Evolution of Oncology and Palliative Nursing in Meeting the Changing Landscape of Cancer Care.

Nursing is a vital health profession. In almost all clinical and hospital settings, nurses offer primary palliative care. Nurses are recognized for their strong philosophy of care for a wide spectrum of disorders. No matter the sickness, condition, or clinical situation, palliative care is considered essential in nursing practice. Palliative care nursing is the provision of palliative care services to cancer patients and their families, regardless of whether cancer can be cured or not. A large body of evidence shows that early palliative care nursing integration improves the quality of life and survival of cancer patients. Due to the intricacy of cancer, the landscape of cancer care is shifting. Cancer is a life-threatening disease with a high mortality rate. Oncology nurses' skills and experience are vital in providing specialized patient care and fulfilling the needs of patients and their families. The current study examines the shifting environment of palliative care nursing in oncology. However, new palliative care nursing approaches are required to adapt to the evolving cancer scenario.

1. Introduction

An illness always needs proper caring along with the treatment course to improve patient's life quality throughout the period of illness [1]. The centred care provided by the family members and caregivers of the patient to relieve stress, anxiety, and ease the signs and symptoms, while suffering from a life-threatening illness is called palliative care [2, 3]. Palliative care is a measurable and most important factor to bring ease in life and pleasure before the end of life in patient's life suffering from severe illness. The major modules of palliative care are physical, spiritual, social, psychological, and proper guidance to family members for making the right decisions about patient's illness [4].

The provision of palliative care together with therapy of the disease is crucial from the diagnosis to the life-threatening conditions. Nurse is an ideal role model, who provides palliative care to the patient, reducing emotional and psychological burden of the patient and the family members of the patient. Comprehensive palliative care recognizes the end of life as natural death and delivers sociological care to reduce the patient and family discomfort. Cancer is one of the most lethal types of diseases, causing a majority of deaths worldwide and putting severe discomfort inpatients' lives and family members. It is characterized by the irregular and rapid growth of immature cells that occur in different types of cells and tissues, and such cells are circulated in the blood and spread to other distant sites and organs, thereby causing metastases. Cancer is a chronic disease that has the highest mortality rate, and its treatment is long and troublesome for patients, family, caregivers, doctors, and other healthcare professionals. However, current treatment technology is providing the best therapeutic resources, but still palliative care benefits are crucial and significant for patients and their family members [4]. Among the cancer population, profound demographic shifts are contributing to an increasingly elderly and diverse cancer population. The number of people suffering from cancer at age of 65 and older is expected to be double from 48 million to 85 million in 2050 [5, 6].

The increasing cancer population will face multiple changes regarding the treatment course and high-paid cost for the treatment, as well as exceedingly high-level discomfort, anxiety, and psychosocial issues [7]. All these issues are concerned with proper cancer care, which has also high-cost share along with this course [8]. Such a high expense may increase the burden of cancer care and treatment that may be beyond the affordable range for patients and family members. The patients may feel a severe economic burden, which may lead to emotional and spiritual discomfort [9, 10]. The cancer patients often acquire multiple chronic conditions, requiring extensive and expensive palliative care services [11, 12]. So, this poses challenges because cancer acquires multiple chronic conditions that need long and intensive care to increase the average survival and improve patient's life quality [13].

In high-quality caring of cancer patients, family caregivers have also a crucial role [14]. In general, for cancer patients' longer survival, their family caregivers like relatives, friends, and neighbours provide quality care without being paid for these services. These caregivers are responsible managers during cancer treatment, as they manage side effects from both cancer and treatment, even having no professional experiences. At the same time, they offer extraordinary emotional spirit to the cancer patient [15, 16]. Research studies declared that caregivers often experience a huge burden while caring for the cancer patients [17]. Nurses are the prime heathcare professionals, who offer bedside care to cancer patients and can effectively engage the family caregivers in caring for the cancer patients. Nursing practice is very significant in the establishment of the relationship between patients, family, and caregivers. The palliative care nursing is the philosophical and comprehensive care, which is deeply expressed in palliative care policy, research, and practice [18]. Palliative care offered by nurses to the cancer patients is considered a hope of change in lives of cancer patients since last decade [19]. Palliative care nursing is the mainstream healthcare service for cancer patients, which assures that how, when, where, and to whom the palliative care should be provided [20, 21].

The main therapeutic model proposed by healthcare professional is the treatment or surgical removal of pathology, which resulted in manifestation, and dominating strategy for individual's health recovery [22]. The emergence of the palliative care nursing in this strategy may lead to help the faster recovery of individual's health by approaching patient's care in the sense of health, psychological issues, emotional, and spiritual aspects of patient and family. So, the cancer patients not only need treatment and management but also need palliative care nursing, and the need of palliative care nursing is also crucial and can be an emerging factor to improve life quality of the individuals with a life-limiting illness like terminal cancer [23, 24]. Furthermore, the increase in deaths of aged population due to cancer even with the availability of improved treatment options is another challenging issue for palliative care nursing for the provision of care [25, 26]. However, malignant illness always has a lot of expenditure and the provision of palliative care nursing can expand the cost [27], but still the palliative care nursing has crucial role in the improvement of life quality of cancer patients and has the emerging landscape in oncology. Additionally, the investigation revealed that the introduction of palliative care has valuable improvement in the early phase of illness when disease diagnosis is confirmed, rather than in those patients who receive standard treatment and care at the late phase of the disease or illness [28]. The practice of palliative care becomes more broadened with the advancement in all aspects and leads to a disconnection between policy and practice [29] and confusion about the provision of palliative care.

We searched PubMed and Web of sciences using the terms “Palliative care,” “Nursing,” “oncology,” and “Cancer care.” We included only English literature and excluded abstract and conferences papers. The current work describes the changing landscape and concept of palliative care nursing for cancer patients with increased mortality and morbidity. This work can be useful for the reader to understand the role of palliative care nursing while treating and caring for the cancer patients, where palliative care nursing can play a surprising role to improve the patient's life quality and provide an ease to the family members and caregivers.

2. Palliative Care and Cancer

Conferring to World Health Organization (WHO), palliative care can be described as “the overall needs for care services to the patients where patient's treatment is of prime importance together with emotional, mental, and physical care,” where the primary goal is to achieve ease of life for patients and family members resulting in improved quality of life for the individuals suffering from life-terminating diseases like cancer [30]. However, the actual purpose and sense of the palliative care is still debatable and known with little evidences. Palliative care is thought to be an indicator of the patient quality of care and improvements in life quality [31]. Previously, without the provision of palliative care the death or disease complications were thought to be the biological indicators. Currently, due to the discovery of health monitoring apparatuses, the significance of palliative care can be reflected as the quality of care can be monitored with such instruments. In this way, the importance and outcomes of palliative care can be explored. Palliative care nursing in oncology is the integration of cancer-directed care along with the whole course of the disease condition, regardless of cancer stages, therapeutic options (chemotherapy, radiotherapy, or surgery), and other clinical complications [31, 32].

Palliative care nursing plays a unique and very important role in the provision of palliative care to cancer patients, which realize complete potential of treatment to patients and their families whether it can be treated or not. Palliative care nursing provided to cancer patients can specifically address the issues like symptomatic control, psychological and social care, ease of communication for patient, ease in making serious decisions, and care at the terminal stage of cancer. The United Kingdom had been declared palliative care, a significant component of cancer care and treatment [32-34]. A huge content of records justifies that the integration of early palliative care nursing results in the improvement of life quality and improved survival of cancer patients [35-37]. The palliative care improves the outcomes of caregivers and helps in reducing the adverse sides of chemotherapeutics at the terminal stage of cancer [36, 38–41]. In the light of these outcomes, palliative care nursing models have been developed and applied in a large number of cancer hospitals and oncology care centres around the globe [42, 43], but even though with huge benefits and paramount understanding only a small number of cancer patients are integrated for palliative care and those are often suffering from the late stage of cancer [44]. The lack of feasible palliative care services and care models is a great challenge for both inpatients and outpatients [44]. Deep and comprehensive institutional efforts are required for the multidimensional cancer care and specialized palliative care services.

Previously, an investigational survey made in the United States had been revealed that twelve percent of the total cancer care centres had no palliative care programs, twenty-seven percent of the centres had no physician specialist for the palliative care services, twenty-six percent of the total did not have palliative care taskforce (nurses and physicians) for the inpatients, and seventy-seven percent among them did not have specified beds and units for palliative care [44]. And thirty percent of the centres in this survey possessed combined clinics for oncology and palliative care, where the nature and direction of the setting were unknown [44]. There was unpredictable palliative cancer care in most of the settings, where the implementation of beneficial interventions was in-applicable and standards were not meeting the minimum criterion to recognize the benefits. The limited resources and high-cost burden in almost all institutions were the main reasons that could not display palliative care services in oncology units, where proper management of the palliative care and oncology was surprisingly needed [44].

These investigations prove that in the United States, there are huge deficiencies in specialized palliative care nursing staff for oncology clinics, and there are deficiencies of regulatory authorities to promote palliative care services for cancer patients, and workforce for palliative care services is required to meet the needs of patient's care. Proper legislation is strongly demanded around the globe for the promotion of palliative care nursing in oncology hospitals and institutes. However, several countries have been incorporated palliative care into the common cancer treatment regimen, while the United States has been also taken serious decisions about integrating the palliative care services as a compulsory part of comprehensive cancer treatments [45, 46]. The American Society of Clinical Oncology (ASCO) has detailed that eminence cancer care “requires access to and the availability of state-of-the-art palliative cancer care rendered by skilled clinicians, buttressed when necessary by palliative care experts” [47]. Realizing this prophecy will need the expansion of a service model that is cost-effective and freely reachable to patients in a range of care settings.

The needs of palliative care nursing are increased day by day worldwide, with the increasing population diagnosed with cancer and its complexity [48, 49]. The demanding palliative care needs suggest comprehensive models for palliative care nursing especially for cancer patients [50]. Nurses are the one who can resolve the palliative care issue for cancer patients in more smooth and reliable way. At present, there are no cancer palliative care-related courses in nursing education (both undergraduate and graduate). In the light of this context, special contents about palliative care should be integrated into the oncology centres and nursing education programmes, which can play mighty role in cancer treatment [51]. However, the nurses practising in other departments rather than oncology may lack expertise of caring cancer patients [52].

Therefore, nurses practising in other departments may need special education and training for palliative care nursing to work in oncology wards and departments. It is an unmet and empirical need to develop strategies and agendas for palliative care nursing to cover the demanding and complex needs of cancer patients, where the nurses should be educated (college, undergraduate, and graduate levels) regarding the intake of oral targeted oncodrugs, caring and advocating of patients, and their family members [53, 54]. As the national organization for oncology nurses, in 2001 CANO/ACIO developed Standards of Care focused on patients. Subsequently, in 2006, CANO/ACIO developed Practice Standards and Competencies for the Specialized Oncology Nurse. The emphasis of these standards and competencies was primarily on specialized oncology nursing practice [54]. Professional nurses have been recognized the gaps while educating nurses for palliative care nursing in oncology departments, so smooth and clear framework for palliative care nursing can be implemented in hospitals. The developed framework provides guidance to nurses working in all practice settings assuring the provision of high-quality services and care to patients living with cancer and those at the stage of end of life. The well-trained nursing community can indeed reduce the burden of cancer globally [53, 54].

There is an empirical need of cancer knowledge for the nurses who are caring for the cancer patients and dealing with their families. Due to huge increase in the number of patients suffering from cancer, a number of patients are considered as outpatients; therefore, nurses may the patients and families regardless of the setting in inpatients or outpatients.

3. Palliative Nursing in Changing Landscape of Cancer Care

The landscape of cancer care is changing and becoming more complex due to the complexity of cancer. In fact, cancer is a life-threatening disease and has a high rate of end-of-life conditions. Nevertheless, inpatients have increased emergence in the cancer hospitals for surgery, diagnosis, chemotherapy, symptomatic treatment, and palliative care, so the landscape of cancer care changed with the changing dimensions of cancer treatment and care towards outpatients [54]. The knowledge and experience of the oncology nurses play important roles in specialized patient care and meeting the care services of patient's care and their families. The Canadian Cancer Society's Advisory Committee on Cancer Statistics (2015) approximations demonstrated that nearly half of whole Canadian populations will develop cancer in their lifetime and approximately 25% of that will die of the disease.

The rapid increase in the cancer patients over last few decades is because of the increasing population, aging, and advancement in the diagnostic procedures. This rapid increase is expected to be continued and may become double in the future decade [53, 54]. With the increasing cancer ratio, palliative care nursing in oncology will also face challenges and need special attentions of the concern departments and policymakers. Nurses in oncology unit secure both physical and mental care of inpatients [55]. Care attitudes necessitate addressing the physical, psychological, social, and spiritual healthcare essentials of cancer patients and their families.

Moreover, the direction of palliative care nursing can be demonstrated as “reducing the pain of cancer and care provision to improve the life quality of the patients, and support for the best possible ways to increase the patient's survival…” [56]. The nurses working in oncology departments can recognize various factors such as systematic therapeutics plans, care services plan, patient's needs, complexity of the illness, contact with patients and family members, emotional attachment with patients who are in the terminal phase of cancer, and facing end-of-life stress [57, 58]. However, there is an inadequate investigation of the experiences of oncology nurses. One example, a hermeneutic study was carried out to describe the experience of oncology nurses caring for dying patients [59]. In-depth interviews were conducted with six oncology nurses who had at least five years of oncology nursing experience and had cared for dying patients. Four themes were described as follows: (1) “knowing the patient,” (2) “preserving hope,” (3) “easing the struggle,” and (4) “providing for privacy.” The investigators determined that nurses accomplished the emotional demands of their work by establishing varying degrees of closeness with patients as they were dying. The nurses described developing close bonds with some patients and, despite not developing these relationships with all patients, they felt they provided good care for those who were dying.

4. Palliative Care Nursing Models in Oncology

There are various palliative care nursing models developed for the care provision to cancer patients and still continued to be developed for the large cancer population including paediatrics, geriatrics, and adult cancer patients. These various models differ in planning, organizing, and focus. However, all of them rely on oncology nurse, and in all models, oncology nurse is the key provider of palliative care to the patients and their families [60-62]. All the models are explained in Figure 1 concisely with their imperative focus.

Figure 1

Various palliative care nursing models for cancer patients [63].

Although having direct contact with cancer patients and with the presence of a number of palliative care programs, there is an urgent and unmet need of educational and training programs for oncology nurses to provide quality palliative care to the patients suffering with life-threatening cancer diseases. Different types of palliative care nursing are listed and explained below.

4.1. Paediatric Long-Term Follow-Up Models

These programmes comprise “late effects clinics” inside children's clinics or hospitals. It was developed for the paediatric cancer patients and was an initiation towards adult's oncology models [64, 65]. The continuous follow-up is recommended in this model to expand the understanding of cancer effects; otherwise, it may develop second cancers. These clinical programmes are not disease-specific and often need multidisciplinary oncology nurse for palliative care servicer.

4.2. Adult Follow-Up Clinic Models

In various adult clinical models, oncology nurse is a key provider of the care services. They may work together with other healthcare teams and may work independently. In this context, the care services need of patients and family members or fulfilled in either national hearth institutes or private clinical settings.

4.3. Disease-Specific Model

Initially, when clinical models were started to develop, clinical programmes were established for the early diagnosis and the provision of care services before treatment of the breast cancer. The oncology nurse not only has the responsibility of palliative care provision but also needs to identify early problems and symptoms. This model is costly enough and may increase the total burden on the family members [66].

4.4. General Survivorship Clinic Model

It is noteworthy that the palliative care nursing cannot be implied in disease-specific clinical settings in most of the cases. Instead, palliative care can be provided in generalized clinical or institutional settings. Such programmes may be staffed by oncology nurse in collaboration with oncologist. In such settings, particular treatment plan is designed by oncologist, oncology nurse, and other healthcare team members. Further care services are provided upon investigation and family member recommendations [67, 68].

4.5. Consultative Clinic Model

In these types of models, patients together with the family members only visit the clinic or hospital once. Comprehensive check-up is proceeded with the continuation of the ongoing palliative care. In such programmes, oncology nurse prepared detailed treatment plan and care summary for the patient and family members. The oncology nurse discusses the improvements in health with the patients and also aware them about the prevention of cancer by quitting bad habits such as smoking, diet, and use of alcohol. Oncology nurses also compel them to exercise and healthy habits. This type of programmes is very simple and cost-effective and can be widely applied [67, 69].

4.6. The Multidisciplinary Clinic Model

It was the earliest applied models and was used in paediatric clinics and oncology units. Although this is a significant model from theoretical point of view, it is not practical in the cancer institutes and hospitals because it extremely challenging to provide multidisciplinary care service to the patients at the same place in the same clinics. With changing landscape of oncology, it becomes more difficult to provide care services to patients and apply these models.

4.7. The Integrated Care Model

The increasing complexity of cancer and its changing landscape are noteworthy to identify the type of best palliative care model for cancer patients to improve care services and save the workload. In this model, the formal visits of oncology nurse and oncology team are made. The patients in this model are in the supervision of oncology nurse receiving care and treatment at the same place. In this model, oncology nurse provides palliative care services even when the treatment ends and patient is on maintenance therapy. In this model, routine follow-up is made by oncology nurses and family members are given with proper information and understanding about the disease condition and care service [67, 69].

5. Transition to Primary Care

The care needs of cancer patients are challenging for family members, where oncology nurse plays a key role in care provision, as well as making positive contact with the family members of the patients. The patients not only need care services in the cancer institutes but also need care services after the termination of treatment. So, the primary care providers in homes (family members and caregivers) must be educated with proper information about care and symptoms. In such situation, oncology nurse together with oncology team or in collaboration with oncology team can give guidelines about the primary care and disease symptoms. Hence, strong communication between oncology nurse, patients, family member, and primary care provider is always demanded [70, 71].

6. Conclusion and Future Perspective

The current study emphasizes the wide role of oncology nurses in palliative care, which encircles the key and major contribution of nurses. In oncology hospitals and clinics, the philosophy of palliative care has a major conflict with nursing practice. The palliative care nursing can be understandable when experienced it in specific illness and nursing theory comprehensively supports it. Nurses are well trained and aware of the pathophysiology and required skills to evaluate the patients' needs of care in all domains of life, giving hope of life to the patients suffering from life-threatening illness like cancer. However, it should be comprehended that with the changing landscape of cancer, palliative care nursing is facing many challenges and needs special attention to fulfil the care needs of the patients in oncology units and clinics. Nurses secure central position in providing palliative care to the patients and their family members. The direct contact with patients, family members, and caregivers makes them able to provide mental, social, emotional and physical care, and support. As with changing landscape of oncology, the needs of cancer patients are changing; therefore, nurses need to adopt with the changing healthcare needs of the patients and their families. The development of more unique palliative care nursing models is needed to cope with the changing landscape of cancer.