More and more Americans are embracing complementary medicine to help manage their illnesses alongside conventional therapies, and in oncology, nurses know well how important these interventions can be to improving patient and survivor quality of life.

In this month’s cover story, we talk with several experts who rightly recognize the oncology nurse’s critical role in this arena—not only in supporting patients’ efforts to find relief from the rigors and emotional stressors of a cancer diagnosis and treatment, but also in optimizing the safe use of integrative approaches.

This role includes opening up a dialogue with patients about complementary therapies, identifying licensed providers who have experience treating patients with cancer and survivors, and making sure that those therapies patients are adding to their conventional treatments become part of routine nursing assessments.

A healthy diet is an essential aspect of holistic care of the patient with cancer right through to the survivorship phase, and in this issue, oncology nutrition experts from the John Theurer Cancer Center offer a wide array of ideas and strategies for promoting patients’ nutritional health during treatment and to assist them in maintaining healthy eating habits after treatment and thus lower their risk of recurrence.

Also in this issue, we feature our recent interview with one of the leading experts in the field of occupational exposure to toxic substances, Melissa McDiarmid, MD, MPH, who heads the Division of Occupational and Environmental Medicine at the University of Maryland. McDiarmid, who was named an Oncology Nursing Society honorary member last year, says that the evidence is in on the carcinogenic, reproductive, and other health risks posed by exposure to hazardous drugs, and it’s time to stop arguing and focus on the solution. We couldn’t agree more.

Our strategic alliance partners are once again sharing practical ideas to enhance cancer and survivor care, among them, the “Heels of Hope” patient navigation program at the UNC Lineberger Cancer Center where volunteers team up with patient advisors and healthcare staff to provide nonclinical support to patients—identifying and resolving barriers to care and providing emotional support. At the Smilow Cancer Hospital at Yale-New Haven, an innovative writing program is helping patients to heal by sharing their stories, and at Case Western Reserve University’s Frances Payne Bolton School of Nursing, leaders are placing a priority on ensuring that oncology nurses are trained to provide quality palliative care to patients and their family caregivers.

We hope these research highlights, conference coverage, and expert insights will help you in your practice. We invite you to share your comments and suggestions, and as always, thank you for reading.

Articles

From the Chairman

More and more Americans are embracing complementary medicine to help manage their illnesses alongside conventional therapies, and in oncology, nurses know well how important these interventions can be to improving patient and survivor quality of life.


Caring for the Whole Patient-for Nurses, It Comes Naturally 

Cancer centers throughout the country are faced with an increased demand for cancer care and a shrinking oncology workforce.

 As a result, institutions are struggling to find innovative ways to deliver patient-centered quality care in a cost-effective manner.

In North Carolina, many institutions are facing these same challenges, especially since cancer has surpassed heart disease as the leading cause of death across the state in 2013.

 North Carolina is a large state with 100 counties and a high percentage of people who are below the national average poverty level.

 The NC Cancer Hospital at UNC is the only public cancer hospital in the state with a mission to provide care for its residents regardless of their financial ability to pay for their care or where they live. This is a mission that is taken very seriously at the NC Cancer Hospital where we provide 135,000 patient visits each year.

 Each patient is unique, and our goal is to optimize patient safety and quality of care.

The NC Cancer Hospital is the clinical home to UNC Lineberger Comprehensive Cancer Center (LCCC), which is one of three National Cancer Institute (NCI)—designated comprehensive cancer centers in the state. The hospital has been in operation since 2009 and was designed with in- put from a variety of stakeholders, including patients and healthcare providers. LCCC provides a collaborative home for over 40 departments, including the Schools of Medicine, Dentistry, Gillings Global Public Health, Eshelman School of Pharmacy, and the College of Arts and Sciences who work together within the University of North Carolina at Chapel Hill.

The cancer research center has a reputation for bringing together outstanding scientists and physicians to conduct research that improves the prevention, early detection, and treatment of cancer. Members include Nobel Laureates such as Aziz Sancar, MD, who are dedicated to working collaboratively with communities, healthcare providers, patients, and caregivers to address challenges in cancer treatment as well as healthcare disparities throughout North Carolina.

Hospitals and healthcare systems have confirmed the growing benefit of having trained engaged volunteers to support the healthcare team and increase patient satisfaction.

 Lay health advisors have a rich history in North Carolina of utilizing trained volunteers to promote health and disease prevention.

Building upon their success, and the success of Harold Freeman’s model of patient navigation,

 four models of patient navigation were developed by the UNC Cancer Network in 2008. The goal was to ensure timely delivery of cancer services and resources to individuals using nurse and lay patient navigators. These models of patient navigation have increased throughout North Carolina and continue today.

In 2009, the North Carolina Cancer Hospital (NCCH) embarked on a mission to partner with patients and families to improve the healthcare experience for all our patients. By creating a 

, past and present patients, families, and caregivers were invited to serve as volunteers on various committees throughout the NCCH in order to build collaborations within the health system. Allowing them to offer their unique perspectives and valuable feedback regarding the care they received as patients has helped to ensure that the highest quality of comprehensive, safe, and compassionate care be delivered at the NCCH.

A coordinator was identified and was responsible for ensuring that all members had been interviewed and screened appropriately through volunteer services. Members needed to be dedicated, objective, and represent the diversity of the demographic and geographic population served by the NCCH. Additional training was provided to ensure they had the appropriate skills and understanding of their role. The coordinator was responsible to ensure that these patient advisors were fully integrated into the various committees, such as ethics, emergency department, facility design, survivorship care planning, patient satisfaction, Patient-Centered Outcomes Research Institute (PCORI) grant writing, and website redesign, throughout the NCCH. Partnering with patients and families has enabled these advisors to celebrate many successes and increase patient satisfaction at the NCCH. They share their experience and the importance of patient-centered care with students from the Schools of Public Health, Medicine, and Nursing and also led the development of a caregiver support group based upon needs identified during their own experience.

One area to highlight is the collaborative efforts that took place for the development of the lay navigation model of support for cancer patients within the NCCH that exists today. Members from the PFAB, healthcare staff, physicians, chaplains, volunteer program, and hospital leadership came together and identified an unmet need among the underserved cancer patients being treated at NCCH.

These patients included racial/ethnic minorities, the uninsured and underinsured, low-income, and those residing in rural dwellings who required additional support beyond usual clinical care to achieve success with their treatment.

A lay navigation committee was developed with the goal to implement and integrate a volunteer lay patient navigation model of support called “Heels of Hope.” Lay volunteer navigators would work with nurse navigators to provide nonclinical support to patients, including identification and resolution of barriers to care and providing ongoing emotional support, thus enhancing the overall patient and caregiver experience.

For the purpose of this pilot, lay navigators were identified as UNC volunteers who receive additional training to ensure they have the necessary skills when interacting with patients, caregivers, and members of the healthcare team.

Partnering with the volunteer program, UNC chaplains, and nurse navigators, the PFAB was critical to ensure success with the ongoing training, orientation, and support that volunteers would require. Many members of the PFAB participated in the development of the program. Board members were able to share their own experiences with the committee in order to ensure that the training was comprehensive and that gaps in care could be addressed.

The Heels of Hope Lay Patient Navigation Model and patient advisors further integrate patient-and family-centered care into the culture of the NC Cancer Hospital. Almost all of the lay navigators and the PFAB members are cancer survivors and caregivers. Patient advisors provide feedback from their participation on committees to increase the quality of care and improve the patient and caregiver experience. Today, lay navigators are providing additional nonclinical support in the following clinics:

• Bone Marrow Transplant Unit (inpatient)

Outcome measures are being collected and shared with the UNC Cancer Committee as part of the accreditation process with the American College of Surgeons Commission on Cancer.

A cancer diagnosis can be a devastating experience. Utilizing trained volunteers as patient advisors and patient navigators is one way to systematically address the complex and fragmented healthcare system while providing emotional support for patients and families during a difficult time.

The lay navigators and patient advisors bring a unique perspective and a personal dimension to cancer care. It is our hope that this commitment to caring will reduce the patient’s fear and frustration, improve timely access and adherence to care, and result in better outcomes and quality of life.

Jean Sellers, MSN, RN, is clinical administrative director at the UNC Cancer Network in Chapel Hill, North Carolina, where Loretta Muss, RN, serves as coordinator of the Patient and Family Advisory Council of NC Cancer Hospital, UNC Healthcare.

1. Institutes of Medicine. Delivering High-Quality Cancer Care: Chart- ing a New Course for a System in Crisis. Washington, DC: National Academics Press. 2013. www.iom.nationalacademies.org. Accessed September 28, 2015.

2. North Carolina State Center for Health Statistics. Statistics and Reports: Vital Statistics, Volume 2: Leading Causes of Death. www. schs.state.nc.us/data/vital.cfm. Accessed September 28, 2015. 3. US Census Bureau. North Carolina Quick Facts, 2014. www.quick- facts.census.gov. Accessed September 28, 2015.

4. UNC Lineberger Comprehensive Cancer Center. Fact Sheet. https://unclineberger.org/files/fact-sheets/unc-lineberger. Accessed September 28, 2015.

5. Hotchkiss RB, Fottler M, Unruh L. Valuing volunteers: the impact of volunteerism on hospital performance. 

6. Wynn J. The transforming power of patient advisors. 

7. Earp J, Eng E, O’Malley M, et al. Increasing use of mammography among older, rural African American women: results from a community trial. 

8. Freeman HP, Rodriguez RL. History and principles of patient naviga- tion. 

9. American College of Surgeons Commission on Cancer. Cancer Program Standards 2012: Ensuring Patient-Centered Care [v.1.2.1, released January 2014]. http://facs.org/cancer/coc/programstan- dards2012.html. Accessed September 28, 2015. 

Feature Story

Cancer centers throughout the country are faced with an increased demand for cancer care and a shrinking oncology workforce.1 As a result, institutions are struggling to find innovative ways to deliver patient-centered quality care in a cost-effective manner. 


Patient Advisors and Navigators Join Forces to Improve Cancer Care

More people than ever are using complementary and integrative therapies (CIT) to manage their illnesses in addition to conventional treatments. A study published in 2011 found that about 53% of American adults used CIT at some point in their lifetime, and 42% said they used it within the past year. People with cancer reported even higher use: 65% of cancer survivors used CIT at some point, and 43% used it within the past year.

The five modalities of complementary therapies include mind-body, manipulative and body-based, biologically-based, energy, and alternative medical systems. According to Gwen Wyatt, PhD, RN, FAAN, the most common types of CIT oncology nurses hear about from their patients are those of the mind-body modality. These therapies, such as meditation, mindfulness, and yoga, are often helpful for the patient and have very low risk, Wyatt, a professor at the College of Nursing at Michigan State University in East Lansing, explained. Manipulative and body-based therapies, such as reflexology and acupressure, are also considered fairly low risk, Wyatt noted. “We have increasing evidence of their efficacy,” but, she added, assessments should be made regarding how appropriate each therapy would be for individual patients.

When speaking with patients about possible therapies, nurses must weigh the potential benefits versus the potential risks. For example, while yoga may help a patient with relaxation or flexibility, a deep tissue massage could be harmful if that patient had low platelets.

From the patients’ perspective, their preference for mind-body modalities is likely because these therapies are noninvasive, Rebecca Lehto, PhD, RN, said. “They don’t involve ingesting substances, such as herbs, vitamins, or supplements, and they don’t involve needles.” In addition, if the patients are receiving treatment at a cancer center that offers integrative healthcare or has an integrative health department, these are the types of therapies predominantly offered. In addition to supporting oncology patients, many of these departments are also involved in CIT clinical research.

Mind—body therapies such as meditation are very portable. As the patients learn the techniques and how to use them, they can be practiced while sitting in treatment waiting rooms, for example, Lehto explained. “Patients can experience real benefits over time.” Lehto is an associate professor at the College of Nursing at Michigan State.

Identifying the Patients’ Therapy Goals

Patients often depend on their nurses for information about available treatments and therapies, including complementary therapies. This fits in well with the nursing focus on a holistic approach to patient care, Lehto said.

“We want to integrate the whole person into nursing care. One thing about integrative modalities is that they’re framed to address quality-of-life issues and perhaps improve emotional symptoms that a patient might be experiencing, as well as to potentially impact patient function,” she continued. “These kinds of parameters are so essential to a patient’s well-being, as well as for personal empowerment.” Just as not all patients receive the same medical treatment, their approaches to and needs for complementary therapies differ. By discussing the issues with their patients, nurses can determine what types of therapies might be of benefit to them.

To start, it’s vital to determine if their patients’ goals are realistic. “If they’re looking for something that is going to cure their cancer, we don’t have any complementary therapies that have shown the same type of efficacy as conventional treatment,” Lynda G. Balneaves, PhD, RN, said.

Are they looking for relief of physical issues, such as fatigue, nausea, or pain? Or are they trying to deal with depression or anxiety? Or both? Determining if they have used complementary therapies in the past and the outcome is also helpful. Balneaves is the Director for the Center for Integrative Medicine at the University of Toronto in Canada.

Balneaves also pointed out that a difficulty faced by many nurses is finding the time to speak to their patients about these issues. “To me, the biggest challenge is time, and for nurses, being able to find time in their busy practices to actually sit down with the patients and ask them about their beliefs and values, and what they’re most interested in learning about.”

When asked for referrals, nurses may find themselves unsure of how to proceed, particularly if they work in smaller communities with limited resources.

“When I consult with health agencies, I encourage them to do an investigation of the local practitioners and to have a list within the facility of the ones who have been checked out in terms of their credentials and their ability to work with patients with various conditions,” Wyatt said.

“I’m always looking for those that are sensitive to cancer diagnosis, because some work only with patients who have arthritis, for example. So you have to have practitioners who are familiar with patients who have the diagnosis, and who have certification or a license if it is available in that therapy. These are the types of things that need to be considered.”

Unfortunately, this type of information is not always available. “It’s time-consuming and expensive to do a full community assessment of which therapists and practitioners in the community are really providing the services that they market, and that they are qualified to provide the services,” Wyatt acknowledged.

There is a good bit of information on integrative health available online, as several websites are dedicated to the topic. However, it’s vital that nurses know which sites are safe for their patients and which should be avoided.

Websites like the National Center for Complementary and Integrative Health and the Complementary and Integrative Medicine section of MedlinePlus, which are federal government sites, are safe sites for patients to explore, as are major hospital and healthcare system sites.

Nurses may want to suggest to their patients that they download a workbook made available through the National Cancer Institute: 

Talking about Complementary and Alternative Medicine with Health Care Providers: A Workbook and Tips

. This workbook contains documents that your patients can use to keep track of their CIT use and their providers, as well as their conventional medical therapy. There is also a glossary and cancer CIT resources. The workbook reviews types of questions patients should ask their healthcare providers and gives the reader other resources. A document like this can give nurses and patients a foundation on which to base their discussions.

There is some secrecy involved in CIT use on behalf of many oncology patients. A 2012 study looked at 305 patients who were receiving radiation therapy. A total of 43.6% of the study participants reported using CIT, but only 12.1% of the patients said that they had discussed their CIT use with their radiation oncologist, and only 11.1% mentioned it to their medical oncologist.

Nurses must support disclosure, Balneaves said. “Nurses are in a really great position of trust. Patients will often open up to us, so we have to make sure that we don’t shut down that dialogue. It’s important that we start acknowledging complementary therapies as a reality in many patients’ lives and ensuring that we’re considering their whole care plan.”

Wyatt said that the best thing is to be straightforward with the patients who are reluctant to discuss CIT use with their physician. “Some of the therapies can actually interfere with the medical treatments. So if the medical practitioner understands what else the patients are doing, then they can adjust or give them advice so that the patients can see that it’s to their advantage to inform their health providers of what they’re doing.”

It is for this reason that nursing assessments of oncology patients should include more than the standard overview. “We have to get to the point that the assessments we do on patients when they come into the clinic are not just about blood pressure and pulse, but also about what therapies they are using,” Wyatt said. If such discussions become part of the regular routine, patients may feel more comfortable talking about CIT.

Keeping up to date on CIT research is another part of working with oncology patients. There are several resources online for nurses that review the use of integrative therapies in supportive care. In 2014, the 

 published clinical practice guidelines regarding integrative therapy for patients who have breast cancer.

 While the researchers concluded that more well-designed controlled trials were needed regarding CIT and its benefits, they found that therapies such as meditation, yoga, and massage, were appropriate for patients who were seeking to manage stress, anxiety, depression, and fatigue.

A year earlier, the American College of Chest Physicians published evidence-based clinical practice guidelines on complementary therapies and lung cancer.4 The researchers also concluded that certain types of complementary therapies, such as acupuncture, mind-body therapies, exercise, and massage, should be integrated with standard oncology care, and that such therapies could help patients manage symptoms such as anxiety, mood disturbances, pain, quality of life, and treatment-related side effects.

Nurses are also encouraged to do their own research to match their patients’ requests and interests. The NCI has a database, where nurses can find links to sites for research articles on CIT in scientific journals, the Cochrane Library, a directory of health organizations and research resources, and information on ongoing clinical trials. The site also has a link to CIT therapies, from A to Z, which offers an exhaustive list of therapies, some which nurses may never have heard of.

Barriers to use of integrative medicine among some healthcare professionals persist, however.

Wyatt encourages nurses to have an open mind to complementary therapies. “There are oftentimes barriers to professional thinking about complementary therapies, because they are not all well integrated into nursing programs, and certainly not into all medical programs,” she said.

“There always tends to be a bit of fear around something that people don’t understand well. I would encourage nurses to really enjoy the literature that’s out there and available about evidence-based practice in the area of complementary therapies, so they become better informed themselves and they can better answer their patients’ questions.”

National Center for Complementary and Integrative Health

Medline Plus: Complementary and Integrative Medicine

Office of Cancer Complementary and Alternative Medicine (OCCAM)

https://cam.cancer.gov/health_information/talking_about_cam.htm

https://cam.cancer.gov/health_information/cam_therapies_a-z.htm

Marijke Vroomen Durning, RN, is a freelance writer who specializes in patient education, and health and wellness topics. 

1. Mao JJ, Palmer CS, Healy KE, et al. Complementary and alternative medicine use among cancer survivors: a population-based study. 

2. Ge J, Fishman J, Vapiwala N, et al. Patient-physician communication about complementary and alternative medicine in a radiation oncology setting. 

3. Greenlee H, Balneaves L, Carlson LE, et al. Clinical practice guide- lines on the use of integrative therapies as supportive care in patients treated for breast cancer. 

4. Deng GE, Rausch SM, Jones LW, et al. Complementary therapies and integrative medicine in lung cancer: diagnosis and management of lung cancer. 

Cover Story

More people than ever are using complementary and integrative therapies (CIT) to manage their illnesses in addition to conventional treatments.

Integrative Healthcare: Caring for the Whole Patient

“What’s your opinion about using hair color?” I asked my doctor shortly before beginning chemotherapy. “I don’t have an opinion,” he said. “Talk to one of the nurses.” The nurse in the room with us, whose own hair was colored, answered my question with another: “Why would you want to put more chemicals in your system?”

That snippet of the cancer experience from the patient’s side was written by Judy M, part of an essay she wrote for the personal story—writing program at Smilow Cancer Hospital at Yale-New Haven.

The program began its third year at Smilow in September 2015 as part of the Art Expression Program of the Complementary Services Department. The idea came from Charlotte Evans, a retired New York Times reporter and editor who, as a volunteer, functions as the group’s coach. Current and former Smilow patients are welcome to join after attending one orientation class. And while there is no requirement that they write about their illness and treatment, that’s what often emerges.

Art Expression, whose coordinator is Dana Shaffer provides a true healing experience. A broad spectrum of classes and workshops—taught by volunteers&mdash;offers patients the opportunity to explore creative and collaborative outlets. Beyond that, the Complementary Services Department offers patients oncology massage, reiki, guided relaxation, yoga and meditation. All services are free.

Expressive writing has been shown to be helpful for cancer patients. According to a 2015 study by Gallo et al, “…it is evident that the strategies of expressive writing improves the management of the disease, [and] reduce[s] the physical and psychological symptoms related to the tumor while reducing the emotional distress in patients…”

The Smilow group meets on a continuing basis every other Thursday morning—usually four to six patients around a table in a 7th floor conference room with a view of the healing garden.

Charlotte begins each session with a “ripped from the headlines” feature—two or three current articles that have to do with cancer, writing or both. Then there is a “process” discussion, during which participants talk about what has helped them write since the last session or what has gotten in the way (other than treatments and medical appointments).

Then comes the main event—reading what they have written, with feedback from around the table, lastly from Charlotte. Although the group is supportive, it isn’t a typical support group. The comments are tightly focused on the writing&mdash;content, style, organization, usage. They are delivered with kindness, and with an eye toward producing a trim and compelling essay that can help bring a sense of order to a chaotic time of life. Tears sometimes flow with the reading, but everybody understands.

As well as being an expressive outlet, the essays serve as a resource over time. Patients can go back several weeks or months and gain perspective on how things have changed, for better or worse. As the author EL Doctorow once said, “Writing is like driving at night in the fog. You can only see as far as your headlights, but you can make the whole trip that way.”

The Art Expression Program is working to produce an annual Patient Story Writing publication that could be used to give nurses and other medical professionals a better understanding of the physical, emotional and spiritual demands of a cancer diagnosis. With adequate funding, the collection of essays would also lend itself to a staged-reading event.

So, what decision did Judy M make about dyeing her hair?

“Self-esteem. I wanted to feel better about myself. Coloring my hair was a simple thing that I could do for myself. Empowering. Something I could control. Plus, Dr. Google didn’t absolutely, positively, forbid it. And it wasn’t as if I didn’t have cancer already.”

Judy M, who wrote about whether or not to dye her hair, died in May of 2015. Her husband has given permission for her essays to be published in an effort to help others.

For more information about the Art Expression Program, contact 

1. Gallo I, Gamino L, Di Monte V. The use of expressive writing in the course of care for cancer patients to reduce emotional distress: analysis of the literature. 

Partner Perspectives

"What's your opinion about using hair color?" I asked my doctor shortly before beginning chemotherapy. "I don't have an opinion," he said. "Talk to one of the nurses." 

Helping Patients Tell Their Stories 

		Polly Mazanec, PhD, ACNP-BC, AOCN, ACHPN, FPCN

	Polly Mazanec is adjunct assistant professor at the Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio, and a palliative care nursing education consultant. Pamela Malloy is director and coinvestigator of the End-of-Life Nursing Education Consortium (ELNEC) Project, American Association of Colleges of Nursing.

Research has demonstrated that integrating palliative care early for patients with advanced cancer improves outcomes such as quality of life, mood, patient satisfaction, prognostic understanding, health service use, and survival.

 As a result of groundbreaking research during the past 6 years, the American Society of Clinical Oncology promoted integrating palliative care into standard oncology care at the time a patient is diagnosed with advanced, metastatic disease.

 However, much work remains to be done. Most recently, the Institute of Medicine has called for improving quality of palliative care, especially nearing end of life in its 2014 report highlighting the barriers to accessing quality palliative care, among them, fragmented care delivery systems, lack of service coordination, and unsustainable costs for care.

Oncology nurses can be instrumental in breaking down existing barriers and are essential partners in the delivery of quality palliative care to their patients and families. In its 2014 position paper, “Palliative Care for Persons with Cancer,”

 the Oncology Nursing Society recognized that oncology nurses are in a unique position to advocate for patient access to palliative care and that oncology nurses must possess the knowledge and skills required to meet the recommendations for the eight domains of palliative care in the National Consensus Project (NCP) Guidelines: structure and processes of care, physical aspects of care, psychological and psychiatric aspects of care, social aspects of care, spiritual, religious, and existential aspects of care, cultural aspects of care, care of the patient at end of life, and ethical and legal aspects of care.

Since 2000, the End of Life Nursing Education Consortium (ELNEC) has educated over 19,950 ELNEC trainers from all 50 states, with content translated into nine languages. ELNEC’s Core Curriculum is divided into eight modules closely aligned with the NCP Guidelines: palliative nursing care; pain management; symptom management; ethical/legal issues; cultural and spiritual considerations in end-of-life care; communication; loss, grief, and bereavement; and final hours.

Most adult oncology nurses take the ELNEC-Core Course, and since 50% of the test items on the Oncology Nursing Certification Corporation examination are based on the NCP’s domains of palliative care, the ELNEC-Core Course can be extremely helpful to oncology nurses preparing for the OCN, AOCNS, and AOCNP certification exam.

The ELNEC curriculum gives oncology nurses the generalist palliative care knowledge that they need to care for patients, families, colleagues—and themselves. For example, in the pain management module, opioid equianalgesic conversions are discussed so that the oncology nurse can readily identify if a cancer patient in severe pain is receiving the appropriate dose of pain medication; if not, the nurse can advocate for the correct dosing.

Managing symptoms like fatigue, nausea and vomiting unrelated to chemotherapy, and dyspnea, are presented in the symptom module. Strategies to deal with ethical dilemmas that cause moral distress for oncology nurses, such as futile cancer treatments in the last days of life, the use of aggressive technologies that do not support patient goals of care, and family conflicts, are presented in the communication and ethics modules. Supporting patients and families dealing with anticipatory grief is addressed in the loss, grief, and bereavement module, as well as the importance of self-care for the oncology nurse dealing with multiple losses. For more information about ELNEC and/or to register for an upcoming course, go to 

Generalist and specialty palliative care education also is available through schools of nursing. At Frances Payne Bolton (FPB) School of Nursing, Case Western Reserve University, the faculty is committed to preparing undergraduate and graduate students to provide palliative care to oncology patients and those with life-limiting illnesses.

The ELNEC core curriculum is integrated into the final clinical undergraduate course. With the leadership of Carol Kelley, PhD, ANP-BC, all MSN students in adult-gerontology primary and acute care, family, pediatrics, midwifery and anesthesia are required to complete the ELNEC training prior to graduation. The training is part of a 2-day one-credit course which includes a day devoted to ethical issues. Students receive a certificate acknowledging that they are ELNEC Trained and this certificate becomes an important part of their graduate portfolio for future employment.

Additional education is available for those who are interested in specialty training in palliative care and oncology. The MSN program at FPB offers five credits at the graduate level (3 credits palliative care and 2 credits oncology) to provide additional expertise in such specialty palliative care skills as advanced pain and symptom management and advanced communication skills. Most oncology nurse practitioners do not get this content in their generic graduate training. These four courses prepare practitioners with such skills as leading an interdisciplinary team, holding family meetings, and managing complex pain and symptoms associated with advanced cancer. For more information, visit 

Oncology nurses have the responsibility and the power to influence their patients and the public by integrating palliative care into quality cancer care. ELNEC training can provide oncology nurses with the tools to improve the quality of life and quality of care patients and families receive.

1. Bauman JR, Temel JS. The integration of early palliative care with oncology care: the time has come for a new tradition. 

2. Smith TJ, Temin S, Alesi ER, et al. American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care. 

 Dying in America: Improving Quality & Honoring Individual Preferences Near the End of Life. 

Washington DC: National Academy of Sciences. http://iom.nationalacademies.org/~/media/Files/Report%20Files/2014/EOL/Key%20Findings%20and%20Recommendations.pdf. Accessed July 14, 2015. 4. Oncology Nursing Society Position Statement. Palliative Care for Persons with Cancer. 2014. 

https://www.ons.org/advocacy-policy/positions/practice/palliative-careAccessed 

5. National Consensus Project. Clinical practice guidelines for quality palliative care, 3rd ed. 2013. 

http://nationalconsensusproject.org/NCP_Clinical_Practice_Guidelines_3rd_Edition.pdf

Preparing Oncology Nurses to Provide Palliative Care to Patients and Families

		Lisa Schulmeister, RN, MN, APRN-BC, OCN®, FAAN

Oncology Nursing Consultant, Adjunct Assistant Professor of Nursing

		Louisiana State Health Sciences Center in New Orleans, Louisiana

How can it be lung cancer? asked my neighbor. I don’t smoke. My 36-year-old neighbor added that she’s never smoked, and in fact, has never even taken a single puff of a cigarette.

The American Cancer Society estimates that of the 221,200 new cases of lung cancer which will be diagnosed in the United States this year, 105,590 are women,

 and of these, 1 in 5 are women like my neighbor—“never-smokers”&mdash;those who have literally never lit up or who have smoked fewer than 100 cigarettes in their lifetime. Over the past decade, lung cancer among never-smokers has increased 33%, and if lung cancer in nonsmokers was its own category, it would rank among the ten deadliest cancers in the United States.

Only 15% of lung cancers are diagnosed at an early stage, and for many young women who are nonsmokers, like my neighbor, lung cancer symptoms often are initially attributed to something other than lung cancer. My neighbor had been treated with antibiotics for over a month for what her primary care physician thought was an upper respiratory tract infection.

She told me that when healthcare providers see the diagnosis of lung cancer in her medical record, they ask her if she’s still smoking. “I want to scream that I’ve never smoked!” she tells me. The American Cancer Society reports that people with lung cancer often are judged negatively—by both the public as well as some healthcare providers&mdash;because lung cancer is so strongly linked to smoking. Even people with lung cancer who have never smoked may be subjected to this stigma.

The causes of lung cancer among never-smokers are not fully understood. According to the US Environmental Protection Agency (EPA), the leading cause of lung cancer in people who have never smoked is exposure to radon gas. Radon occurs naturally outdoors in harmless amounts, but can become concentrated in houses built on soil with natural uranium deposits. The risk of lung cancer is higher for people who have lived for many years in a radon-contaminated house. Because radon gas cannot be seen or smelled, the only way to know if excessive radon levels are present is to test for it.

Both the EPA and the Surgeon General recommend testing all houses below the third floor for radon, and test kits are available online, at home improvement stores, and via the National Radon Program Services at Kansas State University (

). It’s thought that about 20,000 deaths per year are caused by radon-induced lung cancer.

Each year, an estimated 3400 nonsmokers die of lung cancer as a result of breathing secondhand smoke. For many nonsmokers, this exposure occurs in the workplace. Laws that ban smoking in public places are expected to reduce the prevalence of secondhand smoke, and will likely reduce the incidence of lung cancer caused by secondhand smoke. Other workplace-related causes of lung cancer include exposure to asbestos and diesel exhaust. Work-related exposure to these carcinogens has decreased in recent years as a result of increased governmental and industrial measures to protect workers. It’s also thought that both indoor and outdoor air pollution increase the risk of lung cancer among never-smokers.

Lung cancer among never-smokers is twice as common in women compared with men. Genetic mutations associated with non-small cell lung cancer in non-smokers (EGFR. ALK, and ROS1 mutations) are more common among women than men, and these mutations are associated with a more favorable prognosis and a better response to treatment with targeted agents.

My neighbor has been diagnosed with adenocarcinoma, the most common type of lung cancer found in young, nonsmoking women. By the time it was diagnosed, it had spread to her liver. The 5-year survival rate for metastatic lung cancer is a dismal 4%.

The average age of a lung cancer diagnosis is 70. Only 2%-3% are younger than age 40. Several studies are in the works to better determine how and why lung cancer occurs in young, nonsmoking women. My neighbor does not have single risk factor for lung cancer, and wonders why it happened to her. Her oncologist told her that we now know that anyone with lungs is at risk for lung cancer.

1. American Cancer Society. What are the key statistics about lung cancer? 

http://www.cancer.org/cancer/lungcancer-non-smallcell/detailedguide/non-small-cell-lung-cancer-key-statistics

Nurse's Notes

How can it be lung cancer? asked my neighbor. I don't smoke. My 36-year-old neighbor added that she's never smoked, and in fact, has never even taken a single puff of a cigarette. 


October 2015

Caring for the Whole Patient-for Nurses, It Comes Naturally

Patient Advisors and Navigators Join Forces to Improve Cancer Care

Integrative Healthcare: Caring for the Whole Patient

Helping Patients Tell Their Stories

Preparing Oncology Nurses to Provide Palliative Care to Patients and Families

Young Women, Never-Smokers, and Lung Cancer