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Integrated cancer care: linking medicine and therapies

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VOL: 98, ISSUE: 34, PAGE NO: 35

Gillian Peace, MPhil, BA, SRN, RMN, is clinical information coordinator/key worker, the Cavendish Centre for Cancer Care, Sheffield

Collaboration between different medical disciplines can be a challenge, but for a diverse group of complementary therapists, including homoeopaths and hypnotherapists, building bridges with colleagues in conventional medicine is potentially more difficult. However, the benefits of an integrated model of care for patients can make the effort worthwhile.
Collaboration between different medical disciplines can be a challenge, but for a diverse group of complementary therapists, including homoeopaths and hypnotherapists, building bridges with colleagues in conventional medicine is potentially more difficult. However, the benefits of an integrated model of care for patients can make the effort worthwhile.


This article discusses a model of care developed by a centre offering complementary therapies to patients with cancer. The aim was to win the confidence of colleagues in conventional medicine and develop collaborative partnerships with them while tailoring therapies to patients' individual needs.


Many patients who use complementary therapies, even in the NHS, do so in addition to mainstream medicine, but this is not necessarily integrated care. So what is? As a patient once described it: each therapy that she received, from chemotherapy to massage, had equal value. She was offered various therapies according to need throughout the different stages of her illness, sometimes concurrently, sometimes on their own. She used the term 'interwoven' care and drew a diagram that resembled the double helix of a DNA molecule to illustrate her view.


My own analogy is taken from spinning. You can pull a piece of fleece apart easily but put a twist in it and, no matter how fine the thread, it has strength. Similarly, interwoven rather than parallel care has strength and versatility.


According to the Foundation for Integrated Medicine (1997), integrated health care involves professionals working together to provide access to a wider range of effective and safe treatments than are currently available in the NHS. The model of care developed at the Cavendish Centre for Cancer Care in Sheffield aims to address the key issues of 'working together' and 'providing effective and safe forms of treatment'.


The centre
The Cavendish Centre for Cancer Care was set up as a charitable trust in 1992. It is a multidisciplinary service that offers support and complementary care to patients with cancer, and their carers and children, through all stages of their illness. The aim is to enable patients to live through their illness with maximum independence and the best possible quality of life.


The therapies on offer include aromatherapy, massage, shiatsu, acupuncture, counselling, homoeopathy, visualisation, relaxation, hypnotherapy, healing and art therapy. They are free and were chosen because they are widely accepted as appropriate and relatively safe when practised by competent therapists. For some there is, in specific circumstances, evidence of effect.


In the early years staff at the centre had difficulties developing trust and credibility with mainstream colleagues, despite a year-long preliminary pilot study that confirmed the need for such a service (Peace and Simons, 1996). Legitimate concerns were raised about the safety and effectiveness of complementary therapies. While recognising the importance of responding to the concerns of both health professionals and the government, we felt we should not compromise our attempt to meet patients' expressed needs nor their right to be involved in making decisions about their health care. To achieve a more integrated approach to care, improve relationships with local hospital and community health professionals, and provide evidence of effectiveness, we focused on three key areas: assessment, the role of the key worker and evaluation.


Assessment
New patients are offered a comprehensive hour-long consultation conducted by a key worker. Its purpose is to enable the patient and key worker to define the patient's most important needs and concerns, and decide on a plan of action. A therapy is chosen that is most likely to meet the patient's expectations and address his or her concerns. There follows a course of therapy - no more than six sessions - by a therapist experienced in working with people with cancer. The patient's progress is then reviewed by the key worker and a joint decision is made on whether discharge or further treatment is necessary (Case history 1).


Tailoring patient need to therapy has been likened to the service offered by a delicatessen as opposed to a supermarket. While a delicatessen provides a narrow range of specialised products, preselected and tailored to meet customer requirements, a supermarket maximises choice with little control over consumer decisions (Luff and Thomas, 1999). The supermarket approach could leave patients vulnerable to exploitation and unsafe practice. They might also have unrealistic expectations of the benefits of complementary therapies, while serious conditions could remain undiagnosed. An initial consultation in which patients' needs are assessed can prevent them from making uninformed choices (Case history 2).


Sometimes the initial consultation alone is enough to meet a patient's needs. Patients are given the opportunity to tell their story, make sense of the illness experience and construct meaning. By listening and allowing patients to express their feelings, key workers enable them to feel that what they have experienced is important and valued. Key workers can also explore and affirm patients' strengths and resources, which boosts their confidence in their ability to cope and helps them to feel more in control (Case history 3). A thorough assessment of need is efficient as well as effective practice. Time taken before intervention can pre-empt problems and prevent inappropriate referrals.


The role of the key worker
The centre's key workers are nurses or doctors with a background in conventional medicine. They are knowledgeable and experienced in cancer care and the complementary therapies on offer, and know the therapists who work at the centre. They also understand the ways in which these therapies can be used as an adjunct to conventional cancer treatment.


Key workers are also trained to use an assessment model, originally derived from Maguire et al (1993), which is a patient-centred narrative drawing on their cues and body language to establish and explore their primary concerns. Importantly, key workers are also objective practitioners with no investment in any specific therapy.


Key workers are responsible for coordinating care, monitoring and reviewing patients' conditions and communicating with the patient's medical team. After assessment, and with the patient's permission, they write to all relevant health professionals to inform them of the centre's intervention and its objective, and again at review to inform them of the outcome. Discussions between key workers and the medical team can also help to meet the patient's needs. These measures have increased professional colleagues' confidence and made them more willing to refer patients to the centre, which is borne out by an increase in the number of referrals from consultants and GPs over recent years.


Evaluation
We have become more aware of the need to demonstrate that our care provides measurable benefit to patients. Commissioners of care have to make difficult decisions when allocating resources because of competing priorities (Keeley, 1999), while health professionals must select the most beneficial and cost-effective treatment for their patients. We need to provide evidence that what we offer has a legitimate place in patients' overall care. It is not enough to point to patient satisfaction surveys or the absence of complaints. To date, however, there are no agreed methods to evaluate complementary therapies. The task is further complicated by difficulties in evaluating palliative care interventions (McWhinney et al, 1994; Grande and Todd, 2000).


We use a modified version of Paterson's (1996) Measure Yourself Medical Outcome Profile (MYMOP) to evaluate our care. To our knowledge this is the only measurement tool that includes complementary therapies and has been validated in a primary care setting. It is also short and simple to use.


The tool uses patient-generated scores to evaluate changes in patients' concerns and physical and mental well-being after intervention. The extent to which a patient's initial expectations are met is also measured in the centre's version. In a recent audit of 157 patients, 63% indicated that their expectations had completely or almost completely been met, while 88% reported improvement in their main concern (Peace and Manasse, 2002).


Conclusion
We are currently working to validate a modified version of the MYMOP with its creator, Charlotte Paterson. We hope that it will be relevant in a variety of cancer care settings where complementary therapies are used.


While it is clear that our service is providing measurable benefits to patients, we cannot claim all the credit for the improvements made. For example, patients may say that they believe that massage provided by the centre helped to relieve tension and pain, then add that they recently had radiotherapy and their GP has prescribed antidepressants. We can claim only that the improvements occurred during the period the patient attended the centre.


But that is what integrated medicine is about: each specialist contributing to the patient's overall care. And it is nurses who are best equipped to coordinate this care, whether they work with cancer patients or in other contexts of care where complementary therapies are integrated with conventional medicine. They can use their skills in listening to patients' express their needs, increase their knowledge of the therapies available and refer on to appropriate therapists where necessary. We believe the model of care used at the Cavendish Centre maximises the chance that complementary intervention is effective, efficient and safe.


CASE HISTORY 1


Janet Carter,a pharmacist,had been diagnosed with melanoma seven years before she came to the centre for assessment.A recent scan revealed liver secondaries and she was due to start chemotherapy and interferon.She was aware of her uncertain prognosis and wanted to do something to boost her immune system.


She appeared composed, but wept when she talked about her children and contemplated not being there to care for them.She wanted to encourage herself and those she loved to think positively and live hopefully without being unrealistic about the possible outcome.


After discussing a number of therapies,Ms Carter was drawn to healing and relaxation.It was agreed that she should start with two sessions of relaxation and visualisation.These techniques can be learnt quickly with the help of an experienced hypnotherapist.The aim was to help her become competent in relaxation before chemotherapy to give her a greater sense of control during it.She could then see a healer for four sessions before review.


At review she felt well,despite having recently completed chemotherapy.She was using the relaxation techniques and believed the healing had raised her energy levels.Later,a scan showed her tumour had reduced.She went into remission and resumed her usual routine.She has had three recurrences and has returned for brief periods of support. She is currently in remission.



CASE HISTORY 2


Daniel Mills came to the centre after surgery for gastric carcinoma.His oncologist had discussed chemotherapy,but left him to choose.He was undecided,but leaning towards not having it as the benefits were not guaranteed.


At assessment it became clear that this decision was secondary to the fact that he had constant pain in his leg and ankle,which he believed was not associated with the cancer. His main concern was to obtain pain relief.His GP had prescribed physiotherapy after an X-ray of the spine and pelvis had shown a possible slipped disc.


As the pain was severe and constant Mr Mills had referred himself back to his surgeon,who had ordered an MRI scan.He was due to have it the day after his assessment at the centre.The assessor advised that before a complementary therapy was offered it was important to know the result of the scan as the cause of the pain would dictate the most appropriate treatment.Mr Mills was given information on the therapies available should he wish to contact us after the results were known.He agreed that the assessor could write to his GP,oncologist and surgeon about the outcome of the assessment.


A week later the surgeon informed the centre that the cause of the pain was bony metastases.Mr Mills was treated with a course of radiotherapy complemented by analgesia.His pain remained under control over the ensuing months and he did not contact the centre again.



CASE HISTORY 3


Sarah Taylor came to the centre shortly after her mother had been diagnosed with an inoperable brain tumour.Her initial concern was about how her four-year-old daughter would cope with the death of her her grandmother.But as she recalled the events leading up to and after her mother 's diagnosis,it became clear that her own feelings of guilt,fear and grief were paramount.


Her mother had been having 'funny turns ' for some months,which were initially diagnosed as panic attacks. Ms Taylor felt guilty that she had not insisted that her mother obtain a second opinion.She feared that her mother had given up hope after the tumour diagnosis,despite a proposal that radiotherapy might impede the advance of the disease.


Her mother refused to be discharged from hospital, although her condition was not terminal.She wanted to be left to die and not to be a burden to her family.Ms Taylor wept as she spoke about her fears for herself and her family.


Options to help her cope were discussed,but she felt that by talking about her concerns she had been able to recognise that her main sources of support were within herself and her family.It had been a relief too,she said,to shed tears without feeling she was adding to her family 's distress.She was assured she could contact us again if new concerns arose,but she has not taken the offer up in the six months since her first contact.Her mother has been transferred to a hospice and goes home for weekends.


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