Page 60 Complete Your CE Test Online - Click Here recommendations for every cancer screening type after their treatment [209]. Other wellness planning includes future vaccine considerations as well as exercise and dietary plans tailored to the patient’s current status and needs. As an additional resource in its Survivorship guideline, NCCN also has a listing of websites and organizations for the health professional and the patient, that cover many topics and needs, such as legal and work-related issues, nutrition and weight management, heart health, and smoking cessation as well as other survivorship guidelines [209]. End of life Despite all of the progress that has been made in cancer care, many people who have cancer still die due to cancer. For some people the cancer recurs; for others, especially those whose cancers were found in late stages, the cancer went into remission. Some people do not want to accept that there is little that can be done for them, and prefer to keep receiving aggressive treatment. Others do not want the additional side effects and activity limitations, and are ready to move on. For a lot of people, it is a difficult transition from treatment (or diagnosis) to looking toward the end of life. Clear communication can help It is important to communicate clearly with the patient about what is happening. Some doctors are reluctant to speak directly about death with a patient, and often use ambiguous or optimistic terms when talking about prognosis and care plans. But patients who are aware of their terminal status have a higher quality of life and are more likely to receive care that is consistent with their preferences. According to the NCI, nearly 90% of patients want to be informed about their life expectancy, and more than half want to know about end of life decisions [185]. It is possible to simply ask the patient how much they want to know about the likely course of their illness; some people want details while others like key points. Some would rather it be discussed with family members instead, but that should happen only if the patient states that as a preference. And a corollary question is how much say patients want themselves or family members to have in making decisions about care [45]. It is also important to emphasize that it is okay to ask any questions, even those that might not have a clear answer. For the vast majority of patients who want to know, nurses can open a conversation with open-ended questions such as: ● ● “How are you feeling about ending treatment?” ● ● “What do you see yourself doing next?” ● ● “What concerns do you have about your cancer at this point?” Most patients are aware that they are not going to live as long as they hoped or expected, and some want to talk about it even though it is an emotional topic. The nurse can validate the sadness and other emotions without false reassurance by listening to the patient and pointing out that it is normal to grieve and go through a lot of different emotions in this situation. These emotions can include anger, fear, anxiety, sadness, and depression, among others [35]. Guilt, regret, and despair may emerge as the patient reflects on their life. Concerns about pain, being a burden to others, loss of dignity and control, and feeling alone are also common themes when patients think of impending death [35]. The nurse can reflect back the patients’ concerns with some reframing on what the patient might be able to do and what the oncology team or palliative care/hospice team can do to address these concerns, depending on what has already been planned or discussed. The nurse will need to share with the oncologist any new information gained about the patient preferences from this discussion as well patients’ information or treatment needs that go beyond the nurse’s knowledge or scope of practice. Advance directives Near the end of life, it is important to involve family and home caregivers in discussions and planning. Discussions about advance directives and patient preferences near end of life are most likely to be implemented if those that are closest to the patient are aware of them and able to advocate to have the patient’s wishes followed [9]. Any time the patient is being admitted or re-admitted to the hospital is a good time to review orders about attempts at resuscitation or do-not- resuscitate orders. Advance directives only take effect when the patient becomes unable to make decisions and speak on his or her own behalf. The directives can take several forms, the best known of which is the living will. The living will lists the measures the patient does and does not want under different circumstances (such as CPR, IV fluids, or being on a ventilator). Because it is impossible to foresee all of the possible circumstances that may arise, it is a good idea to appoint a trusted family member or friend to make such decisions at any point the patient becomes unable to speak for himself or herself. That kind of advance directive is a “Health Care Power of Attorney” or a “Durable Power of Attorney for Health Care.” Neither of these advance directives can be used to make financial or legal decisions on behalf of the patient; they only apply to health care. They must be in writing and signed by the patient; some states require witnesses and other measures [9]. The National Hospice and Palliative Care Organization’s website CaringInfo offers forms and information at no cost that are accepted by each state (see “Patient Resources”). There are other types of directives, for example, the “Five Wishes” form, which is recognized in 42 states as of 2016. This lists the person the patient wants to make their health care decisions if they cannot, and outlines the patients’ wishes and choices [9]. It is available online for a small fee (USD $5 as of early 2016 -- see “Patient Resources”). Hospice Hospice is a team-oriented approach to providing expert medical care, pain management, and emotional and spiritual support for patients whose life expectancy is no longer than six months. Most hospice care is delivered in the home, and many require the 24-hour presence of an in-home caregiver [185]. Hospice eligibility criteria The criteria for hospice eligibility are based on state and federal regulations. A physician needs to certify that the patient is suffering from a life-limiting illness, with a life expectancy of no longer than six months. The patient must sign a statement choosing hospice instead of other forms of treatment. Hospice may be considered when a patient who has cancer: ● ● Presents with distant metastatic disease. ● ● Has progressed from an earlier stage of illness to metastatic disease and: shows continued decline in spite of therapy; refuses active treatment; and/or chooses palliative and hospice care. ● ● Has a poor prognosis; for example, patients with pancreatic and brain cancers can be eligible for hospice without meeting all of these criteria [185]. Concerns about hospice enrollment – Patients, families, and doctors Patients and caregivers might assume that hospice is only for the final days of life. Unfortunately, doctors often have trouble predicting life expectancy and often wait until death is only days away before the patient is referred for hospice. This tends to make hospice admission a hasty transition, and the patient reaps few benefits of hospice care [185]. Patients, families, and even doctors may have negative perceptions of hospice, believing that it will hasten death. Studies have shown that this is not the case; in fact, mean survival tends to be longer for some people in hospice, especially with diagnoses like lung or pancreatic