Clinical problem
The common concept surrounding palliative care is that it is afforded to patients within inpatient care units and hospice care by specialty palliative care nurses. This has meant that palliative care is only confined to those patients within these settings and thus limiting the accessibility of these services for outpatients populations with chronic or caner illnesses. Patients in need of palliative care usually have physical and psychological problems that require early and constant monitoring and intervention which can only be afforded through palliative care (Zimmermann et al., 2014). While these patients do not seek to cure their illnesses, their primary objective of seeking care is to prolong life but at the same time ensure that they live a quality life even within the limiting health factors. Palliative care has a similar objective and that includes the education for patients as well as guided training to cope with the various issues that the particular illness imposes on them (Greer, Jackson, Meier & Temel, 2013).
One of the key aspects of appropriate caring for cancer and chronic illness patients is the early integration of palliative care aspects in their care plan. However, the inpatient and hospice care units are only designed to accommodate patients who cannot sustain a quality life in the absence of professional clinical care. This then implies that patients in who have had recent diagnosis for these illnesses or those who are in their early days of diagnosis of an illness cannot access palliative care to support them and help begin appropriate coping mechanism at an early stage (Greer, Jackson, Meier & Temel, 2013). It becomes a challenge for patients in their early stages of an illness as they are only expected to seek or access palliative care in the later stages when the illness has significantly progressed. In essence it limits the benefits of palliative care (Hui et al., 2014). There is enough evidence to suggest that palliative care when offered alongside curative care has enormous benefits if afforded at an early stage. In fact, it stands out that when palliative care is afforded alongside curative care form an early stage, the self-efficacy of the patient is improved significantly so that they can easily cope with the implications of the illness in the later stages (Zimmermann et al., 2014).
Significance and purpose
This forms the basis on which the integration of palliative within outpatient care settings becomes a necessity especially in an era when chronic illnesses are becoming a pandemic to the society. The patients and families will benefit from learning about their illness and thus develop innate measures to cope if only they access these services at an early age and stage. On the other hand, this will help eliminate the need for hospice care even in the latter stages and thus minimize the burden of high patient populations within hospice and inpatient units even in stages when the patient and family can manage the condition (Greer, Jackson, Meier & Temel, 2013). The purpose of this research is thus pegged on answering the question “For patients in early stages of cancer and chronic illnesses, does the integration of palliative care in oncology care within outpatient units as compared to standard oncology care improve self-efficacy and the quality of life in the latter stages of the illness?”
In answering this question, the objective is to expound on the notion that palliative care is only afforded to patients in end-of-life care; a perception that has actually led to the marginalization of palliative care (Partridge et al., 2014). Palliative care has to be viewed as a process in which the patient and their families can initiate early coping mechanism and evolve with the progress of the illness so that they are not confined to a situation where the latter stages of the illness become a burden to the patient and the family care givers (Tappen, 2011). The patient has to be assured that the latter stages of the illness will not have a significant, uncontrolled role in determining their quality of life and self-efficacy. Self-efficacy is built on a deep understanding of the illness and an actual desire to develop tailored coping mechanisms which is possible when early patient education ifs afforded; palliative care is designed to support this aspect (Melnyk & Fineout-Overholt, 2015).
Theoretical framework
The primary purpose of integrating palliative care in oncology care is based on the need to improve the self-efficacy of the patient by affording them the channels to seek education and knowledge in regard to their illness and thus utilizing the knowledge in the management of their care as well as developing innate coping mechanisms. When patients are well informed about the health issue, they tend to develop a sense of responsibility especially with the knowledge that their condition is manageable and that they can continue to live quality lives even with the condition. However, this is only possible when the education is availed at the right time and particularly in the early stages of the illness before the progression of the illness to severity (Kristin Rotegård et al., 2011).
Chronic illnesses have a tendency to begin with low severity and gradually advance to lethal states when the patient’s functionality is severely limited. At this point, the ability to initiate education for patients is not possible die to the fact that the coordination and cognitive capabilities of the patient are significantly minimized by the illness. When early education is offered, patients recognize that the treatment process seeks to prolong their lives and that they are the active players in this case (Kristin Rotegård et al., 2011). With this knowledge, the sense of responsibility for their illness tends to increase significantly and the patient is develops a passion for self-care and self-efficacy. Thus, the integration of palliative care in oncology care during the early stages is built on the need to afford patients a chance to manage their self-efficacy as a step towards positive living.
This perspective is based on Dorothy Orem’s Self-Care deficit theory. The theory posits that individuals have the ability to be self-reliant and even so demonstrate high levels of responsibility for their health and wellness. The theory has its belief that individuals are distinct and that they each one has their unique health needs otherwise referred to as deficits. These deficits can be met when an individual is fully aware of their specific health issues and can take active measures to respond (Alligood, 2013). However, for individuals to meet their needs the first step is to make empower them materially and knowledgeably. In this respect, the theory identifies that when an individual has knowledge of the health issues or problems, they are more likely to develop behaviors and attitudes that support meeting the specific needs or deficits.
When individuals cannot meet those needs, they are likely to seek the intervention of the nurse. The nurse actualizes the nursing process which is described as the professional practice of helong individuals meet deficits by empowering them knowledge or otherwise. The integration of palliative care within oncology care settings poses as a channel or avenue along which the nurse can aid patients with early stage cancer and chronic illnesses to develop self-care attitude and behaviors and thus improve their self-efficacy even as the illness or condition progresses with time (Alligood, 2013). Palliative care incorporates more than the treatment and medication and takes into context the aspects of patient education and training on coping mechanisms at every stage of the illness. In this case, palliative care as part of oncology care would help empower the patients so that they develop coping mechanisms and gradually optimize their self-care and self-efficacy as they accept their prevailing health limitations (Alligood, 2013).
This enables them to see each progression of the illness and the associated functional limitation as a new challenge that they have to overcome from within. The self-care agency, that the theory defines as the ability of an individual to engage actively in self-care is conditioned by factors such as age, life experience, developmental status, health, resources availability as well as self-care demand for therapy all which are supposed to be fulfilled within a specific timeframe/duration (Alligood, 2013). The palliative care system has previously been confined to the hospice care units meaning that patients with early cases of cancer and chronic illnesses cannot access the very critical knowledge to support self-care. The self-care theory has its basis on the fact that people should view health as a continuum rather than an instant and thus continuously engage in activities that support their wellbeing. This them provides the justification as to why palliative integration in oncology care is important in that it helps redefine the perception of health as a continuum and thus give individuals the chance to cope and adapt to the ever-changing functional and cognitive capabilities (Kristin Rotegård et al., 2011).
Literature Review
Hui et al. (2014) in their study note that palliative care is more of an inter-professional role that involves helping to improve the patient’s quality of life in cases of chronic and advanced illnesses while also helping families address the concerns that are associated with having such a patient and ultimately facilitating decision making. The authors are of the view that the integration of palliative care form the point of diagnosis helps increase awareness and promote self-care for patient as well as facilitating care giving abilities for the family members. In their study, Hui et al. (2014) sought to establish how the timing and the setting of referrals for palliative care influence the quality of life for the patient. Based on their retrospective study, the researchers utilize data form clinical records for all persons living within Houston who had died from advanced cancer for the period between September 2009 and February 2008. A total of 366 cases were utilized with 120 of the individuals having had received early palliative care for less than three months before their death and a further 169 having received PC as outpatients. The quality of life indicators utilized in the study included hospitalization rates, ER visits, hospital deaths, hospital readmissions and intensive care unit admissions within the last thirty days of life of the patient. The early visits for PC as well as outpatient referrals for PC were associated with ER visits (39% v 68%), fewer hospital deaths (17% v 31%), fewer hospitalization rates (18% v 34%), reduced ICU admissions (4% v 14%), reduced hospital readmissions (52% v 86%). However, outpatient PC was associated with lower levels of aggressive end-of-life needs and care and thus more preferable than the standard oncology care and the early PC visits. The results indicated that patients who received outpatient end of life care had a higher quality of life than those who received inpatient care. The researchers are of the view that these findings support the need to avail and increase accessibility to PC care at early stages and importantly within outpatient units to reduce the need for intensive end-of-life care and improve the patient’s self-efficacy even in advanced stages of the illness.
Greer et al. (2013) in their study focus on developing a logical and practical rationale for the early integration of PC into oncology units. The researchers are of the view that many patients and their family caregivers do experience significant physical, psychological and emotional distress in the manifestation of advanced cancer. The researchers note that up to 30% of patients within the palliative care facilities do experience anxiety, depression and adjustment disorders and these can cause psychological morbidities. The cause for this is associated with ineffective and poor patient-physician relationships. The researchers note that patients who begin PC in the early stages tend to develop trust with their primary care providers are more likely to report depression and disorders to their physician as opposed to those who begin PC care in the later or advanced stages. Further, patients who report or seek PC in the early stages of their illness are less likely to have their caregivers develop psychiatric disorders as opposed to those who seek PC in later stages. This is associated with the ability to manage depression and anxiety as well as coping mechanisms at an early stage when early visits are implemented. Late visits are associated with anxiety and inability to cope at a time when the cognitive and coordination abilities have significantly declined.
Most cancer patients especially from low income households tend to receive or seek PC care at the late stages of the illness and this essentially implies poor quality care. Lee et al. (2015) in their study sought to establish the availability, utilization and prevalence of emergency visits by these patients and further explore why emergency department visits are high among cancer patients in end-of-life care. The researchers based their evidence on a retrospective cohort study that involved the monitoring and tracking of ambulatory care service records prior to death from the Taiwan’s National Health Insurance Research Database. The researchers incorporated 32, 772 patients who had malignant cancer and who had visited the emergency departments as well as a total of 23, 833 patients who apparently die over the duration of the study. In the mortality group, emergency visits had a prevalence of up to 81.5% and these seemed to increase exponentially towards the end-of-life. Elderly patients were also more likely to visit EDs for respiratory, digestive cancer or metastases and this applied more prevalently to the male population. These results indicate that the general perception is that cancer patients should seek medical care at later stages when the illness has progressed to severity. It is not possible to determine the varying gender preferences and the researchers are of the view that further studies should explore why the female gender is less likely to seek PC even in the later stages. The results indicate the low regard for ED utilization even when available and this can be attributed to a knowledge gap within the population. The diagnosis stage should be used as the time when the patient and the family are informed of the need to begin early PC and this could help improve the utilization of such services and help break the notion that PC is only availed in end-of-life care.
Zimmermann et al. (2014) utilized a clustered randomized controlled trial to establish the impacts of early PC for patients with advanced chronic illnesses and cancer based on an assessment of various indicators of quality of life. The study was conducted at the Princess Margaret Cancer Centre for the period between December 1st 2006 and February 28th 2011. A total of 24 medical oncology units were placed randomized by the use of a computer-generated sequence based on clinic size and site of the tumor to consultation and monthly follow up by a member of the PC team or standard cancer management. The intervention groups was subjected to early PC care and regular follow ups while the control groups was subjected to standard care. Symptom severity, quality of life, care satisfaction as well as medical interactions were measured at baseline and then monthly for the next four months. The results indicated that for the 461 patients who had completed the baseline values, that is, 233 in the control group and 228 in the intervention group, up to 393 completed one or more follow up assessments. There were minimal changes in the indicators after the third moth but in the fourth month there were notable differences in the across the indicators all in favor of the intervention group. These findings support the idea that early integration of PC has long term benefits even through the short tern benefits may not be significantly visible. There is every reason to afford patients more than just the normal or standard cancer care and integrate PC particularly within outpatient settings.
In Partridge et al. (2014), the researchers sought to analyze the outcomes of a service model that had been developed to aid I n the integration of PC in the entire care continuum for cancer. The service model was based on the need to have a system that will allow for sustainable, acceptable, equitable and feasibility plan for care facilities to help them recognize and implement PC within the outpatient units and settings for increased accessibility. The model posits that patients who are diagnosed with early cases of cancer need be placed within a record that helps them develop close partnerships with the care providers and care facilities so that the follow-up mechanisms can be accomplished. The researchers are of the view that such models when tailored to respective clinical units are likely to spur new partnerships and impact positively on the patient satisfaction, care provider satisfaction, costs savings, adequate reimbursements all which have significant influence on the ability of the patient and family to seek early PC.
References
Alligood, M. R. (2013). Nursing theorists and their work. Elsevier Health Sciences.
Greer, J. A., Jackson, V. A., Meier, D. E., & Temel, J. S. (2013). Early integration of palliative care services with standard oncology care for patients with advanced cancer. CA: a cancer journal for clinicians, 63(5), 349-363.
Hui, D., Kim, S. H., Roquemore, J., Dev, R., Chisholm, G., & Bruera, E. (2014). Impact of timing and setting of palliative care referral on quality of end‐of‐life care in cancer patients. Cancer, 120(11), 1743-1749.
Kristin Rotegård, A., Ruland, C. M., & Solveig Fagermoen, M. (2011). Nurse perceptions and experiences of patient health assets in oncology care: A qualitative study. Research and theory for nursing practice, 25(4), 284-301.
Lee, Y. H., Chu, D., Yang, N. P., Chan, C. L., Cheng, S. P., Pai, J. T., & Chang, N. T. (2015). Emergency visits among end-of-life cancer patients in Taiwan: a nationwide population-based study. BMC palliative care, 14(1), 1.
Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing and healthcare: A guide to best practice (3rd ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. My work setting: Hospice
Partridge, A. H., Seah, D. S., King, T., Leighl, N. B., Hauke, R., Wollins, D. S., & Von Roenn, J. H. (2014). Developing a service model that integrates palliative care throughout cancer care: the time is now. Journal of Clinical Oncology, 32(29), 3330-3336.
Tappen, R. M. (2011). Advanced nursing research: From theory to practice. Sudbury, MA: Jones & Bartlett Learning.
Zimmermann, C., Swami, N., Krzyzanowska, M., Hannon, B., Leighl, N., Oza, A., & Donner, A. (2014). Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. The Lancet,383(9930), 1721-1730.
