Roles of Nurses in Palliative Care and Pain Management for Geriatrics With Colorectal Cancer: A Scoping Review for Quality Improvement

Knowledge of nurses and their roles in palliative care

A nurse with adequate knowledge of palliative care can assist in attending to a patient and their needs at the initial or critically ill stages. This can make a nurse decide on the specific needs of the patient, design, conduct, and evaluate therapeutic and non-medical interventions efficiently. Interestingly, nurses without technical knowledge of medicine can understand the processes and mechanisms and assist in pain management after certain years of experience. Hence, patient experience matters and must be given more attention in addition to technical knowledge, which can help a nurse serve the patient better. Therefore, interactions between physicians and nurses remain important for the successful implementation of this non-medical intervention. Some nurses might be unaware of the volume of pain experienced by patients; therefore, consistent training programs must be provided at regular intervals, which can aid in better palliative care.^[16] The institute or hospital must assist nurses in reaching this task and in successful medical or nonmedical interventions with a positive attitude. In this regard, occupational hazards and harassment must be avoided to improve the safety of nurses in the workplace.^[17]

Nurses with a master’s degree or a PhD can offer innovative practices based on the preferences of cancer patients and educate them as scientists. They can educate people at risk of cancer about the hazards associated with smoking and obesity, as well as expose the environmental and occupational risks in their locality. In this way, they can help provide ideas about preventing cancer, disease incidence, and occurrence, in addition to establishing treatment outcomes. In this regard, higher education in nursing, such as a doctoral degree, seems fruitful in providing novel options for therapy. This may also aid the early detection of cancer in the process of improved survival and/or terminal life care. Knowledge of certain types of cancer, and creating awareness about it, has helped give significant outcomes in several low- and middle-income countries. In this way, nurses can help patients die peacefully and aid their families in coping with the loss.^[18]

Nursing care after palliative resection, which is deemed successful in patients with severe postoperative symptoms, seems effective when the patient’s quality of life is poor.^[19] In addition, palliative resection can improve patient symptoms, increase comfort, and improve survival rates, while cancer is localised to a primary site and at distant sites to a certain extent. It is important to note that non-resection surgery does not provide significant relief from symptoms.^[20] In this case, inputs from a nurse can be efficient in influencing changes at work while traveling and in communal life. In general, a nurse who is engaged in educating the patient and caregivers about the pre-operative procedures can improve the postoperative outcome concurrently.^[21]

Moreover, conversations through telephone calls can improve patient care and survival even after 6 months when the length of hospice care provided to terminally ill patients is limited. Patients with higher symptom burden showed more interest in conversations with nurses, and the interventions were flexible.^[22] Nurses help patients cope with the fear of the cost of therapy, as they feel guilty of the burden experienced by their family, and patients who are anxious feel that their lives are less worthy.^[23] In short, patients with an early diagnosis using biomarkers have successful surgical interventions and better palliative care.^[24] Thus, assessment of patient care by nurses is feasible and improves the quality of their life, as suggested by clinical studies on patients with CRC.^[25-27]

An interesting study found that role-play, card games, digital games, board games, reflection games, and experimental games were effective in palliative care training.^[28] The duration of palliative care is critical, along with the right dosage at the precise timing of treatment. Three months of palliative care is not enough for most patients, and therefore, prolonged care is required.^[29] The spiritual dimension of care is another criterion to be considered by nurses during palliative care.^[30] Collaborative care-taking via adaptive leisure nursing has the capacity to improve self-care, psychological, and psychosocial well-being of older people with CRC.^[31] Query by nursing revealed that patients anticipated the facts on their survival time, to expect their way to the choice of the second line of treatment.^[32] Although the patients wanted more information on their likelihood of cure, side effects, and predicted outcome, patients were allowed access to review a booklet and a video over a period of 2 weeks. Yet, it did not provide any positive output on the recovery expectation of a CRC patient, which could be studied further through related methods.^[33]

Nursing and pain management

Pain is an established phenomenon in geriatric cancer patients and is often left untreated.^[34] Pain management in older patients is often less frequent than expected to the required standard. The percentage of pain endured by a patient increases from approximately 40% at the treatment stage to approximately 70% at the terminal stage. Excessive medication can expose the elderly to unwanted side effects; however, limitations in medical management can result in psychological complications associated with depression. Older patients believe that pain is associated with age and is not a concern. Most patients ignored the pain linked with the use of analgesics and tried hard to maintain their integrity and freedom. To reduce pain, a self-report of pain based on a scale of 0-10 and a previous medical or pathological history must be reviewed. Furthermore, behavioural assessments (for example, non-verbal modes such as crying or yelling) must be noted. Later, inputs from caregivers, including nurses, should be received, and analgesics may be suggested for managing pain. Pain often leads to quarantined behaviour of the patient and enduring feelings and thoughts of loneliness. In such cases, patients could be given options, such as pill boxes, to take daily medicine without any hindrance or assistance.^[35]

The most common or major cause of pain in older people is related to therapeutic interventions (> 80%). Pain is more frequently associated with the lower body and pelvis. Pain endurance is assessed daily and must be addressed at all times possible by healthcare providers and caregivers, including nurses. Neuropathic pain may be due to hyperalgesia and responses to causes other than pain, such as allodynia, in which pain memory is witnessed. Therefore, peripheral neuropathy can be either associated with cancer or not linked to it. Sympathetic pain in the hands, chest, head, and neck may be caused by allodynia, hyperpathia, or hypoalgesia. Changes in posture can also be used to identify the nociceptive pain associated with drug use. Besides, cancer patients exhibit behavioural changes with enhanced anxiety and depression. Patients will have low confidence, intense thoughts of negativity, enhanced dependence on external inputs, and be emotionally down.^[36]

Nurses must be aware that more than 80% of patients with cancer-related pain have around two to four symptoms on average. Nurses must first consider the ability of the patient to manage pain, assess it, and identify the cause. Additionally, nurses should provide medicines based on their efficacy, ensure effective pain control, and provide personalised therapy based on their medical history. This intervention may either be pharmacological or non-pharmacological, and nurses must be aware of the therapeutic and adverse effects of the therapy. Necessary changes, if any, must be made to improve sleep in the patient.^[37] Moreover, the nurse must be certain that pain relief occurs after 4 hours of drug intake, and help in the intake of medications for cancer without the consent of the patient or their complaints.^[38]

Pharmacological interventions

Therapeutic interventions should not always be evidence-based, and extensive research is mandatory for the application of drugs in cancer care. Therefore, the positive or adverse effects of non-steroidal anti-inflammatory drugs, anticonvulsants, antidepressants, and corticosteroids must be analysed. Other non-invasive and complementary therapeutic approaches must be applied for personalised and better management of pain in cancer patients.^[39,40]

Also, non-steroidal anti-inflammatory drugs such as aspirin, diclofenac, ibuprofen, piroxicam, and celecoxib, nonopioid analgesics such as acetaminophen, and anticonvulsants such as neurontin, pregabalin are prescribed for pain management, irrespective of the severity. Opioid analgesics, such as codeine and tramadol, are prescribed for moderate pain in addition to the above-mentioned drugs, whereas morphine, oxycodone, hydromorphone, fentanyl, and methadone are prescribed for severe pain. In this regard, non-steroidal anti-inflammatory drugs are considered effective for pain management, and opioids may not be appropriate.^[41-43] Moreover, antidepressants (e.g., duloxetine and amitriptyline), antiepileptics (e.g., oxcarbazepine and carbamazepine), and anaesthetics (e.g., lidocaine) are effective in managing neuropathic pain.^[44] Besides nursing via conventional methods, like traditional Chinese medicine, can be used in addition to alleviate pain symptoms in cancer care by absorption through skin, exploring the acupoints and conductivity of meridians.^[45]

Nurses are expected to administer accurate doses of therapeutic drugs to particular patients via a precise route. Since they spend more time with the patients in comparison to other healthcare providers, nurses must be experienced in both medical and non-medical interventions for the management of pain. Patients have fears or misapprehensions about being addicted to a drug, insensitivity to the drug, feeling sedated or inadequately treated, and respiratory dysfunction. Nurses should understand the fears of patients and address them appropriately on an individual case basis.^[46,47] Opioids must be administered considering the threat of dependence, and nurses must deliver the optimum dose to the patient. All prescribed medicines should be verified, and suspicious use of drugs must be scrutinised and addressed.^[48]

Management of non-pain symptoms

Shortness of breath as a non-pain symptom in CRC can be treated by proper surveillance of breathing across the airways by alternative positioning, providing airway adjuncts, clearing mucosal secretions, improving the symptoms of aspiration, and encouraging better breathing. In addition, oxygen demand should be minimised with limited activity, and the reduction of fever should be targeted to prevent hyperoxemia.^[49,50] The inhalation of epinephrine or albuterol has been suggested in cases of wheezing.^[51,52] In addition, hemodynamic support must be provided by monitoring cardiovascular distress, such as arrhythmia, if any.^[53] Infections must be avoided and managed in cases of undesired events such as CRC progression.^[54] Both cancer- and treatment-related factors can lead to fatigue, and enhanced physical activity can help reduce fatigue.^[55,56]

Psychosocial and psychiatric distress, including delirium, panic attacks, distress, anxiety, and depression, are commonly observed in CRC patients. Consistent screening and continued follow-up can be advantageous. Increased physical activity and patient adjustment to their stoma, with advice from ostomy nurses, can support this cause too.^[57,58] Educational nursing intervention can empower the CRC patients undergoing chemotherapy to take care of their own well-being with new adaptations in their lifestyle. Nurses assist doctors in helping cancer patients find a safe location for dressing comfortably. The advice of nurses on how to use an ostomy bag can promote the patient’s self-esteem, engage socially with less fear.^[59-61] Cancer cachexia can be managed by treating cancer itself, which may reverse the symptoms of fat mass loss and anorexia. An elevated nutritional intake can help manage these symptoms. Several progestins, hormones, cannabinoids, immunomodulatory agents, and heart medications are used to manage cachexia and anorexia.^[62,63]

Psychological distress can cause a patient to be agitated, and suicidal thoughts can arise because of frustration and feelings of dependence. Non-pain or psychological symptoms can be reduced by simultaneously reducing pain symptoms. Nurses should understand the root cause of depression, and symptoms must be screened and assessed. Precise medication must be provided, in addition to patient education and long-term follow-up. Nurses must promote a patient’s belief in passive death and reduce the feelings of anger in terminally ill conditions.^[64] In addition, the use of antiemetics, such as ondansetron, fosaprepitant, and palonosetron, with regular follow-up can reduce nausea and vomiting in cancer patients.^[65]

Studies indicate that nurses were usually advised to perform an evaluation of physical function in the elderly previous to chemotherapy.^[66] Among CRC patients, fatigue was the most common symptom, followed by dyspnoea, drowsiness, and ascites, the conditions which worsened before death, following hospitalisation. Delirium and hallucination were near-end-of-life symptoms. These symptoms can aid in providing better palliative care by nurses.^[67] It is important to note that palliative chemotherapy provides improved survival and quality of life after toxicity assessment. In this regard, World Health Organization (WHO) provides the note for performance status through grade 0 to 4: Grade 0: Normal functioning without any form of constraint; Grade 1: restricted to heavy work yet can do light work; Grade 2: Can do self-care but unable to do any other work with 50% of sleeping hours; Grade 3: Able to perform limited self-care with less than 50% of sleeping hours; Grade 4: Totally disabled and confined to bed or chair. For instance, the overall survival of patients after treatment with 5-fluorouracil is half compared to camptothecins. Hence, the choice of drug seems inevitable. The doses should be made based on the performance status of the older people.^[68] A nurse navigator, allocated to be the cancer “contact nurse,” was more likely to be contacted than a nurse who is at a ward or the emergency department.^[69] It was observed that patients who were attended by a cancer “contact nurse” experienced better psychosocial support, experience, and care.^[70]

Non-pharmacological interventions

Non-pharmacological interventions aim to manage the effects of the disease and the psychological, social, and cultural aspects of pain. Meditating and gradual relaxation, being conscious during sleep by dreaming, recurring or uniform pattern of respiration, biofeedback, therapy by touch, transcutaneous electrical nerve stimulation, hypnotherapy, hearing music, acupressure, and treatment with heat and cold using ice packs or heating pads are non-invasive modes of managing pain. Other non-invasive techniques, such as acupuncture, massage, reflexology, tai chi, yoga, aromatherapy, and cognitive-behavioural therapy, have also been applied to manage pain symptoms.^[71-73]