The Nurse's Role in Cancer Treatment Decisions for Elderly Patients
Debi Fischer is a nurse at the University of Miami surgical oncology step down unit. Prior to that she worked in orthopedics and neurology for many years. In addition to her nursing experience, she has earned a master’s degree in social work. Becoming a Licensed Clinical Social Worker was a lon-sought-after goal which she finally attained. She is a caregiver for her family and her dogs as well.
An oncology nurse is an observer in what is sometimes a life-and-death drama. But sometimes, we must step into the scene and help the patient get information about what might happen before the curtain falls.
In my work as a surgical oncology nurse, I sometimes deal with patients who have been diagnosed with the most lethal cancers, such as pancreatic and ovarian cancers. Often, these cancers have metastasized already, and the patient returns post-op to the floor after a stay in the surgical intensive care unit with drainage tubes, as well as total parenteral nutrition (TPN) through a PICC line and a Foley catheter. Many of these patients are in their late 50s to early 60s, but I have seen many patients in their 80s, too.
In your practice as an oncology nurse, do you ever wonder how much an older patient can withstand when they have gastrostomy-jejunostomy (GJ) tube, colostomy, ileostomy, and urostomy tubes? Would you want to have this alphabet soup of tubes after you reach a certain age? Also, is there a magic age at which certain treatments should be limited? What if you, as the nurse, feel that the patient might be better off letting go and deciding not to seek treatment or go for palliative care, such as a drain, if they have a blocked duct and pain medication, or the alternative, enter hospice care?
The answer of course lies with the patient, their family, and the physician. All 3, in consultation with each other, should come to the decision to either proceed with invasive treatment or let nature take its course and allow the patient to die a natural death without putting them through lengthy surgery, chemotherapy, and/or radiation. In nursing lingo, the patient who is a “walkie talkie,” better known as someone who can speak, walk, take themselves to the bathroom and back, is continent and usually the kind of elderly patient a surgeon will operate on.
I have seen cases where a patient is diagnosed with advanced cancer and the family is told by the physician that under no circumstances are they a candidate for anything other than a drain for a blockage and pain medication. This is because they perhaps have another underlying neurological or cardiac condition and are already in a wheelchair. Maybe they can’t communicate anymore due to the ravages of Parkinson’s Disease. In cases like this, the patient’s mind is still sharp, and they have the desire to live, but are already weakened by an underlying disease. In some of these cases, the surgeon may want to spare the patient any further deterioration from lengthy surgeries like a Whipple procedure for pancreatic cancer, or a debulking procedure with a total hysterectomy as well as chemotherapy for ovarian cancer. In these situations, patients and their family members should come to an agreement on the best course of action, be it palliative or hospice care.
I have also seen other situations where the family does not even tell their relative that they are dying to spare the patient the anxiety of knowing the end is near and the fear that might go along with this. This might happen when the relative has power of attorney due to the patient being unable to make their own healthcare decisions.
Counseling and patient education could greatly enhance the ability for elderly people and their families to make informed cancer treatment decisions. Memorial Sloan Kettering Cancer Center in New York City has a program for patients who are older (65+) and experiencing cancer.1 This program is geared toward the patient who wants cancer treatment, and the goal is to find the appropriate level of treatment they desire. An interdisciplinary team covers all aspects of care including surgery, if the patient wants to go this route, as well as chemotherapy and radiation. Other services include occupational therapy, physical therapy, and social work. In addition, there are palliative care and geriatric psychiatry programs, as well as clinical trials for elderly patients that are available.1
An oncology nurse is the observer in what is sometimes a life-and-death drama. The patient and their family are trying to navigate a bad script and find a solution to the patient’s final act. But we are not just the audience. Sometimes, we must step into the scene and help the patient get information about what might happen before the curtain falls. As with a movie or play with alternative endings, we can reveal the path to each one by giving them information to make an informed decision. Then, armed with the facts, they can decide their course of treatment.
Ultimately, it is a quality-of-life issue. What kind of quality of life will an elderly patient have if the recovery process from cancer will, in the end, only prolong their suffering? If an elderly patient can make an informed decision to go through the process of surgery and/or radiation and chemotherapy, then they are entitled to this route and all it entails.
- Help for Older Patients. Memorial Sloan Kettering Cancer Center website. mskcc.org/cancer-care/diagnosis-treatment/symptom-management/help-older-patients. Accessed August 21, 2018.