Page 40 Complete Your CE Test Online - Click Here 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 cancer. A big issue is that patients are often referred to hospice just a few days prior to death [28]. The patient and family may also believe that accepting hospice care means giving up hope. They may not understand that for many people, hospice care can afford them more symptom relief which can give them the chance to do what is most important to them, such as spending some quality time at home with loved ones. It may be important for patients and families to know that they can change their minds about hospice even if they have already been admitted to hospice care [28]. Hospices’ own enrollment policies may contribute to their underuse in the United States [28]. Results from a national survey of 591 U.S. hospices showed that 78% had at least one enrollment policy restricting access to care for patients with higher-cost medical care needs, such as chemotherapy, radiation, transfusions, and total parenteral nutrition. Such policies are more likely to be found at smaller hospices, for-profit hospices, and hospices in rural areas of the country [2]. For patients who choose hospice or other in-home care, it is important for caregivers to know what to expect as death approaches. For example, caregivers may find it alarming or jarring when the patient starts to show little interest in food and drinks less liquid. Mental status changes, pain, constipation, and other issues can be managed with help from hospice or home care nurses. It is important that all the caregivers know that, if the patient does not want life-sustaining measures, they should call hospice or home care providers for any problems, rather than calling Emergency Medical Services (EMS). In most cases, calling 911 means that EMS must take resuscitation measures and route the patient to emergency care, unless the patient is conscious and can verbally refuse such care [35]. CANCER SCREENING Cancer screening can help find and treat several types of cancer early. Early detection is important because when abnormal tissue or cancer is found early, it is typically less complicated to treat, and treatment tends to be more successful. By the time symptoms appear, cancer might have begun to spread which makes it harder to treat, averaging less successful outcomes. However, there are hundreds of possible screening methods with varying levels of supporting evidence, and each with its own possible benefits and harms. Because of this, there are organizations that review the evidence, evaluate the pros and cons of various cancer screening methods, and make recommendations for clinical practice. Given the potential fallibility of public health measures, this is a serious task that requires wide-ranging vision and careful consideration. Even with these caveats, a surprising number of groups participate. Some physician groups make recommendations within their practice areas (for example, the American Congress of Obstetricians and Gynecologists and the American College of Gastroenterology). Even cancer treatment centers will have their own interpretations of cancer screening guidelines. So when health professionals speak of cancer screening guidelines, it is important to know which guidelines are under discussion. This section will focus on the best-known national groups that have been making broad cancer screening recommendations for many years. These include the U.S. Preventive Services Task Force (an independent panel of volunteer health experts since 1984) and the American Cancer Society (a donor-supported nonprofit since 1913) [283,8]. Both are reputable and well-respected. Their cancer screening recommendations are different in a few places, but agree on many points. Sometimes the differences are based on how certain research findings are valued or weighted, and often indicate issues that need more research or consideration. Health care providers can choose options from one or the other set of cancer screening guidelines based on the patient’s values and preferences, health insurance situation, and even what is available in the geographic area. Screening recommendations change from time to time as new tests are studied and new evidence comes in to support or counterbalance the older studies. It is a good idea to visit these websites (http://www. and and review their cancer screening guidelines at least once a year to find out what changed.