Managing Patients On Chemotherapy

Chemotherapy and Emotions

Chemotherapy can affect overall health, threaten a sense of well being, disrupt day-to-day schedules, and put a strain on personal relationships which may cause major changes in a person’s life. Patients may feel fearful, anxious, angry, or depressed at some points during their chemotherapy. These emotions are normal and understandable but may also be disturbing. There are ways to cope with these emotional “side effects,” just as there are ways to cope with physical side effects of chemotherapy. Stress that continues without relief can lead to a condition called distress. Emotional problems can also result from distress. These problems include depression, panic attacks, or other forms of anxiety and worry.

Depression

It is normal to grieve over the changes that cancer brings to a person’s life. A sure future seems uncertain and dreams and plans may be changed forever. If the patient has been sad for a long time or is having trouble carrying out day-to-day activities, he/she may have clinical depression, which affects one in four cancer patients. Clinical depression causes great distress, impairs functioning, and might affect the patient’s ability to follow their cancer treatment plan. Clinical depression can be treated and patients should be encouraged to get help. Clinical depression can be treated with medicine, counseling, or a combination of both, and they can reduce suffering so as to improve the patient’s quality of life.

Symptoms of Clinical Depression

  • Port or arm accessible clothing on treatment days.

  • Loss of interest or pleasure in almost all activities most of the time

  • Major weight loss (when not dieting) or weight gain.

  • Being noticeably slowed down or restless and agitated almost everyday.

  • Extreme tiredness (fatigue) or loss of energy

  • Trouble sleeping with early waking, oversleeping, or inadequate sleep.

  • Trouble with focusing thoughts, remembering, or making decisions.

  • Feeling guilty, worthless, or helpless.

  • Frequent thoughts of death or suicide (not just fear of death), suicide plans or attempts.

Some symptoms, such as weight changes, fatigue, or forgetfulness can be caused by cancer treatment. If five or more of these symptoms are noticed almost daily for two weeks or more, or are severe enough to interfere with normal activities, it might be depression. In this case, the patient should be checked for clinical depression by a qualified health or mental health professional (preferably a psychiatrist). If the patient tries to hurt himself/herself, or has a plan to do so, refer the patient immediately to the doctor or a psychiatrist.

What to do:

  • Encourage the depressed patient to continue treatment until symptoms improve, or to talk to the doctor about different treatments if there is no improvement after two or three weeks.

  • Promote physical activity, especially mild exercise such as daily walks.

  • Make an appointment for mental health treatment if needed.

  • Provide transportation for treatment if needed.

  • Engage the patient in conversation and activities they enjoy.

  • Remember that it is allright to feel sad and grieve over the losses that cancer has brought to their lives.

  • Realize that being pessimistic and thinking things are hopeless are symptoms of depression and should get better with treatment.

  • Reassure the patient that with time and treatment, he/she will begin to feel better.

  • Keep in mind that caregivers and family members can become depressed too. If the patient or caregivers/family are suspected of having depression, it is advisable to refer them to the doctor or psychiatrist.

Abstain from:

  • Keeping feelings inside.

  • Forcing someone to talk when not ready.

  • Blaming the patient on another person for feeling depressed.

  • Telling the patient to cheer up if seem depressed.

  • Trying to reason with the patient whose depression appears severe; talk with the doctor about medicine and other kinds of help.

Anxiety and Fear

During treatment and recovery, it is normal for cancer patients to be fearful and anxious. For most of them, finding out that they have cancer or that the cancer could come back causes the most anxiety and fear. Fear of treatment, doctor visits, and tests might also cause apprehension (feeling that something bad is going to happen). Patients may be afraid of uncontrolled pain, dying, or what happens after death, including what might happen to loved ones.

Symptoms of Anxiety and Fear

  • Anxious facial expression.

  • Uncontrolled worry.

  • Trouble solving problems and focusing thoughts.

  • Muscle tension (may also look tense or tight).

  • Trembling or shaking.

  • Restlessness, may feel keyed up or on edge.

  • Dry mouth.

  • Irritability or angry outbursts (grouchy or short-tempered).

If the patient has these symptoms and are interfering with his/ her life, a mental health evaluation may be helpful. Keep in mind that sometimes, despite having all the symptoms, the patient may deny having these feelings. If patients are willing to admit that they feel distressed or uncomfortable, therapy can often help.

What to do:

  • Encourage but do not force the patient to talk.

  • Encourage the patient to share feelings and fears.

  • Listen carefully to patient’s feelings. Offer support but do not deny or discount feelings.

  • Remember that it is alright to feel sad and frustrated.

  • Get the patient’s help by referring to their doctor and/or psychiatrist, and also give information about counseling and/or support groups.

  • Advice that meditation, prayer and other types of spiritual support may help.

  • Refer the patient to a doctor and/or psychiatrist who can prescribe anti-anxiety or anti-depressant medicines.

Managing Adverse Psycological Effects Of Cancer

Anger

Anger is a common feeling for many people living with cancer. Although anger is often one of the first emotional reactions to a cancer diagnosis, anger can develop at any time throughout treatment and survivorship. A person living with cancer may experience anger about the way cancer has disrupted his/her life or the way family members and friends reacted to the diagnosis.

Coping with anger:

The best way to deal with anger is to identify and find a healthy way to express it:

  • Recognize anger. It is important to identify when a person is angry by him/herself. Sometimes people act on their anger - for example, by yelling at their spouses before they are fully aware that they are struggling with the emotion.

  • Avoid taking out anger on others. A person living with cancer may focus his/her anger about the disease on family and friends which could drive away much needed support. It is important to direct anger at the cause of the feelings rather than other people.

  • Do not let anger mask other feelings. Anger may also be mixed with other emotions. Anger is sometimes used to hide other painful feelings that are difficult or uncomfortable to express such as sadness or hopelessness.

  • Do not wait for anger to build up. Express feelings as soon as it is recognized. Should not wait until anger starts to boil over then it is more likely expressed in an unhealthy way.

Find a safe way to express anger. There are a number of healthy ways to express and release anger:

  • Discussing the reasons for anger with a trusted family member or friend.

  • Doing physical activity while feeling anger at its full intensity.

  • Yelling out loud in a car or private room.

  • Exploring complementary therapies such as massage, relaxation techniques, music or art therapy.

Isolation

Isolation can have a real negative impact on health and well-being. It is common for anyone affected by cancer to feel lonely or isolated. These feelings can occur at any stage of the illness, at the time of diagnosis, during or after treatment. It may be because they may feel that no one understands what they are going through or it may be that their appearance has changed as a result of the cancer or its treatment. For example, some cancer treatments can cause hair loss or weight loss. These changes can add to sense of being isolated and different from those around them. There are many things can be done to help feel less isolated and also help manage emotions:

  • Talking to family and friends. Patients are most likely to feel comfortable talking to family and friends about how they feel. Family and friends can hopefully give support they need. But not everyone has family or friends, and some people find it difficult to talk to people close to them. In this case, they may find it easier to speak to someone they do not know so well, such as a work colleague or counselor.

  • Counseling and professional help. There are many organizations and healthcare professionals ready to provide counseling and emotional support for them.

  • Self-help and support groups. Cancer support groups or support centres are available. Sometimes these groups are led by healthcare professionals. Patients may find that other members of the group are in a similar position. It is quite usual for a group to include people with different types and stages of cancer. This wider experience may help them look at their problems from different perspectives.

  • Speaking to healthcare professionals. Patients can talk about their fears, anxieties and worries to their GPs or cancer specialists. If they have a cancer nurse or pharmacists, they can call them for support even after they have returned home from hospital.

Fear of Recurrence in Cancer Survivors

Fear of recurrence is very common in cancer survivors. Even with years of no sign of the disease, survivors may constantly worry that every ache or pain is a sign that cancer is recurring. These fears will fade with time but may never go away completely. Advise the patient to cope with the fear by being honest with his/her feelings. This is to avoid feelings of guilt. Ask the doctor about what the patient can do to reduce cancer recurrence. Once patients have done all they can to reduce risk and acknowledge their fears, they can take control of those fears and positively influence their future health.

Advise patients to:

  • Take care of their health. Focus on keeping healthy by eating a healthy diet with plenty of fruits and vegetables, exercising each day and getting enough sleep. These actions may help the patient recover from cancer treatment and also help put the patient’s mind at ease by giving a greater sense of control.

  • Keep all the follow-up appointments. Patients may fear the worst when it is time for the follow-up appointments. This should not prevent them from going. Use the time with the doctor to ask questions about signs or symptoms they worry.

Managing complications due to cytotoxic extravasation

Extravasation of the drug can produce extensive necrosis of the skin and subcutaneous tissue. This not only adds to the misery of the seriously ill patient but can also cause serious functional loss, as most often, the forearm and hand veins that are used for infusion.

  • The infusion should be done by an experienced staff with knowledge of extravasational side effects and their management.

  • Emergency drugs and antidotes should be kept at the patient’s bedside.

  • The nurse and patient should be fully informed about the symptoms and complications of extravasation.

  • The infusion should be started in the forearm as the muscles will protect the nerves and vessels from injury in case of extravasation. The use of veins on the dorsum of hand, wrist, and cubital fossa can lead to injury to the nerves, vessels, ligaments, and bones during extravasation as these structures lie without any protection from muscles in these areas. Moreover, as these areas are involved in limb movements, it is relatively easy for the IV canula to get dislodged leading to extravasation.

  • Place an intravenous canula in the vessel in a single attempt, secure it with transparent adhesive tape. Never use a butterfly cannula.

  • First, run normal saline or 5% dextrose in the intravenous line. This will not only hydrate the patient—a prerequisite for chemotherapy, but will also be confirmatory for the proper placement of the cannula in the vein as the fluid will not flow at desired rate in case of improper placement.

  • Do not start infusion in the limb with a history of either intravenous catheter insertion distally within 48 hours, or numbness, and radiation or lymph node clearance.

  • If possible, use central venous catheter for infusion

  • Avoid use of high-pressure infusions.

Signs and Symptoms

An extravasation should be suspected if one or more of the following symptoms occur

  • The patient complains of burning, stinging, pain or any discomfort at the injection site. This should be distinguished from a feeling of cold that may occur with some drugs. The patient is often the first person to become aware that something is wrong with the IV therapy, so instruct him/her at the beginning of treatment to inform staff of any acute change during treatment.

  • Observation of swelling, redness, mottling or blistering at the injection site. This should be distinguished from the ‘nettle rash’ or ‘flare’ effect seen with some drugs.

  • Care should be taken when no ‘flash back’ or blood return is obtained on aspiration. However, this is not a sign of extravasation if found in isolation and the presence of blood does not exclude extravasation.

  • There is increased resistance felt on the plunger of the syringe of a bolus drug administration, this however, could be due to possible changes in the position of the body.

  • There is absence of free flow or the rate of flow is remarkably reduced. This may not be recognisable when using an infusion pump.

Common Questions

Can I drink alcoholic beverages?

Although a small amount of alcohol can help the patient relax and increase in appetite, alcohol may also interact with the drugs which could reduce their effectiveness or worsen their side effects. For this reason, some patients drink less alcohol or avoid it completely during chemotherapy. Be sure to ask the doctor if it is allright for the patient to drink beer, wine, or any other alcoholic beverages.

Can I smoke?

Smoking may cause respiratory problems and should be avoided.

Should I take vitamins or supplements?

Advice the patient that no diet or nutritional plan can “cure” cancer, and taking vitamins and mineral supplements should not be considered as substitute for medical care. The patient should not take supplements without the doctor’s knowledge and consent.