SPECIAL NURSING CONSIDERATIONS

Modern technology and advances in antineoplastic therapy have led to longer survival of patients with cancer. Therapies for neoplastic disease also may result in several distressing and potentially life-threatening toxicities. Management of symptoms related to cancer and its treatments can be complex, pose challenges for the critical care team, and require ongoing comprehensive assessment and anticipation of problems. Interventions may include pharmaceutic interventions, nonpharmacologic interventions, and psychosocial support. Physical and psychologic care is vital if patients are to survive a life-threatening critical event and continue to battle their neoplastic disease. One of the challenges unique to caring for patients in an oncology ICU is staff dichotomy. Depending on the policies governing the ICU, a patient's care may be directed by the oncologist, the surgeon, the intensivist, or in some cases, all of these specialists. Under usual circumstances, regardless of who is directing the care, there is collaboration among the services and the multidisciplinary team. Conflict can arise when there are differences of opinion as to treatment priorities, perception of potential treatment effectiveness, or prognosis of the patient or when care decisions are made unilaterally. 2 The oncologist and intensivist bring different perspectives to a clinical situation. 29 These differences can make care objectives unclear and result in confusion for the ICU staff and family members. The nursing staff must struggle sometimes to integrate two differing opinions. One of the primary responsibilities of caring for families in the ICU is providing current information about the patient's clinical status. 23 Providing accurate information may be challenging given the multiplicity of physicians involved in the care of the patient. In a recent study, 17% of families of patients who died in the ICU felt they had received insufficient or unclear information. 21 Under ideal circumstances, the objectives and limits of care are addressed by the services, the family, and, if feasible, the patient at the time of ICU admission. 9 A systematic approach to clinical decision-making regarding care must be used. The use of treatments may be difficult to predict on ICU admission. Goals of treatment must be agreed on and shared. Which therapies are to be used, and to what end, can then become part of the plan of care. Ongoing evaluation of the patient's status and collaboration between the oncologist and intensivist should be inherent within the plan. The ICU has been described as an emotionally charged, intense work setting. 18 Several nurses in one study felt that family members "look to the nurse for the `real' answer" 18 for information regarding prognosis and evaluation of quality of life. Families often express concerns about the plan of care. If conflicting messages are sent by the various services, confusion and dissatisfaction can result. Avoiding staff dichotomy through ongoing collaboration and family and staff updates can help promote optimal patient outcomes. Critical care medicine has two distinct purposes. The first is the use of technology to restore critically ill patients with potentially reversible illness to the best possible quality of life. The second is to provide patients who are hopelessly ill and their families with humane care and accurate information during the dying process. 32 Few patients or families are willing to continue the discomfort of life-support systems after a reasonable trial has demonstrated that their benefit has come to the point of diminished returns. 5 New technologies, new drugs, and the use of combinations of therapies for the management of neoplastic diseases have improved life expectancy. This aggressive management, however, is not without consequence. In addition to multiple-organ dysfunction and the consequences of myelosuppression, patients with neoplastic disorders are admitted to the ICU for a variety of life-threatening diagnosis- and treatment-related comorbidities. Data from a recent investigation revealed that acute respiratory failure, hypotension, septic shock, dehydration, pneumonia, fevers, bleeding, congestive heart failure, fluid overload, and pericardial effusion accounted for most admissions in one oncology ICU. 15 In addition to these comorbidities, patients with cancer experience numerous physiologic and psychologic symptoms. Nausea, vomiting, fatigue, mucositis, anorexia and cachexia, and constipation are some of the more common symptoms that result from cancer and cancer treatment. Therapies associated with the development of these symptoms include single and combination chemotherapeutic agents, radiation therapy, monoclonal antibodies, biologic-response modifiers, and bone marrow transplantation (BMT). 9 The development of the symptoms is related partially to the inability of antineoplastic agents to distinguish rapidly dividing normal cells from cancer cells and partially to organ toxicities. 4 These symptoms can complicate the clinical situation, increase morbidity in the ICU, and add additional measures in the management of the critical care patient. The symptoms may be intermittent or continuous and can cause varying levels of distress. 2 An understanding of these symptoms, their causes, and their associated implications for care are essential to meet the multidimensional needs of the patient. Critical care management of the oncology patient requires an understanding of how these symptoms affect a patient's quality of life and recovery from life-threatening complications. Adequate assessment and prompt recognition and management of the symptoms are essential 25 but may pose a challenge for those caring for the patient, because the symptoms are not always observable. Symptom distress is defined as the "degree or amount of physical or mental upset, anguish, or suffering experienced from a specific symptom, e.g., nausea, fatigue, insomnia." 26 Failure to recognize and treat symptom distress can result in enhanced distress and additional problems for the patient. Aggressive use of high-dose chemotherapy and radiation therapy is common in the treatment of solid and hematologic malignancies. Myelosuppression is a common and anticipated treatment-related toxicity. The resultant thrombocytopenia and neutropenia create unique problems for these patients. Associated high levels of morbidity and mortality may be reduced with meticulous nursing care.