Dying can be an acceptable outcome for patients who are at the end of the dying trajectory. And health providers particularly, nurses who spends the most time with patients are responsible for making this period for both the patient and their family as comfortable as possible (class notes, 2018). In this case study, a patient who is a 58 year-old male and at stage IV of lung cancer, it is important to look at the trajectory and to examine some of the signs and symptoms that are likely to put this patient in multiple organ dysfunction in order to provide care that will alleviate the discomfort to the patient while providing competent nursing care to patient’s significant other and sister.
Lung Cancer is a type of cancer that begins in the lungs. The lungs are two spongy organs in your chest that take in oxygen when you inhale and release carbon dioxide when you exhale (Mayo Clinic, 2018).
Smoking is the cause of most lung cancers and exposure to secondhand smoking can also lead to lung cancer.
lung cancer also occurs in people who never smoked nor were exposed to prolonged secondhand smoke. In these cases, there may be no clear cause of lung cancer. Some other risk factors include family history, exposure to radon gas, and exposure to asbestos and other carcinogens (Mayo Clinic, 2018).
Smoking cause damages to the inner lining cells of the lungs. Inhale cigarette smoke, full of cancer-causing substances (carcinogens), causes changes to the inner lining lung tissue almost immediately (Mayo Clinic, 2018). With time, the damage causes cells to act abnormally and eventually cancer may develop and spread (metastasizes) to other parts of the body, such as the brain and the bones. Once the cancer spreads beyond the lungs, it is generally not curable, and treatments is directed towards providing comfort care to decrease signs and symptoms and to help you live longer (Mayo Clinic, 2018).
At stage IV of lung cancer, the patient will start to undergo multiple organ failure as oxygen and carbon dioxide exchange is impaired and cells of the body are deprived of the needed oxygen to function and begin to die (Sole et al, 2017). With the spread of the cancer and the resulting tissue ischemia, the inflammation cascade is initiated systemically to maintain homeostasis while releasing chemical mediators. These mediators increase the permeability of the cells walls, shifting fluid from the intravascular space into the extravascular spaces (third spacing) which results in hypovolemia. These mediators also cause clotting, impaired fibrinolysis, and systemic vasodilation (Sole et al, 2017).
In the lungs, a failure of normal gas exchange, the resulting arterial hypoxemia leads to lung injury, atelectasis ensues, and blood flow is not oxygenated contributing to ventilation/perfusion mismatch (Sole et al, 2018). The cells become leaky leading to alveolar flooding and an increased diffusion distance for oxygen and infection soon follow contributing to further compromised lung function. Tissue repair is initiated with the influx of inflammatory cells into the injured lung, results in fibrosis and hyaline membrane formation, the cardinal pathologic features of late ARDS (Sole et al, 2018). At this progressed stage of the disease, the patient will be placed on a ventilator to help with work of breathing which can further increase lung injury with volutrauma and barotrauma.
Renal dysfunction kicks in with the systemic inflammation response with its associated vasodilation and systemic shock causing hypovolemia and decrease cardiac out. The kidneys fail with decrease perfusion, and creatinine and BUN levels increases, electrolyte imbalances, and oliguria (Sole et al, 2018). Nephrotoxic medications, vasopressor agents used to increase cardiac output further causes reductions in renal blood flow, and the patient is placed on dialysis to filter the blood (Sole et al, 2019).
In the cardiovascular system, peripheral vascular tone is decreased mainly due to vasodilation activity of inflammatory mediators and nitric oxide. The cells become leaky and permeable causing edema (third spacing) and leading to further organ system dysfunction. Systemic oxygen delivery is impaired due to hypotension and with decreased cardiac output (Sole et al, 2018).
With decreased cardiac output, less oxygen supply, and advanced diseased state, Gastrointestinal (GI) blood flow is decreased, leading to impaired GI motility, and alteration in normal microbial flora. Opportunistic microbes become displaced as stress ulcers develop causing infections or even sepsis (Sole et al, 2018). Prophylaxis enteral feeding and proton pump inhibitors are helpful to decrease infection.
Hepatic dysfunction is evidenced in hyperbilirubinemia and cholestasis, liver protein synthesis is altered, serum C reactive protein and alpha-1 anti-trypsin is elevated.
With perfusion mismatch at the lung level as evidenced by decrease levels of oxygen, and carbon dioxide levels increase and decreased cardiac output, brain tissue perfusion is altered. The patient’s level of consciousness is affected and will be reflected in the Glasgow Coma Score. Cerebral edema, possible abscesses in the brain, metabolic alterations, and decreased cerebral perfusion pressure can also be present in this advanced diseased state (Sole et al, 2018). This could also be the reason for the need for either the patient’s sister or the significant other to make the decision as to what kind or treatment will be best for this patient as levels of consciousness is significantly impaired.
The hematological system under goes adaptive response with Leucocytosis in the acute face of the disease in response to a variety of stresses. Anemia as a result of chemotherapy medications, and the disease process will be present from bone marrow suppression. With the inflammation process, or through heparin induced thrombocytopenia results in disseminated intravascular coagulation (DIC) in which all the clotting factors in the blood are used up exposing the patient to extreme bleeding with lab values of prolonged PT and aPTT, and INR greater than 1.5 (Sole et al, 2019)
In an advance disease state and with systemic inflammation response cascade, the immune system ability to fight infections become altered. With that, opportunistic microbial disease-causing organism through hospital acquired infections overwhelms the patient in a hospital setting (Sole et al, 2018).
Metabolic and endocrine systems are also affected as the cancer spreads to these organs. And this may lead to hyperglycemia, adrenal insufficiency and increased serum lactate levels (Sole et al, 2019).
Some of the related symptoms and their recommended treatment in advanced state lung cancer are: the patient will be in respiratory distress with the use of accessary muscles to breath and would have to be intubated; dysrhythmias are also present related to decrease cardiac output and dysfunction and patient is placed on an ECG monitoring and treated with antiarrhythmics; generalized weakness and deconditioning; anxiety and uncontrolled pain treated with anxiolytics, opioids and morphine; and dyspnea treated with breathing treatment and oxygen therapy (class notes, 2018). As heart fails, fluids and sodium are restricted, oxygen, morphine and antibiotic treatment will be recommended. As the liver fails and ascites develops, recommended treatment includes, diuretic medications, albumen, Lasix, paracentesis, indwelling catheter with a three way stop cap (class notes, 2018).
Nausea and vomiting related to the disease process and decrease GI motility, gastric tumor from liver or pancreas, bowel obstructions, and intra-cranial pressure (projectile vomiting), can be treated with antiemetics (class notes, 2018). Heparin therapy will also be recommended to prevent clotting. Some non-pharmacological treatment will include, quite rooms, semi fowler positioning, music therapy, massage and hand holding. If the patient exhibit signs of terminal agitation characterized by restlessness, anguish and complete cognitive failure, palliative sedation is recommended with propofol and intubation (class notes, 2018).
The patient is in the expected quick trajectory of death with stage IV lung cancer and will be experiencing grief, and so is his gay partner whom he had been in a relationship with over 30 yes, and the patient’s sister who has not been on good speaking terms with the brother since he “came out.”
The three phases of grief that the patient’s significant other and the sister could experience are the Avoidance Phase, Confrontation Phase, and the Reestablishment Phase. In the avoidance phase, both sister and significant other will be in a state of disbelief, shock, numbness, confusion and will be in denial with the passing of their loved one (class notes, 2018). At this stage, the task that must be completed is to adjust to the change caused by the death of their love one by taking steps to deal with the reality of the death (acceptance). These can be accomplished by understanding what the death means to them, examining and maximizing one’s coping strengths and limiting weaknesses; maximizing social support and minimizing social isolations; and seeking professional help (Doka, 2013).
The second phase of grief is the Confrontation Phase. Survivors anxiety level increase where the survivors feels the significance of the loss; guilt as survivors my feel that this happened because of something bad they did or wished they had told the dead enough that they love them; anger could be directed to the dead for leaving them or blaming others or self for the death (class notes, 2018). The survivors can go into a state of depression, despair, sadness, preoccupation, and yearning and wanting the dead and yet not able to have their presence (class notes, 2018). Some task to be completed at this state includes the bereaved working through the pain of grief, acknowledging and talking about the complexity and emotions of the death, preserving self-concept and redefining and establishing relationships with family and friends (Doka, 2013).
The third phase of grief in the Reestablishment Phase. Both the sister and deceased’s significant other experience relief and are able to think about other things besides death; Guilt may also be experience as survivors feel it may be wrong to stop dwelling on the dead; anxiety that the dead is not there for them in the future; and survivors start to reinvest in the present and in the future (class notes, 2018). The task in this phase is for the bereaved to engage in reconciliation or acceptance; making and continuing in a new peace that will help them without the presence of the dead and by having an enduring connection with the dead while making new life connections (Doka, 2013).
The deceased sister could experience intense grief response because she may blame herself for not talking to the brother since he “came out” 35 years ago that he was guy. She may have lost the opportunity to talk things over with the brother and to reconcile her difference with the brother and to make sure the brother knows that she loves him. She may try to bargain for time wishing the brother could recover so she can have those conversations and to reconcile. The deceased significant other can experience disenfranchised loss in that, he may not be accepted as family of the deceased and may not be able to moan the deceased in public.