Page 18 nursing.elitecme.com Complete Your CE Test Online - Click Here Most dietary supplements do not appear to cause harm during cancer treatment. For some time, herbal supplements were posited to be harmful when taken during chemotherapy or radiation therapy because high antioxidant levels might interfere with the mechanisms of chemotherapy and radiation. After a lot of debate on the matter, it was generally concluded that although more research is needed, there is little evidence of harm except to smokers receiving radiation therapy, who had shorter survival in a clinical trial where they took high doses of beta carotene supplements than smokers who did not take them. In one study, high doses of supplemental vitamin E (taken alone) were linked to a slightly higher rate of prostate cancer in men who had lower levels of selenium in the body. Finally, St. John’s wort can accelerate excretion of a number of drugs because of its induction of 2C9, 2C19, and 3A4 in the CYP-450 enzyme system. This can make a number of drugs less effective (see “Drug Interactions”). Different practices and facilities may have different ways to advise patients about these possibilities. Antidepressants and other drugs that affect serotonin levels can precipitate serotonin syndrome, especially when taken with other drugs that also affect serotonin levels, such as opioids, ondansetron, metoclopramide, and certain anticonvulsant drugs that may be used for adjuvant pain management. Sometimes these combinations can be avoided, but patients need to know what to watch for, such as mental status changes, neuromuscular changes (e.g., muscle rigidity, clonus, restlessness, shivering, tremor) and autonomic hyperactivity (e.g., sweating, diarrhea, flushing, tachycardia) so that preventive interventions can be taken quickly. Many people who take these medicines every day (and often even the doctors who prescribe them) are unaware of this potential problem. Finally, of course, drugs can interact by potentiating each other or magnifying the same effects, for example, the CNS depressant effects of opioids and benzodiazepines, which can also potentiate those of other drugs or alcohol. Drug side effects During this period, it is also a good time to review common side effects with the patient and get an idea of how well informed he is regarding the risks and benefits of his proposed treatment. In some settings, patients may need to sign a consent form before they start cancer treatment, so the nurse will need to document teachings in the record. This is also a good time for information handouts and sharing reliable resources patients can call or visit online with questions, such as the American Cancer Society and the National Cancer Institute (see “Patient resources”). It is also a good idea to caution patients that there are a lot of unreliable information sources on the Internet, and many scammers, and useless “treatments.” Patients can learn more about these issues at the FDA’s website, http://www.FDA.gov Informed consent for cancer treatment True informed consent is an exchange of information between the patient and provider and can be revoked at any time. The patient, proxy, or guardian needs to know the diagnosis, proposed treatment, purpose of treatment, expected risks and benefits of the proposed treatment, possible alternatives to the proposed treatment and these likely outcomes (including no treatment), how long treatment is expected to last, and how treatment will affect their normal activities – all this before consenting to treatment. The patient should also be given the chance to ask questions, confer with family or others if needed, and be clearly informed that she can take back consent at any time even if a form is already signed. The patient should also understand that she will be kept up-to-date as things change or new information comes to light (for instance, if her labs require changes or delays in treatment, or if new clinical trial information becomes available about the drugs that are being used). Some practices use a consent form for cancer treatment and others do not, but a consent form cannot replace the process of informed consent. Informed consent starts well before the initiation of treatment and is continued all the way through treatment. Whether or not a form is used, informed consent is an ongoing process over time. For more detail, a modifiable informed consent discussion guide for cancer treatment can be downloaded at no cost from the American Society of Clinical Oncology (ASCO) website. The discussion guide has reminders of the main points that need to be covered and documented in the patient record. For practices that are interested in a consent form, a modifiable example can be found there also (see “Resources for Nurses”). Follow-up questions and unexpected problems It is also very important to be sure that the patient and family know how to reach the oncologist, including nights, weekends, and holidays. This information, along with a list of what the patient should call regarding (and which concerns should be considered emergencies for immediate notice) should be given in writing. Nurses may have to emphasize this at each visit, as many patients are reluctant to bother the doctor even if they have life-threatening complications. Drug interaction evaluation The full drug and supplement list from the history should be shared with the oncologist along with any new history information. The same list, along with cancer treatment medications and symptom control drugs proposed in the treatment plan, should also be submitted to an expert on drug interactions who may be able to identify additional problem areas and propose possible solutions. Generally, the best consultant for this evaluation will be a clinical pharmacist. In some settings, the pharmacist is given time for direct patient teaching regarding medications and side effects, avoiding drug and food interactions, and more. Cancer Treatment Treatment settings The majority of oncology services has shifted from a historically inpatient model to outpatient care. Patients can receive cancer treatment as inpatients, at home, or as outpatients at a clinic, doctor’s office, or hospital. No matter where treatment is given, the nurse and care team will need to check back with the patient often, watch for side effects, and help the patient control or manage these. This has a lot of implications for nurses. First, nurses have less time with the patient than with inpatient care, so she has less time to monitor, get feedback, assess, educate, or develop trusting relationships. Much of the time with the patient may be designated for tasks, which will be numerous and varied. Second, there is often less formal training for nurses and other staff and less support toward this end because of smaller staff sizes and less funding. There may be less time allotted to patient preparation and monitoring. Especially in smaller outpatient settings, health care professionals have lost some of the departments, procedures, and structures of support for basic patient safety. Professionals must bring the essential components forward so that there are policies and procedures that delineate and support safe professional nursing practice. Given the high risks and difficult balances that come with cancer care, nurses and other health care professionals must be sure that there is a structure in place for outpatient facilities to maintain safe, effective, timely, and high-quality care. Safe and quality care requires the methods, means, and staff availability to assess and monitor the patient from beginning to end of cancer treatment, and even beyond. This is not just physical care; it is also imperative to have readily available tools to assess mental health and coping in patients and caregivers; prioritize for the most important educational needs; and set up straightforward methods for documenting those assessments and teaching. All cancer care facilities must meet standards of care for the protection of the patients. Even though hospitals have infection control departments that have policies, procedures, and resource professionals, the guidance is often less detailed, or even missing, in some outpatient settings. Outpatient facilities should have infection control and prevention policies and procedures as outlined by the Centers for Disease Control Basic Infection Control and Prevention Plan for Outpatient Oncology Settings: Minimum Expectations for Safe Care (updated November 2015). This document can be downloaded at no cost from the CDC website (see “Resources for Nurses”). The document includes a helpful checklist to be sure that everything is addressed. The Infection Control Plan covers everything from staff training to vaccines and personal protective equipment, from managing patients or staff with