Room for Improvement in Symptom Management

TON - November/December 2014 Vol 7 No 6

Even though oncology nurses are charged with improving patients’ cancer-related and treatment-related symptoms, there is much room for improvement, according to Susan C. McMillan, PhD, ARNP, FAAN. McMillan received the Distinguished Nurse Researcher Award at the Oncology Nursing Society 39th Annual Congress and gave a presentation about symptom management in oncology nursing.1

McMillan is Thompson Professor of Oncology Quality of Life Nursing at the University of South Florida in Tampa as well as the Director of the Oncology Nursing Program. She has conducted numerous studies in the field of symptom management, with a concentration on pain management and, more recently, constipation. The main focus of her efforts has been to improve symptom management and quality of life for cancer patients.

In her talk, she mentioned that the trajectory of cancer care is changing, and it is now recognized that palliative care should be given much earlier in the course of therapy to address patients’ symptoms.

McMillan’s studies of pain management in cancer patients show that appropriate pain assessment is important and that, when pain is properly assessed, patients have less need for sedation and their pain intensity is reduced.

A study she conducted in 2006 found that cancer pain was significantly undertreated, and RNs were giving only about one-third of the prescribed doses of pain medications.

“Many patients had daily unrelieved pain, and 18% of the patients with moderate pain got no analgesic,” she said.

Patients’ charts revealed inadequate pain assessment. Only 4% of the patients in the study had been rated for pain, and the site of pain was documented in only 53%.

A study done in the hospice setting in the year 2000 (N=85) about nurses’ knowledge and attitudes about pain management in cancer patients showed that not only did nurses have inadequate knowledge about pain, but their attitudes toward pain treatment were based on false assumptions. This study also showed that patients’ pain was being undertreated.2

Nurses knew the least about physiology of pain, pharmacology of analgesics, treatment goals, and nonpharmacologic methods. Furthermore, 84% did not know that around-the-clock dosing is preferable, and 82% falsely believed that around-the-clock dosing increased the risk of sedation and respiratory depression.

One might assume that because this study was conducted 14 years ago there has been some improvement. Sadly, not much has changed. McMillan reported on a repeat of the same study on nurses’ attitudes conducted in 2014 (N=41, to be published) showing that, in some domains, nurses’ scores were even more disappointing. The scores on knowledge about pain ranged from 39% to 81%, with a mean score of 63%. Only 17% of nurses scored higher than 70%, which would be equivalent to an “F” if they were graded on test results.

Looking at attitudes in that study, 95% disagreed that around-the-clock pain care is better, and 95% agreed that around-the-clock dosing increases the risk of sedation and respiratory depression. Only 15% agreed that patients in pain can tolerate higher doses of opioids without worrying about respiratory depression.

McMillan emphasized that pain is not the only symptom cancer patients experience and certainly not the only distressing symptom they have. A recent study using the Cancer Symptom Scale reported the following symptoms in cancer patients treated in hospice: fatigue (83%), pain (73%), dry mouth (71%), drowsiness (60%), loss of appetite (56%), and shortness of breath (55%). Patients cited fatigue, loss of appetite, constipation, difficulty sleeping, and cough as the most distressing.

The oncology nurse should find out from individual patients which symptoms are the most distressing, she continued. “We can’t help them if we don’t know what they are experiencing and how distressing the symptoms are. I encourage all oncology nurses to use a multisystem assessment,” she said.

McMillan currently has a grant from the National Cancer Institute to study constipation with a multidisciplinary team. She noted that constipation is the major side effect of opiates, and that patients report distress and pain related to constipation. Yet constipation is undertreated and often ignored, even though it is very treatable. In rare cases, constipation, if left untreated, can cause bowel perforation and death.

Regarding the current state of symptom management, McMillan said: “We need to do better. It is the oncology nurse’s job to address symptom management. Become involved in evidence-based projects to study these problems.”

References
  1. McMillan SC. Distinguished Nurse Researcher Award: are we there yet? Symptom management in oncology nursing. Presented at: Oncology Nursing Society 39th Annual Congress; May 1-4, 2014; Anaheim, CA.
  2. McMillan SC, Tittle M, Hagan S, et al. Knowledge and attitudes of nurses in veterans hospitals about pain management in patients with cancer. Oncol Nurs Forum. 2000;27(9):1415-1423.

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