Nursing the Oncology Patient

From diagnosis to end of life, oncology technicians play a vital role in supporting patients and their families. Veterinary oncology is a rapidly growing field with cancer being such a common diagnosis in small animal practice and with owners having an increased willingness to choose treatment for their pets. As one side of the treatment team, veterinary technicians, have immeasurable importance as a support to patients and their families. The first step in the process of cancer care is diagnosing disease. Being able to obtain a diagnostic sample whether through cytology or biopsy is vital to developing a plan of action. Although as veterinary technicians we are not directly involved in making a diagnosis, it’s imperative that we understand proper sample handling and submission. Knowing how to handle samples properly is crucial in obtaining diagnostic samples. After the initial diagnosis it is truly important to then establish the patient’s care team moving forward. This team relationship is of extreme importance. It is made up of the owner, patient, primary care, and specialists. Clients are the most vital part of the team. They see their pets everyday, and will be the ones to assess a patient's quality of life each week during/after treatment. It is important to remember that the goal is always to meet the medical needs of the patient and the non medical needs of the owner. The next step in cancer care treatment is to discuss the options and how best to approach that based on each client's needs. Regardless of the financial constraints, time limitations, or physical capabilities of the client, all options should be discussed; whether that be supportive, curative, or palliative care, hospice or euthanasia. Having an open and clear discussion at all stages of the treatment process, will better aid the owners in making informed decisions about next steps. It is important to maintain open lines of communication and make decisions together based on how the patient is responding and the changing needs of the owners. Since diagnostics and treatment options continue to improve and become available, frequent conversations about the owners goals are encouraged. When it comes to presenting options to owners; it is best to start with a “sound bite” approach. The diagnosis of cancer has already been very shocking and difficult; especially with so many stigmas still associated with it. It is okay to ask owners if they would like to take time to process before deciding on what they’d like to do. It is key to remember that chemotherapy is not the only option when it comes to cancer care. Other options may include surgery, radiation, or other non traditional therapies. It is good to remind owners that some disease processes may not even require further treatment after surgical excision and monitoring the patient is enough. Another choice for clients is to simply “do nothing” approach, where palliative care alone is chosen; this is a perfectly reasonable alternative. While reiterating to the owner that we can offer many things to help patient’s quality of life by decreasing clinical signs and giving them time in order to make an end of life decision. The myths and misconceptions surrounding cancer can often create a barrier for the owners when making a decisive plan. While many owners will do their own research, it is our job as their care team to make sure they have the most accurate information. The most common misconception of cancer treatment for pets are that it’s going to harm the pet, it will be financially devastating, and that it’s not worth it. This is where technicians play a vital role in educating clients. Dispelling these myths is going to be essential in formulating the best plan. Chemotherapy is the principal modality of cancer care. With that being said, it is known to cause many side effects. In order to properly support the patients undergoing chemotherapy treatment, it is important to know what side effects or oncologic emergencies are most common. Some of the main things to focus on during the course of treatment are pain management, GI/nutritional support, and systemic hematologic support. The comfort level of the patient is of the utmost importance to all involved within the care team. When communicating with owners, it is important that realistic expectations and parameters are established. Pain should be assessed at the same frequency and on the same schedule as regular physicals. Nutritional support for these patients begins with assessment. As technicians we play an important role in history taking and evaluation of body condition. It is important to ask questions regarding diet changes, appetite, preferred food, medications and/or supplements that have been added. Bone marrow is one of the most sensitive organs to chemotherapy, so hematologic side effects are common. Neutropenias, anemias, and thrombocytopenias are most common. Of the changes in the patient’s CBC, neutropenia is the one that is most likely to be life threatening due to the increased risk of sepsis. This is why it is crucial to take temperatures at all rechecks for patients undergoing chemotherapy. Knowing the myelosuppressive potential for chemotherapy drugs being administered allows the team to make a plan for monitoring blood counts, as well as administering prophylactic antibiotics following additional chemotherapy, if that approach is chosen. Some common oncologic emergencies that may be encountered when caring for a patient undergoing treatment or palliative care include hematologic, metabolic, urologic or orthopedic. Febrile neutropenia, malignant hypercalcemia, sterile hemorrhagic cystitis, and pathologic fractures are the front runners. One of the most challenging aspects of oncology is that many of your patients will not be cured of their disease. Euthanasia for these patients will eventually need to be performed, although some owners will not accept euthanasia under any circumstances. For these owners, discussions about hospice care are very important to ensure their pets are as comfortable as possible. There is never a “good time” to have end of life discussions, the time will vary from patient to patient and also owner to owner; it should be discussed at whatever level seems comfortable. For some clients this discussion will happen at the first visit when deciding on a treatment plan. Most owners will want to know “when is the right time”; This is their opportunity to make a list of positive aspects of their pet’s life at a time before treatment has started and the disease has progressed. This can be very helpful in acting as a baseline for future assessments of the impact of cancer and treatment on their quality of life, as well as a signal for owners to discuss euthanasia. When euthanasia is not wanted; this should not be questioned by the team. In such situations, the owner should be instructed how to provide the best hospice care possible. The main goal being peace, comfort, and dignity. During hospice care, pain control and nutrition is very important. Remind owners that if the patient's condition worsens or their decision changes, euthanasia is always open for discussion.