have a wide range of skills that they use in their everyday work and that are now being used fully in the development of chemotherapy nurse-led clinics. The welcomed extension of the chemotherapy nurse role offers benefits for both patients and nurses. In addition there are wider implications for the trusts that run the nurse-led clinics: acute trusts are under considerable pressure to make savings to address budget deficits (Cancer Capacity Coalition, 2005).