TREATING A PATIENT WITH CANCER:
MAINTAINING PATIENT QUALITY OF LIFE

Introduction
Cancer is one of the most prevalent diseases in the U.S. Case (2011) noted that the 2010 report of the American Cancer Society (ACS) indicated that more than a million an d a half new cases of cancer are diagnosed every year. Along with physical disease, cancer also brings a significant impact on the patient’s overall quality of life (QOL). This paper asserts that for optimal patient outcome, healthcare workers, particularly nurses, need to attend to the cancer patient’s overall QOL rather than simply focusing on the physical disease of cancer.
This essay will first address the issue of understanding what constitutes the patient’s QOL. Then key factors that directly affect the QOL are reviewed in the context of current best evidence. That will be followed by a section that addresses the nursing implications of this subject. The paper concludes with a brief summary and conclusion about the importance of maintaining patient QOL in cancer patients.
The first element, is thus to define what is meant by “quality of life.” The next section of this paper addresses that specific issue.

Defining Patient Quality of Life
Before patient QOL can be addressed in a nursing practice, it is essential to understand what is meant by QOL. Bahrami (2011) has noted that no specific, well accepted definition of patient QOL exists. One reason for this lack of consensus on QOL is that life quality is a highly individual concept with different people having different items as important to them (Bahrami, 2011). In addition to being specific to an individual, QOL is also often highly culture-specific (Bahrami, 2011). While many studies consider primarily the domain of physical quality of life, it is more important to define the concept more holistically, considering not only the physical, but also the psychological, spiritual, and social aspects of the patient (Bahrami, 2011). Bahrami (2011) has concluded that QOL can be measured by considering specific aspects of life. In a series of semi-structured interviews with cancer patients and their nurses, physical aspects of patient quality of life include the sense of wellness, being on solid financial ground, having plenty of food and drink, being able to purchase any needed medicines or supplies, and having control over they body to maintain normal body functions (Bahrami, 2011). In terms of psychological aspects of QOL, Bahrami (2011) found that an important element is how the patient feels about their status; this may also be extremely variable, changing often throughout the day.
Spiritual aspects of patient QOL are also important. Bahrami (2011) found that patients needed to be able to discuss existential issues, as well as discuss their thoughts on life and death, their beliefs (or lack of belief) in the afterlife, and so on . Bahrami (2011) also found that patients facing a life-threatening disease such as cancer often felt a keen or even urgent interest in elements of life that are frequently ignored or taken for granted assumptions, such as that their world is a safe place, that they are independent enough to care for themselves, that they are invulnerable, or that no life-threatening health issue could happen to them (Bahrami, 2011). Even the environment of being in a hospital—being confined to a small room—can have an impact on the patient’s QOL (Bahrami, 2011).
Finally, perhaps one of the most critical aspects of QOL is to recognize that ultimately, facing a life-threatening disease can be an extremely lonely business (Bahrami, 2011). Depending on cultural issues, friends and family members may be loath to discuss issues of death and dying, leaving the patient to cope with a possibly frightening experience all alone (Bahrami, 2011). Cancer can have the effect of bringing people closer together, or it can split them apart (Bahrami, 2011).
Ultimately, patient QOL includes each of those aspects, but also such categories as happiness, satisfaction with the current life status, and, most especially, having sufficient power or control to be able to make meaningful choices about their lives or about what happens to them (Bahrami, 2011).

Factors Affecting Patient Quality of Life
As noted earlier, there are many factors that contribute to the patient’s QOL. Some of the most important factors are those that stem from psychological elements of QOL. Studies have shown that there are numerous specific factors that can strongly impact the QOL for cancer patients. This section describes a number of these factors to better understand how they affect the patient. The first of these is the issue of simple human communications. Cancer patients generally do not stay in the hospital for the duration of their illness, but instead are briefly hospitalized for treatments, then released to live at home. Beaver, Williamson, and Chalmers (2010) considered the issue of such newly discharged patients and how their quality of life could best be attended to, even when the patients were no longer in a hospital environment. In a study of telephone follow-up visits (as opposed to in-person visits to clinics for regular monitoring), Beaver et al. (2010) compared the preferences of patients between the two monitoring appointment options. As might be expected, the convenience of not having to physically spend time to go to the clinic and instead simply talk with a nurse on the telephone was the clear winner (Beaver et al., 2010). However, the important aspect of that was not only the convenience but that a genuine relationship developed with the nurse calling for the monitoring; these nurses were perceived as highly knowledgeable and they were strongly trusted (Beaver et al., 2010). Furthermore, doing the visit on the telephone was less threatening than going to a clinic—a place where “sick people” are—so that the monitoring phone call was perceived as something normal rather than abnormal (Beaver et al., 2010). Finally, being able to put a face to the nurse’s voice was also extremely important, and gave the patients a sense of security (Beaver et al., 2010).
When it comes to the physical aspects of patient QOL, pain and side effects of treatments is an important issue that can work against maintaining a high QOL for the patient. Nevertheless, there are significant physical aspects to QOL that nurses can help with. All these issues lead to the patient having strong confidence in their nurse. Kvale and Bondevik (2010) conducted a qualitative study of patients’ perceptions of the expertise of their nurses on the oncology ward in a Norse hospital. Patients in this study wanted to believe their nurses had both knowledge of their cancer and its treatment , while also having a human, caring approach to their care (Kvale & Bondevik, 2010). Furthermore, patients asserted that such belief in their nurses’ expertise provided feelings of safety and security while providing the information needed to reassure the patients, and that it resulted in an easier time during chemotherapy sessions and even eases the side effects of the treatment and of the disease (Kvale & Bondevik, 2010).
Beaumont and Leadbeater (2011) also noted that providing patients with appropriate pain relief was also critical to providing a good QOL for the patient. In considering treatment issues for various types of metastatic breast cancer (i.e., where the cancer has spread to lungs, bones, liver, or brain), a crucial aspect of nursing care was to address the patient’s pain in an appropriate way and to be sensitive to the levels of pain the patient is experiencing (Beaumont & Leadbeater, 2011).
Pain is not the only symptom that can overwhelm patients. Several forms of cancer can generate cancer-related fatigue (CRF) (Wanchai, Armer & Stewart, 2011). Addressing this problem pharmacologically is often insufficient to manage CRF effectively (Wanchai et al., 2011). Thus, it may be appropriate to consider the use of alternative or complementary interventions to assist with that problem..\ (Wanchai et al., 2011).
While psychological and physical factors are important in maintaining patient QOL, another set of factors are the social ones. Serious long-term diseases like cancer can wreak havoc on a patient’s social life. One important element that may be severely impacted, either by the disease or by the treatments for the disease, is the patient’s sexuality. Oskay et al. (2011) noted, for example, that cancer causes more sexual dysfunction than other types of chronic disease. This makes it imperative for the nurse to be sensitive to the sexual status of the patient to determine if this is a problem for the patient.
Yet perhaps the most important social factor in the patient’s QOL is the sense of isolation and aloneness that the patient experiences (Duffy, 2012). Duffy (2012) noted that patients with rarer forms of cancer sometimes need to have very aware care from nursing staff. Duffy’s definition of “rarer” cancer is any cancer that is not one of the twenty most common cancers; an alternative definition promoted by the European Union was that a rarer cancer was one with fewer than 6 cases per 100,000 people per year (Duffy, 2012). However, he notes that in the U.K., more than half of all cancer deaths are due to such rarer cancers (Duffy, 2012). Duffy (2012) noted in particular that patients with these less usual forms of cancer may often feel isolated and alone, and pointed out the need for nurses to be aware of the possibility of such feelings. A further cause of isolation among advanced-stage cancer patients derives from the very real possibility that they will die. Providing patients with a person to talk to about their concepts of death and dying can be an important aspect of providing excellent patient care.
As even this brief survey makes clear, cancer is not only a disease of the physical body. With its psychological, emotional, and social impact, cancer can have profound impacts on the patient’s QOL. In the next section, specific interventions and implications for a nursing clinical practice are provided.

Implications for Nursing Practice
If maintaining the patient’s QOL is important, and if cancer can impact all the above factors of QOL, there must be evidence-based guidance on appropriate practices to improve patient QOL This section reviews the implications for clinical practice of this issue and suggests specific interventions that may be helpful at addressing some of the ways in which cancer can impact a patient’s QOL.
One result of a cancer diagnosis is that the process of receiving treatment for the cancer is very challenging, with care that is often fragmented across multiple healthcare groups, and often uncoordinated across those different practices and organizations (Case, 2011). The treatment is often complex and challenging to organize and follow. Case (2011) described the concept of a nurse navigator who, in essence , implements functions such as community outreach, education, and scheduling diagnosis and treatment protocols. This approach is very new, with the National Cancer Institute (NCI) only beginning to train nurse navigators in 2005 (Case, 2011). Nurse navigators have been shown to provide significant assistance to patients with cancer as they attempted to deal with complex decision-making and difficult, often confusing, treatment facilities and third-party payers (Case, 2011) This approach not only eases the patient through the diagnosis/treatment process, but also reassures the patient that there is someone with them so they are not so alone.
A patient with a serious, possibly life-threatening disease such as cancer are highly affected by their nurses’ assessments of their physical and emotional conditions. Martensson, Carlsson and Lampic (2010) investigated the relationship between mismatches of nurse and patient perceptions of their symptoms and the patients’ perceptions of the quality of care they received. Specifically, Martensson et al. (2010) addressed four research questions: do patients and nurses disagree on the patient’s condition (physical and emotional); how do patients rate their quality of care; how do patients describe the care they received; and does anxiety or depression impact the patient’s satisfaction with their care (Martensson et al., 2010). Patients whose nurses provided similar assessments of physical and emotional condition expressed high levels of satisfaction with their care. However, when the nurse significantly underestimated the patient’s depressive symptoms, the patient rated their quality of care lower (Martensson et al., 2010). Generally, all patients rated their quality of care as being quite high, however (Martensson et al., 2010).. Finally, patients with higher levels of anxiety and depression on arrival generally rated their quality of care as significantly lower (Martensson et al., 2010). These results imply that nurses should be particularly sensitive to assess the patient’s condition with the same level of seriousness as the patient does and not to downplay the degree of pain or the degree of depressive symptoms; both approaches result in lower patient satisfaction with their quality of care (Martensson et al., 2010).
As noted earlier, cancer patients are often also troubled by extreme fatigue, caused either by the cancer or by the treatment protocols they undergo in an attempt to heal their disease (Wanchai , Armer, & Stewart, 2011). Addressing this problem pharmacologically is often insufficient to manage CRF effectively (Wanchai et al., 2011). Therefore, Wanchai et al. (2011) reviewed non-pharmacological interventions to assist patients with this problem. The authors concluded that any of a number of interventions were potentially helpful with CRF, including exercise, counseling, sleep therapy, and other complementary therapies (Wanchai, Armer & Stewart, 2011). However, in doing the review, the authors noted that the supporting studies used to justify these conclusions tended to be small in scale and of fairly poor quality, causing the authors to suggest the need for more research. (Wanchai, Armer & Stewart, 2011).
In considering the psychological and social issues, communications between nurse and patient is an extremely important aspect of producing satisfactory patient care (Stajduhar et al., 2010). Stajduhar et al. (2010) did a qualitative analysis to determine what characteristics of communications from healthcare professionals were most valued by cancer patients. By doing a secondary analysis of a large-scale qualitative study, the authors discovered that there were four key elements of effective communications with cancer patients: respecting how important time is to the patient; exhibiting caring; acknowledging the patient’s fears; and being sure to balance hope and honesty (Stajduhar et al., 2010). This paper is highly appropriate for the thesis statement. It provides evidence of the importance of understanding the emotional context from which cancer patients operate.
. Verbal communication is not the only psychological issue that may trouble cancer patients. Since sexuality is of great importance to most people’s quality of life, and since both gynecological cancers and their various treatments (i.e., surgery, chemotherapy, radiation, etc.) frequently negatively impact sexuality, this review study was useful for helping identify appropriate methods for addressing these issues with patients (Oskay et al., 2011). The authors reviewed a number of methods for assessing the patient’s sexuality, noting that an individual’s sexuality affects virtually all aspects of a person, including intellectual, emotional, and social aspects, as well as enhancing personality, communications, and social bonds (Oskay et al., 2011). There are several standard methods that can help in assessing sexuality, and a number of interventions that can be tried as appropriate , based on scientific studies and also some based on complementary or alternative sources (Oskay et al., 2011). In the latter realm are such interventions as using an Eros-Clitoral tool to increase genital blood flow; using herbal preparations (yohimbine and L-arginine combination of herbs), vaginal lubricants, and applying vaginal jellies prior to intercourse (Oskay et al., 2011).

Conclusion
The above interventions provide only a sampling of potential ways nurses can intervene to improve overall patient QOL. The evidence presented in this paper provides support for the importance of nurses addressing the patient’s QOL. Improved QOL translates in a fairly straightforward fashion to improved patient perception of the quality of care they received Perhaps one of the bellwether studies that most directly addressed this specific point was the paper by Martensson et al. (2010), which noted that when nurses assessed a higher level of depression than the patient did, it did not affect the patient’s perception of the quality of care they received. It is possible that the reason for these results may be that when nurses underestimate the emotional needs of the patients, they do not receive the support and care required for them to thrive (Martensson et al., 2010). Earlier studies, such as that by Walker et al. (2003), have produced similar findings, including finding that when nurses provide attention to emotional needs of cancer patients is a predictive factor for patients’ perception of quality of care (Martensson et al., 2010).
Thus issues such as improving communication to patients, paying attention to their degree of pain or chronic fatigue, increasing emotional sensitivity, and addressing the patient’s sense of isolation are all strategies that should pay off by improving overall perceived patient quality of care, and thus, in turn, improve the patient’s QOL.
The evidence presented here thus supports the idea that the optimal quality of care results from paying close attention to improving the patient’s overall QOL. Nurses who have an empathetic, caring touch are both reassuring to patients and calming to them; they may also provide a certain amount of pain relief. Addressing a complex condition such as cancer requires the nurse to consider the patient holistically, to take into account the social, financial, and physical issues in their patients’ lives. Evidence indicates that following such an approach to patient care may well result in greater success in treatment and more effective and responsive health care.

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