November 26, 2004
The Management of Nausea and Vomiting in Palliative Care
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* Terminal care
* Terminal care: symptom relief
These key words are based on subject headings from the British Nursing Index. This article has been subject to double-blind review.
Aim and intended learning outcomes
The aim of this article is to provide greater insight into the issues surrounding nausea and vomiting for palliative patients, including guality of life issues, treatment of symptoms and nursing care. After reading this article you should be able to:
* Recognise the effect of nausea and vomiting on quality of life.
* Understand the causes of nausea and vomiting.
* Describe the emetic process.
* Outline the pharmacological and non-pharmacological approaches to the management of nausea and vomiting.
* Explain the significance of nursing care to the patient with nausea and vomiting.
For a patient with a progressive, incurable disease such as cancer, maintaining quality of life is paramount. Nausea and vomiting can have a profoundly negative impact on quality of life. If these symptoms are to be managed effectively, nurses need to understand how debilitating and distressing they can be for the patient and his or her family.
There are many nursing, medical and practical measures that can be used in the management of nausea and vomiting, but it is essential before attempting any of these measures that the cause or causes of these symptoms are identified and also that the emetic process is understood.
Before discussing the management of nausea and vomiting, it is appropriate to define palliative care. Nurses need to have a firm grasp of the concept and principles of palliative care and, therefore, understand the importance of quality of life when the quantity is uncertain. In this way, the negative effect that these symptoms have on quality of life can be appreciated more fully.
The most common definition of palliative care was provided by the World Health Organization (WHO) in 1990 and updated in 2002: Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life- threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative care:
* Provides relief from pain and other distressing symptoms.
* Affirms life and regards dying as a normal process.
* Intends neither to hasten nor postpone death.
* Integrates the psychological and spiritual aspects of patient care.
* Offers a support system to help patients live as actively as possible until death.
* Offers a support system to help the family cope during the patient's illness and in their own bereavement.
* Uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated.
* Will enhance quality of life, and may also positively influence the course of illness.
* Is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.'
Twycross and Wilcock (2001) describe four cardinal principles of palliative care:
* Respect for patient autonomy (patient choice).
* Beneficence (do good).
* Non-maleficence (minimise harm).
* Justice (fair use of available resources).
The National Institute for Clinical Excellence (NICE) (2004) guidance Improving Supportive and Palliative Care for Adults with Cancer identifies a difference between general and specialist palliative care service provision, taking into account the qualifications and experience of staff involved in the care as well as the healthcare setting. It also recognises that patients should play a central role in decision making and that, as the main care providers, families and carers need to be included.
Palliative care focuses on the quality of life of the patient but also takes into account the needs of the patient's family and carers. Using a team approach while also recognising that the patient will need to have one key worker is essential - it is frequently the ward or community nurse that takes this role.
Nausea and vomiting
Nausea and vomiting are two symptoms that frequently accompany each other. However, some patients will experience nausea without ever vomiting while others will only feel nauseated immediately before vomiting.
Nausea can be described as the sensation that immediately precedes vomiting. A cold sweat, increased salivation, a lack of interest in one's surroundings, loss of gastric tone, duodenal contractions and the reflux of intestinal contents into the stomach often accompany nausea (Morrow and Rosenthal 1996).
Vomiting (or emesis) is the rapid and forceful evacuation of the stomach contents up to and out of the mouth caused by the powerful sustained contraction of the abdominal and chest wall muscles (Morrow and Rosenthal 1996).
These two symptoms, the unpleasant sensation created by nausea followed by the physical effort of vomiting, can have a profound impact on quality of life (Mannix 1998).
Vomiting is one of the body's involuntary defence mechanisms that is used to expel toxic or harmful substances. The process occurs as follows (Baines 2000):
* A deep breath is taken, the glottis is closed, the larynx is raised to open the upper oesophageal sphincter and the soft palate is elevated, closing off the posterior nares.
* The diaphragm contracts downwards, creating negative pressure, which opens the oesophagus and distal oesophageal sphincter.
* While the diaphragm moves down, the abdominal muscles are contracted to squeeze the stomach and raise intragastric pressure. The pylorus closes to leave the oesophagus as the only route of exit for the stomach's contents.
Causes of nausea and vomiting
Before treating nausea and/or vomiting, a full assessment should be undertaken to ascertain the possible causes. Without assessment, any treatment offered will at best be trial and error, wasting valuable time and quality of life for the patient, who may have a limited prognosis (a life expectancy of weeks to months). Twycross (1999) states that it is usually possible to determine the cause of nausea and vomiting from the patient's history and a clinical examination.
The causes of nausea and vomiting in patients with cancer can be broken down into two main areas (Box 1). Many of these are either reversible or temporary, so when beginning anti-emetic therapy the causes should also be addressed. For example:
* Treat constipation with more appropriate laxatives.
* Drain ascites.
* Give antitussive for cough.
Polypharmacy is an ongoing issue for patients receiving palliative care - overprescribing of medication because of a lack of careful review may lead to unnecessary drug interactions. Where this is not an issue, many patients find the volume of oral medication overwhelming. Some drugs can be converted to slow-release formulation, other drugs may be replaced by a more potent version, while many drugs are used solely to treat the side effects of existing medication.
Table 1 provides a list of regular medication that a patient with metastatic lung cancer and spinal cord compression may be taking. Table 2 indicates the medication for the same patient following a review by the palliative care team. By making some simple changes, the palliative care team was able to reduce the patient's daily medication intake by 21 doses.
Replacing a 12-hourly morphine formulation with a daily version is one way to reduce oral intake without affecting pain control. COX- 2 non-steroidal antiinflammatory drugs were developed specifically to reduce gastrointestinal toxicity (Flower 2003). Etoricoxib falls into this category; it has fewer side effects and, as a daily formulation it reduces oral medication for the patient. Co-codamol, as a step 2 analgesic, is unnecessary when step 3 analgesics are already in use (WHO 1986). Co-danthramer is a combination of a contact laxative and a faecal softener and is, therefore, a more appropriate approach to opioid-induced constipation than is a combination of senna and lactulose (Twycross et al 2002).
Box 1. Causes of nausea and vomiting in patients with cancer
Assessment of nausea and vomiting Nausea is a subjective experience and only the patient is aware of its severity - a consistent and systematic approach to assessment is necessary for nurses to understand this.
Assessment tools should measure the severity of nausea experienced, the frequency and duration of vomiting and the distress this causes the patient (Miller and Kearney 2004). The Edmonton Symptom Assessment System uses a visual analogue scale to assess a range of symptoms including naus\ea, vomiting, pain, anxiety and depression (Bruera et al 1991). The information given by the patient is then transferred to a graph to provide a measurable record of the impact of symptom control interventions.
Table 1. Medication taken by a patient with metastatic lung cancer and spinal cord compression
Table 2. Medication taken by a patient with metastatic lung cancer and spinal cord compression after review by the palliative care team
Other tools focus solely on nausea and vomiting, for example, the Rhodes Index (Saltzman et al 2003), but perhaps by isolating these symptoms with one assessment tool other symptoms may be overlooked.
Before introducing a tool, its reliability, validity and practicality in the clinical setting should be considered. However, the assessment tool 'must not be a substitute for a good patient/ doctor/nurse relationship' (Ripamonti and Bruera 2002).
Before choosing an anti-emetic:
* Determine the possible causes of the nausea and vomiting.
* Treat reversible causes.
* Review current medication.
* Ascertain the most appropriate route for administration of the anti-emetic.
* Ensure that the patient understands and agrees with the treatment plan.
It has been shown that nausea and vomiting can be controlled in up to 70 per cent of patients by treating with anti-emetics according to the receptor site thought to contribute to the symptom (Lichter 1993). Figure 1 shows the receptor sites in the brain and gut that contribute to nausea and vomiting.
The most commonly used drugs for treating nausea and vomiting and the route of action are shown in Table 3 (Twycross et al 2002). The cause of these symptoms is not always immediately obvious, and in this circumstance the choice of an appropriate anti-emetic can be almost haphazard. However, Twycross and Wilcock (2001) have provided a fourstep anti-emetic ladder that provides a logical and methodical approach to the drug treatment of nausea and vomiting (Figure 2).
Subcutaneous administration There are two types of syringe drivers commonly used in palliative care for delivering drugs subcutaneously:
* The Graseby MS16A syringe driver (blue) - which delivers in millimetres per hour.
* The Graseby MS26 syringe driver (green) - which delivers in millimetres per 24 hours.
Of these two syringe drivers, the MS26 is recommended for use in palliative care, because it is the simplest to use (Dickman and Littlewood 1998). The MS26 requires only the ability to measure the distance that the plunger needs to travel over 24 hours when setting the rate, unlike the MS16A, which requires the nurse to calculate the rate per hour and then convert that to a rate over 24 hours. A combination of up to three drugs can usually be administered safely (provided that compatabilities have been checked), with the main advantage over oral administration being that vomiting will not adversely affect absorption because as the drugs are given subcutaneously the gut is not involved. Coackley and Skinner (2003) make two recommendations for giving anti-emetic drugs via the subcutaneous route:
* For vomiting of more than 24 hours' duration.
* For moderate-to-severe nausea unresponsive to oral antiemetics for more than 48 hours.
Continuous administration of subcutaneous drugs allows for improved symptom management with minimal discomfort and inconvenience for the patient. Regular intramuscular or subcutaneous injections are painful, intravenous administration requires access and can become an infection risk, and the rectal route is rarely appropriate or acceptable (Dickman 2003).
While this type of syringe driver is commonly recognised as simple to use, complications can arise. Nurses caring for a patient with this equipment in situ should be able to manage it competently, recognise complications quickly and problem solve efficiently. As Lugton (2002) explains: 'Patients and relatives feel more relaxed even when symptoms are not alleviated, if nurses are perceived to be available and confident in their approach.'
Table 3. Common anti-emetics and mode of action
Figure 1. Receptor sites contributing to nausea and vomiting
Common complications associated with syringe drivers Painful injection site This can result from irritation caused by the needle being in place for several days, an allergic reaction to the needle or an irritant drug combination. Consideration should be given to using a non-metal needle, a review of the drug combination, increasing the dilution of the drugs or adding hyaluronidase (1,500 units) (which enhances the diffusion of subcutaneous infusions) to the infusion, increasing the rate of absorption of subcutaneous drugs (Twycross et al 2002).
Infusion rate problems This is usually as a result of an incorrect syringe measurement or an incorrect rate setting. When using a Graseby MS26 syringe driver to set the rate, measure the length of the syringe driver (after the line has been primed) in millimetres. The length in millimetres is then the rate that is set (Twycross et al 2002).
The start/test button is often referred to as the boost button - if this is frequently used the infusion will finish early. It is recommended that this button is only used when starting an infusion because it will not give a large enough bolus to provide additional symptom relief (Twycross et al 2002). Pressing the button once will move the syringe plunger forward by 0.23mm. This means that in a 20ml syringe with 150mg cyclizine a dose of less than 1.5mg would be given. It is more effective to have an anti-emetic available as required (PRN) to be given as a subcutaneous injection. Additional doses are then recorded, providing evidence of the efficacy of the current anti-emetic regimen.
Patient refuses to have a syringe driver There is a common misconception that syringe drivers are only used when death is approaching. While it is true that this approach is often used during terminal care, it is not the only reason for doing so. This is where nursing care is invaluable for the patient who may have been prescribed a recommended drug combination to alleviate the symptom, but is too frightened to co-operate. By spending time with the patient, explaining why this approach to symptom management is being used and exploring his or her anxieties, the nurse is ensuring that physical and emotional needs are being met.
Bowel obstruction can be caused by intrinsic or extrinsic pressure by either a primary bowel cancer or metastatic abdominal and/or pelvic disease (Ripamonti and Bruera 2002). It can be a temporary problem but for many patients this may also signal that they are entering the terminal phase of illness.
Figure 2. The anti-emetic ladder
Assessment Patients will often describe a gradual worsening of symptoms rather than sudden onset. This may include a history of worsening constipation and colic, followed by loss of appetite, increasing nausea, fatigue and eventually vomiting (Rawlinson 2001).
Diagnosis Adding the patient's history to abdominal swelling, intermittent abdominal pain (colic) and reduced (or even a complete absence of) bowel sounds will often be enough to suspect a bowel obstruction (Rawlinson 2001). However, radiological investigation should be considered to differentiate between constipation and malignant obstruction, and also to identify those patients who may be suitable for surgical intervention.
Surgery Palliative surgery should be considered for every patient with malignant bowel obstruction. However, not all patients are well enough to undergo this procedure or will live long enough afterwards to reap the potential rewards. Before offering surgery, the following should be considered (Hung 2000):
* Co-morbid conditions.
* Other metastases.
* Nutritional status.
* The presence of ascites.
* Recent chemotherapy.
* Recent pelvic or abdominal radiotherapy.
* The patient's motivation and willingness to have surgery.
For the patient who is considered fit enough for surgery, there is still a risk of post-operative complications, including infection, poor healing and formation of fistulas (Rawlinson 2001).
Intubation The insertion of a nasogastric tube may be used as an adjunct to surgery. For those patients where this is not an option and who consequently have a poorer prognosis this is an invasive procedure. The use of antisecretory drugs - such as octreotide to reduce gastric secretions - and antiemetics frequently negate the need for intubation but where the obstruction is high or at multiple levels complete control of nausea and vomiting may be impossible to achieve. The option of intubation needs to be discussed with the patient who may prefer to undergo an invasive procedure rather than face the prospect of regular emesis (Baines 1998).
There are a small number of patients for whom a venting gastrostomy is an option, again where the obstruction is high or at multiple levels. However, the number of patients deemed inoperable but fit enough for this procedure is small.
For those patients where the obstruction cannot be removed or bypassed surgically, then control of physical symptoms and support during emotional distress become paramount. While most patients are aware of the palliative nature of their disease, a bowel obstruction may emphasise the enormity of this situation. These patients will have some important decisions to make.
Nutrition This can often provoke family conflict where the absence of eating can be seen to hasten death. This issue needs to be explored sensitively with the patient and his or her family. If the patient still enjoys eating normally and is prepared to accept vomiting afterwards, then he or she should continue to do so. However, if postprandial emesis and the resulting colic distress the patient, then to continue to eat will only reduce his or her quality of life.
Hydration This is another potential source of family conflict, which requires close consultation and emotional support from themultidisciplinary team. Artificial hydration should be considered if the patient's prognosis is likely to be measured in weeks and if the frequency of vomiting inhibits oral hydration (Baines 1998).
Pharmacological management Control of pain, nausea and vomiting are the main objectives of any drug treatment offered. If the obstruction is thought to be incomplete, there is an absence of colic and the patient is still passing flatus, a combination of a corticosteroid (dexamethasone) and a prokinetic drug such as metoclopramide (which increases gastric emptying and reduces gastric volume) should be considered (Rawlinson 2001). As well as having an anti-emetic effect, dexamethasone will reduce peritumour oedema and potentially improve the patency of the bowel lumen (Twycross and Wilcock 2001). For a patient with a complete bowel obstruction, a prokinetic anti-emetic will increase colic and a corticosteroid will serve only to increase gastric acid production, causing the patient further discomfort (Baines 1998).
At this time, emesis may be inevitable but the size and frequency of any vomits can be reduced, pain can be managed and nausea reduced to the brief periods before vomiting. While bulk-forming, osmotic and stimulant laxatives (such as lactulose, senna and co- danthramer) should be stopped, it may still be necessary to offer a faecal softener and phosphate enemas to reduce any discomfort from the bowel below the obstruction (Rawlinson 2001).
The drugs that should be considered for managing symptoms in malignant bowel obstruction are outlined in Table 4. Figure 3 highlights the use of hyoscine butylbromide (an anticholinergic) and octreotide (a somatostatin analogue) in the management of bowel obstruction.
Table 4. Drugs for managing symptoms in malignant bowel obstruction
Alan was a 73-year-old man with squamous cell carcinoma of the lung and bone metastases. He was admitted a week after completion of five fractions of palliative radiotherapy to the lumbar spine with lower back pain, colic, constipation (bowels not open for seven days) and a three-day history of nausea and vomiting.
His medication included:
* Morphine sulphate tablets slow-release (30mg twice daily (BD)).
* Morphine sulphate solution immediate-release (10mg as required (PRN)).
* Diclofenac (50mg three times a day (TDS)).
* Cyclizine (50mg TDS).
* Lactulose(10ml BD).
Alan's treatment Radiotherapy to the lumbar spine is a frequent cause of nausea and vomiting (Hoskin 1998). However, Alan had been given ondansetron 8mg daily for the duration of his radiotherapy and, as a result, had coped well with the treatment.
Blood tests revealed dehydration and hypercalcaemia. An abdominal X-ray showed constipation rather than an obstruction.
The initial treatment Alan received was:
* Intravenous (IV) hydration for 12 hours followed by IV zoledronic acid 4mg to treat the dehydration and hypercalcaemia, respectively.
* Administration of subcutaneous analgesia and anti-emetics. The syringe driver contained:
* Diamorphine 20mg
* Cyclizine 150mg.
* Diamorphine 5mg and levomepromazine 6.25mg were available subcutaneously as required.
Figure 3. Use of hyoscine butylbromide and octreotide in managing bowel obstruction
* All oral medication was stopped.
By day two, the patient's nausea and vomiting had settled and pain control had improved. This early improvement in symptoms permitted the use of oral and rectal measures. The following were added to his prescription:
* Co-danthramer (dantron and poloxamer) 10ml BD.
* Daily phosphate enemas.
On day three, Alan's appetite began to return and his bowels had been opened. As there had been no vomiting for the past 24 hours, it was safe to return to oral medication. This time the following drugs were prescribed:
* Fentanyl patch 25mcg.
* Morphine sulphate (Oramorph) 10mg PRN.
* Cydizine 50mg TDS.
* Etoricoxib 90mg OD.
Day four arrived with no new problems and so, after consultation with Alan and the oncologist, he was discharged home. A referral to the local specialist palliative care team was made and he was asked to have blood taken every two weeks to monitor his calcium levels.
On reflection it was easy to see why Alan had become so unwell and on assessment was displaying such distressing symptoms:
* Radiotherapy to the lumbar spine, incorporating a large area of the abdomen with an associated risk of nausea and vomiting. Ondansetron 8mg was prescribed to prevent this.
* This meant that Alan was on two constipating drugs (morphine sulphate and ondansetron), one drug causing gastric irritation (diclofenac) and with only lactulose available to prevent constipation.
* Increasing hypercalcaemia will also cause nausea, vomiting, dehydration and constipation (Bower et al 1998).
Rationale for Alan's treatment For a patient who is already vomiting, oral anti-emetics will have no positive effect. It will also be virtually impossible to provide pain control if the absorption of the oral analgesics is compromised. Bypassing the oral route will ensure that the chosen drug regimen can be properly evaluated.
Once the treatment of the nausea, vomiting and pain has been optimised, the patient will feel able to take oral laxatives, to cope with rectal measures and to spend enough time on the toilet to have his bowels open. It would be unfair to ask a nauseated patient with poor pain control to attempt this.
Conversion to oral medication after 24 hours can be considered if nausea is no longer present and the patient is able to tolerate food. Transdermal fentanyl can be considered once pain has been controlled and studies have shown that it is approximately half as constipating as morphine sulphate (Evans 2003, Ripamonti and Dickerson 2001).
Co-danthramer is a stimulant and softener laxative and therefore is a more appropriate drug for a patient taking opioid analgesics (Twycross et al 2002). Etoricoxib, as a member of the new group of COX-2 anti-inflammatory drugs, will offer a reduced risk of gastrointestinal side effects.
Less common treatments
Not suprisingly, a heavy reliance is placed on antiemetics in the management of nausea and vomiting but this is a science that many patients can find bewildering. Non-drug therapies, as well as acting as adjuvant anti-emetics will also enhance the patient's sense of control and provide an opportunity to actively participate in his or her treatment.
Diet Constipation is a major problem and good dietary advice can prevent it becoming so again. Taste changes are a common side effect of oncological treatments (Ventafridda et al 1998) and different foods need to be tried to see what is acceptable to the patient.
Smells from certain foods may need to be avoided and a side room may be helpful for these patients. Some patients will find carbonated drinks helpful in releasing trapped wind; others have experienced the positive effects of ginger as a herbal remedy (Ernst and Pittler 2000).
Complementary therapies Complementary therapies are used alongside orthodox therapies and are generally given to provide relief of physical and emotional symptoms.
There remains a paucity of randomised controlled trials with good data to support the use of therapies such as reflexology, guided imagery and acupuncture. More qualitative data are available but visit any day hospice and you will also be provided with plenty of anecdotal evidence (NICE 2004).
Cognitive therapy has been used to reduce the psychological morbidity associated with nausea and vomiting, and techniques such as progressive muscle relaxation and guided imagery can provide the patient with coping mechanisms (Kohn 1999).
Cannabis There is much anecdotal evidence about the benefits and pitfalls of using this drug. It is difficult to encourage its use when it is illegal and unpredictable in its strength and efficacy. However, patients may ask about this drug and enquiries should be handled sensitively.
The nearest comparative drug is nabilone, which is classed as a cannabinoid. Tramer et al (2001) conducted a quantitative systematic review of the use of these drugs in nausea and vomiting induced by chemotherapy. They concluded that they were often superior to conventional anti-emetics after chemotherapy but that the side- effect profile - drowsiness, euphoria, inability to concentrate - would limit their use.
One of the most basic but also one of the most important aspects of nursing care is oral hygiene (Macmillan Practice Development Unit 1995), yet this task is frequently allocated to junior or unqualified staff (Crosby 1989).
Simple but regular measures can have a significant impact on oral hygiene, without resorting to complex regimens with strong- flavoured oral rinses (Yarbro et al 1999).
Frequent exposure of the oral mucosa and teeth to the acidic contents of the stomach as a result of prolonged and repetitive emesis may lead to further symptoms and a deterioration in quality of life.
Oral assessment, prompt recognition and treatment of problems, and good oral hygiene should be undertaken to prevent potentially life-threatening infections and maintain the patient's quality of life (Honnor and Law 2002). Dental implications from repeated vomiting include loss of enamel and, in severe cases, exposure of the nerves leading to temperature sensitivity and pain.
Oral hygiene goals should include cleanliness, comfort and prevention of infection caused by uncontrollable side effects of therapy. To achieve these goals, nurses should identify patients with the potential to develop oral complications as early as possible. When developing a plan of care for the patient, the nurse should ensure that it is simple and realistic (Madeva 1996). This needs to take into account what the patient feels able to tolerate and how soon after vomiting the oral hygiene takes place.
Nausea and vomiting can have many causes including various oncology treatments, medication and disease progression. The\re will be times when a combination of these is responsible for the symptoms; however, for the patient they will all have an impact on quality of life.
Patients experiencing nausea often feel too ill to complain, so the first indication for healthcare professionals that there is a problem may be when vomiting starts.
Nausea and vomiting require careful assessment to identify the often multiple causes. A plan of action that the whole multidisciplinary team works to, daily reassessment of the patient and a strategy for future prevention and management are essential to effective management of nausea and vomiting. Accurate assessment of the patient is the key to good practice, spending time with the patient to gain an understanding of his or her perception of the symptoms and the effectiveness of the treatment offered is also important.
Nurses are often the healthcare professionals closest to the patient so are in a position to carry out and assess the treatment plan, but more importantly to explain it and offer support to patients and their families
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* You could test your subject knowledge by attempting the questions before reading the article, and then go back over them to see if you would answer differently.
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NS266 Thompson I (2004) The management of nausea and vomiting in palliative care. Nursing Standard. 19, 8, 46-53. Date of acceptance: September 24 2004.
TIME OUT 1
Reflect on a patient you have cared for who was experiencing nausea and vomiting. Compare the care that was given for the physical aspects of these symptoms with the emotional and psychological support the patient received.
TIME OUT 2
Try to remember the last time you experienced nausea and vomiting. Write down how you felt physically and emotionally at the time.
TIME OUT 3
List what you perceive to be the advantages, disadvantages and potential complications associated with using a subcutaneous syringe driver to administer anti-emetics.
TIME OUT 4
Read the case study. Before reading on, list what measures should be undertaken in the first 24 hours of Alan's admission to find the cause of his symptoms and to gain effective management of them.
TIME OUT 5
Consider what practical measures a nurse can implement to support the patient with nausea and vomiting. This could include addressing issues of privacy, oral hygiene and the ward environment.
TIME OUT 6
List what you consider to be the actual and potential implications of nausea and vomiting for terminally ill patients. This should include the physical and psychological effects and the implications for ongoing disease management.
TIME OUT 7
Now that you have completed the article you might like to write a practice profile. Guidelines to help you are on page 56
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Iain Thompson RGN, is Macmillan palliative care clinical nurse specialist, Clatterbridge Centre for Oncology, Wirral.
Email: [email protected]
Copyright RCN Publishing Company Ltd. Nov 3-Nov 9, 2004