Biopsychosocial Assignment
Most people pay very little attention to their health until it lets them down and they find themselves in hospital. It was relevant that a high number of patients that were admitted appeared to be very discouraged and had quite a negative perception towards their illness. During a recent clinical placement I met a patient called Kath who had been living with a chronic illness, Multiple Sclerosis for a vast amount of years. When Kath found herself admitted into hospital with an unrelated condition to that of her multiple sclerosis, her attitude and responses were very different to those of the other patients on the ward. To Kath her health and well being meant living independently and managing her existing condition. Kath also felt that her health and well being included participating in social activities and being there to support her daughters and grandchildren. Kath had an extremely positive reaction to her newly diagnosed condition and did not perceive it as an ‘illness’ more so just another hurdle to overcome.
I will be looking at a bio-psychosocial model to use within this assignment as a holistic perspective in relation to my patient. It is my intention to use the model to critically evaluate the bio psychosocial factors in relation to my chosen patient. It remains important to recognise that both the psychological factors and social factors are addressed as they are just as important as the biological factors in determining the outcome of the patient.
Consent of the patient has been gained prior to this assignment being written. A consent form has been signed and included with this assignment. For the purpose of this assignment I shall name my patient Kath in order to remain within the confidentiality clause of the Nursing and Midwifery Council (NMC) (2008). The area of practice shall also remain undisclosed.
Kath is a 64 year old lady who has been widowed for 6 years following the loss of her husband, Kath also has 4 daughters. Kath was already living with a chronic illness, secondary progressive multiple sclerosis, with which she had been diagnosed with at the age of 18. Shering (2000) states that “secondary progressive multiple sclerosis being that of MS diagnosed in a young adult in which the severity and frequency of the relapses decreases yet disability slowly increases". Kath admitted that her general health had slowly deteriorated over the years and her mobility had been affected, and she was now confined to a wheelchair. Despite this Kath was determined to continue her life as normal. Kath continued to live alone and lived independently with the ability to continue to look after herself with very little assistance. Her family remained extremely supportive and continued to aid Kath with anything she may need assistance with. Kath mentioned that it was very important to her that she continued to take pride in her appearance. Her relationship with her family was that of a very strong unit and Kath often expressed the closeness she has with her daughters. Kath also spoke about the very active social life she led and was a bit concerned that this hospital admission would interfere with it, this just made Kath all the more determined to sustain a positive attitude towards a swift recovery.
The World Health Organisation (WHO, 1946) defined health “as a state of complete physical, mental and social – well being, and not merely the absence of disease and infirmity” (Cowley) (2002, p.45). According to this definition it would deem that Kath had not been healthy since her diagnosis of multiple sclerosis at the age of 18. However, Kath’s perception of health was unlike this described definition. Therefore proving that each individual does not have the same perception of idealistic health, each person has their own definition of health and what makes them feel ‘healthy’.
This definition has been heavily criticised by Dubos (1979) who intimated that the definition eliminates a numerous amount of people from achieving this exclusive state of health perfection. Dubos (1979) further insists that health and disease cannot be defined solely in terms of anatomical, physiological or mental elements. This definition was also criticised by Seedhouse (1986) who stated that this definition did not take into consideration the social, psychological, spiritual and environmental factors, which are highly significant to each individual’s notions of health. Pike and Foster (1995) further support the opinions expressed by both Dubos (1979) and Seedhouse (1986) by sharing the same opinion with their criticism and further draws attention to the importance of realising that people have their own individual notions of health. Cowley (2002) supports this theory and further argues that it is perplexing to identify the significance of what the notion of health is to any one individual, as we all have different perceptions of what health should be to us.
Although Kath was living with a chronic illness which to others may have appeared to be unhealthy, Kath’s perception of herself and her health was that of being extremely healthy. Kath often concluded that although she was living with a chronic illness this did not deem her unhealthy. Kath felt healthy as she was able to continue to live independently at home and participate in social activities with her friends and family. To Kath her health was not diminished by being disabled through multiple sclerosis as some may have imagined it to be.
Despite Kath’s health problems it was highly important to Kath to maintain her idealistic state of health. Kath was a non-smoker and only consumed alcohol socially at major events. Kath attended multiple sclerosis clinics twice annually unless an unforeseen problem may have occurred, which Kath mentioned rarely happened. Kath felt it to be important that she kept fit and active as she knew the risks of becoming overweight and had therefore learnt exercises that she was able to do despite her lack of mobility.
In particular Kath was aware that she had an increased risk of developing breast cancer. Kath explained that she had a large family history of breast cancer and she felt her chances of getting the disease was much higher as cancer was not only concurrent in her mother’s side of the family but that of her father’s as well. Kath mentioned that there were genetic links for the disease being inherited. Kath made it clear that the feelings she had were more of relief as opposed to dread and worry. It was something that she said she had just been waiting for to come into her life.
Cancer is a term used for diseases in which abnormal cells divide without control and have the ability to invade other tissues, via the blood and lymph systems. Cancer is not just one disease but many diseases. There are more than 100 different types of cancer. Most cancers are named for the organ or type of cell in which they start (National Cancer Institute, 2008).
Cancer progresses by enlarging and spreading to different sites within the body. Its growth at each site interferes with normal development and functioning. Tortora et al (2003) wrote that cancer is an irregularity in the normal pattern of tissue growth. These irregularities cause unrestricted cell growth, usually forming a tumour called a neoplasm. Although a dated piece of research. Souhami et al. (1995) similarly described that a common characteristic of cancer cells is their uncontrolled division (mitosis) which produces an expanding mass of disorganised cells known as a tumour. Tortora et al (2003) continued to define that cancer is a disease of the cells characterised by uncontrolled cell proliferation that usually forms a malignant neoplasm. There are many forms of cancer, and the large majority can be classified into five types based on the kind of tissue in which it develops. The American Medical Association (AMA) (2003) described further that an important characteristic cancer cells is that they do not adhere to each other as strongly as normal cells do.
Morgan (2001) defined that “cancer is a Latin term meaning crab, a word that aptly describes the appearance of a malignant tumour which is irregular in outline and uncontained. Crabs move in a seemingly erratic manner, sideways, often with sudden bursts of movement: cancer appears to grow in a similar way”.
The reported incidence of breast cancer has increased over the past 30 years. This is probably the result of better statistical reporting, better screening methods, increased life expectancy and increased exposure to carcinogens, changes in lifestyle and decreasing mortality rates, which reflects the benefits of early detection, screening and improvements in treatment (Chapman et al. 2000).
Breast cancer is one of the most common cancers in the UK with more than 44,000 people diagnosed each year (Cancer Research UK (CRUK) 2008). With one million new cases in the world each year, breast cancer is the most common malignancy in women and accounts for 18 per cent of all female cancers (McPherson et al 2000). McPherson et al (2000) also suggested that it has been recognised that age remains the greatest risk factor, with most breast cancers occurring in the post-menopausal age group.
It is important to identify which risk factors greatly contributed to Kath’s increased chances of developing breast cancer. Chapman et al. (2000) found that family history plays a significant part in breast cancer development. Between 5 and 10 per cent of breast cancers in Western countries are attributable to genetic predisposition. BRCA 1 & BRCA 2 are human genes that belong to a class of genes known as tumour suppressors mutation of these genes have been linked to hereditary breast cancer. The risk of developing breast cancer is greatly increased if a woman inherits a deleterious BRCA 1 or BRCA 2 mutation. It is estimated that 60% of women who have inherited the BRCA 1 or BRCA 2 mutation will develop breast cancer as opposed to 12% of women who have not inherited the mutation, National Cancer Institute (2009). In normal cells, these genes help prevent cancer by making proteins that help keep the cells from growing abnormally. If you have inherited a mutated copy of either gene from a parent, you have a high risk of developing breast cancer during your lifetime. The risk may be as high as 80% for members of some families with BRCA mutations, American Cancer Society (2009).
Kath was aware of the significance of family history and as she had 4 daughters herself, as well as granddaughters, knew that this would be beneficial not only for her own health but in the event of detecting something while being screened, this would enable her to educate her daughters into being more breast aware themselves.
Age is also recognised as a primary contributing risk factor studies showed that 85% of breast cancer cases had occurred in women over the age of 50 and older Fletcher (2008). Mcpherson et al (2000) also found that women were at greater risk if they were at a post-menopausal age. It is also found that gender is another primary contributing factor to developing breast cancer. Women are more likely to develop breast cancer then men as women have more estrogens and progesterone in their body then that of a man. These hormones stimulate breast cell growth both normal and abnormal, Breastcancer.org (2008). Kath was aware of all the risk factors and was very self aware of the amount of categories she fell into. Breast screening has become more widely used in the UK, with the service being used by an ever increasing number of women. The increase in the reported incidence of the disease may be the result of increased detection through the NHS screening programme, (McPherson et al 2006). Although there is an increase in the incidences of the disease it is proven that the detection of screening is saving more lives. Gøtzsche et al. (2006) reported a 15% risk reduction in mortality in individuals who attended a mammographic screening programme. Another study also proves this by suggesting that the UK breast screening programme is estimated to save 1,400 lives each year (Advisory Committee on Breast Cancer Screening 2006). Another study also showed that a case-control study from East Anglia demonstrated a 48% reduction in breast cancer mortality rates in women who attended the breast screening programme (Allgood et al 2008).
It has become more evident that the majority of women are referred to the NHS via their GP by themselves being breast aware. GPs are usually the first point of contact for individuals with concerns regarding changes in their breasts. Guidelines produced by the National Institute for Clinical Excellence (NICE) (2005) assists the GP to make accurate referrals. (National Institute for Clinical Excellence) (NICE) (2002) also recorded that the majority of women who attended breast clinics for investigation of suspected breast cancer are referred by their General Practitioner. These women are symptomatic, they have themselves discovered the lump or have other symptoms and have been concerned enough to seek the opinion and advice of their General Practitioner.
Bailey (2000) continues to emphasise that the advantages of breast self-examination is that it is a simple, cost-free, non-invasive technique that has a good chance of discovering changes in breast tissue.
Kath had remained active within the breast cancer screening programme, which had always had negative results for her. Kath had a high level of family history of breast cancer which she referred to many times. Kath felt that this was one of the key points that encouraged her to use this service. (National Institute for Clinical Excellence) (NICE) (2002) also noted that a small minority of women are referred to breast clinics from the National Health Service (NHS) Breast Screening Programme.
It has become evident that women in the community are not breast aware. Although more women consult earlier with breast cancer than with other cancers, there is evidence that women in general are still not breast aware (Bailey 2000). Austoker (2003) stressed that the importance of being breast aware and reporting changes without delay cannot be over-emphasised. It is important that women are breast aware and inform their GP immediately if they identify any abnormality.
Although Kath always had negative results from her breast screening, Kath remained breast aware and regularly checked herself. It was during this intervention that Kath found the lump herself. Kath immediately sought the appropriate medical help that was required, and was therefore sent for the relevant treatment required. Kath felt that her immediate response aided her positive attitude. Kath explained that as she was already living with a chronic illness she had often found herself dealing with situations of her health changing all the time sometimes day by day. Research showed that 35% of a study carried out delayed seeking medical assistance for over 4 weeks for various reasons. Often people thought that the symptom would go away, the symptom was not serious and more commonly they delayed as they were too scared to seek medical help, British Journal of Cancer (1999). Kath felt that she was not scared to seek the help that was required as she knew it would be of benefit for herself.
The diagnosis of cancer fills most people with dread Love (2000) stated that the first thing a woman thinks when diagnosed with breast cancer is, ‘Will I die?’ This is quickly followed by ‘Will I lose my breast?’ However, whilst on a recent clinical placement I came across Kath, a patient whose reaction was quite different to her cancer diagnosis. Throughout the entire process of diagnosis, surgery, chemotherapy and recovery Kath remained positive and continued to be determined to sustain everything that she could to recover.
To most women the diagnosis of breast cancer is completely devastating although this was not the case with Kath. Her reaction to her diagnosis was admirable and exemplary. The diagnosis of breast cancer is often seen as a genuinely bad diagnosis which fills people with dread. It is often thought that when diagnosed with cancer their life is over, there is ‘no light at the end of the tunnel’. The NHS has recognised the pressure waiting has on people “Waiting for treatment of any kind is worrying and it is often painful and debilitating. Waiting for diagnosis and treatment for cancer is also potentially life threatening. The drive to end waiting is central to the Cancer Plan.” (NHS Cancer Plan, September 2000). Although dated the relevance is prevalent that Stanton et al. (1998) recognised that cancer creates unique stressors for patients and their families. These patients have a disease they recognise as a ‘real killer’, and one that can lead to intense pain, disfigurement and disability. It appears from literature that cancer diagnosis is generally a very negative experience. Maguire et al. 2006 wrote that once diagnosed, women face the prospect of potentially disfiguring surgery and ongoing treatment, which may continue for up to five years. Kath explained that as this diagnosis was something that she had been expecting for a great number of years. Kath made it clear that the feelings she had were more of relief as opposed to dread and worry. Kath seemed relieved by her diagnosis of breast cancer due to her high family history of the disease. Kath mentioned that she had just ‘been waiting’ for it to happen and felt a great deal of relief when she found the lump and she felt she could now move forwards. Kath highlighted that the uncertainty of when the cancer was going to emerge and what point in her life had finally been taken away with her diagnosis. Therefore, Kath was extremely eager for treatment to begin.
There are many forms of treatment for breast cancer. I shall concentrate on chemotherapy and mastectomy as this is relevant to that of my chosen patient. The term chemotherapy was used to describe the use of chemicals or drugs to treat microbial and later neoplastic diseases McCoy (2003). It has been acclaimed that chemotherapy has been certified as one of the significant therapeutic modalities, and that chemotherapy has assumed an increasing importance. Cytotoxic drugs are defined as ‘cell killing drugs’ and they act against cancer cells McCoy (2003). Chemotherapy unfortunately does not distinguish the difference between normal and malignant cells. McCoy (2003) further suggests that when the cytotoxic drug is introduced into the body it will not only attack cancerous cells but also normal cells proliferating as part of the normal physiological process repair and replacement.
Kath was given chemotherapy following her mastectomy; this is generally known as adjuvant chemotherapy. The purpose of this was to decrease the possibility of metastatic disease and also to enhance the chances of survival.
Often cancer of the breast is too advanced to have breast conservation. About one third of breast cancers are not suitable for breast conservation and mastectomy is performed (Sainsbury et al 2000). Harmer (2000) further highlighted that most management plans for breast cancer will involve some form of surgery for local control of the disease. If the cancer of the breast requires the removal of a large amount of tissue to completely excise the cancer within good margins then this is when a mastectomy is recommended. Harmer (2003) found that about 30% of all cancers require a mastectomy. The most common mastectomy is the total mastectomy. This refers to the total removal of the breast tissue, including the tail of Spence, which extends into the axillary space (Roses, 1999). It is recommended that mastectomy for invasive breast cancer should always be combined with some axillary node surgery.
Body image is a term which may refer to a person’s perception of their own physical appearance, or the interpretation of the body by the brain. Body image is often a barrier when it comes to patients making decisions about their treatment. As such, the loss of a breast for some women can result in negative consequences to body image and self-concept (Frost et al. 2000). Women undergoing mastectomy might have greater post-operative body image problems than those undergoing breast-conserving surgery (Maguire 2000).
In modern-day society, breasts are often regarded as symbols of beauty and femininity, and part of a woman’s sexuality and role as a mother. For this reason, disease of the breast and its treatment may cause great anxiety, and a woman may fear both for her life and her womanhood (The Royal Marsden 2002). Having a mastectomy often leaves a woman grieving for the loss of her breast. Breast cancer can be viewed as a life-changing event and that patients may need to reconcile alterations in body image following surgery, cope with feelings of being a different person and handle the prospect of potential social isolation. These emotions can lead women to distance themselves from family and friends (Lawton 2000).
White (2000) explores the issue of clinically significant body image problems and summarises that they exist when there is a marked discrepancy between body reality and body ideal. This results in negative emotions and behaviour, and interferes in all aspects of an individual’s life. (Dixon 2000) found that 23 per cent of psychological problems following breast surgery related to body image and sexuality. However Potts (2000) takes a feminist perspective and explains that some patients believe that by opting for prosthetics or reconstruction, they are hiding the problem, perhaps in an attempt to shelter other people from the reality of the disease. For most people it would be their first time having surgery that altered their body and therefore would be the first time that they would have had to think about their body image. However, this was not the case with Kath as she had been living with the effects of a chronic illness on her body for a vast amount of years.
MSSociety (2009) define “Multiple Sclerosis as an inflammatory disease of the Central Nervous System. Predominantly, it is a disease of the "white matter" tissue. The white matter is made up of nerve fibres which are responsible for transmitting communication signals both internally within the Central Nervous System and between the Central Nervous System and the nerves supplying rest of the body. In people affected by Multiple Sclerosis, patches of damage called plaques or lesions appear in seemingly random areas of the Central Nervous System white matter. At the site of a lesion, a nerve insulating material, called myelin, is lost”.
Speech can be widely affected by Multiple Sclerosis. It is known as a term called dysarthria. This is where damage is caused in different parts of the brain which affects the way in which speech is produced. Damage in one part of the brain affects the muscles of the tongue and lips making it difficult to pronounce precise words, Multiple Sclerosis Society (2009). Another common symptom of multiple sclerosis is some form of muscular paralysis. Paralysis is more accurately described as paresis which is a medical term meaning partial or mild muscle weakness. Paresis is common in Multiple Sclerosis sufferers but it is not exact as to what extent the paresis will affect them, McFox’s Multiple Sclerosis Pages (2009). Kath suffered paresis of both her legs, better known as paraparesis.
The body image factors cause many women great distress and depression, although this was not the case with Kath, Kath felt that she had the ability to adapt quickly to her new challenge in life. It was admirable that Kath felt it was a new challenge to overcome as opposed to developing an illness that could potentially be life ending. Kate always put forward that her attitude to illness came from the fact that she had been living with secondary progressive multiple sclerosis for the past 46 years. As the years had progressed Kath had adapted to her ever changing symptoms, which eventually affected her mobility and speech. Kath eventually ended up in a wheelchair. Kath mentioned that it was very important to her that she continued to take pride in her appearance. Kath also felt that given all the other problems she had overcome of the years on a daily basis due to her multiple sclerosis, losing her breast was relatively minor. Kath took a great deal of care in her appearance she wanted to look smart but made sure it was practical for her as well. Kath would wear loose comfortable clothing to enable her to transfer from her wheelchair to her chair/bed with ease. Kath wanted to make sure her clothes were smart but fashion and tight fitting clothes were not essential or practical for her. Kath had taken all this into consideration, and Kath also mentioned that this was something she had adapted to and learnt over the years to ensure her independence was not hindered.
It has been suggested that when a woman is diagnosed with breast cancer she goes through all or some of the 5 stages of grief, denial and shock, anger and rage, stress and depression, grief and fear, acceptance and adjustment. Kath felt that she was immediately at the stage of acceptance and adjustment as Kath had already been through this whole process when initially diagnosed with multiple sclerosis. This was just another issue to adapt to. Kath also briefly mentioned that she felt that as she had been living with secondary progressive multiple sclerosis for 46 years she had learnt to adapt and felt that having lived with this illness for so long this diagnosis had not been as much of a hurdle to overcome. Furthermore Kath felt that as she was continually adapting to live with her existing illness she found that she had felt it had been beneficial to cope with the new adaptation she had just encountered.
Following surgery most women have chemotherapy. Kath had a total mastectomy of her left breast. Following this she then went for adjuvant chemotherapy following a rapid healing of her mastectomy to mop up any cancer cells that may have been left behind post mastectomy.
It remains important to be familiar with the side effects that cancer treatments have on women being treated for breast cancer. These side effects are devastating to the patient and the lack of treatment of them can hinder the patients’ recovery. The most frequently reported symptom of cancer and cancer treatment is fatigue (Nail 2002). This was one of the issues which were one of Kath’s greatest concerns as she was so independent and held a very active social life. It has also been noted that it is one of the most difficult symptoms to manage so it is of high importance that health care professionals dealing with these patients are educated to effectively manage the varied symptoms. A dated piece of research also regards fatigue as being the most challenging symptom to manage (Clark et al. 1998).
The fact that the symptoms of repeated chemotherapy or radiotherapy have ongoing effects has been highlighted as it would be easily thought that symptoms end when the treatment ends. Jacobsen et al. (2003) found that most people who undergo repeated radiation and chemotherapy experience severe and long-lasting fatigue that often gets worse after the treatment ends. It was important to Kath to find information on ways to deal with the fatigue to prevent it from interfering with her everyday life. The expectant nausea that Kath had been made aware of during her chemotherapy was again a worry of Kath’s as she felt that this again would impact on her social life as she would be unable to go out as often as she did prior to her admission. It was important to Kath that this was controlled.
Fatigue is a major debilitating and unpredictable symptom in multiple sclerosis. Fatigue is one of the earliest, most common and troubling symptoms of multiple sclerosis, Multiple Sclerosis (2009). Kath mentioned that she had spent years adapting her days to combat the fatigue she suffered on a regular basis and found that the ways she dealt with it worked effectively. Kath felt that she would be able to adjust and learn new coping strategies to fight the increasing fatigue she would suffer from her cancer treatment.
Alopecia is one of the most distressing and visually noticeable effects of cancer treatment.
For some patients, the fear of treatment induced alopecia is so significant that some women may refuse potentially curative chemotherapy (Pruzinsky 2004).
It is apparent that the prospect of hair loss affects a persons’ body image just as greatly as that of mastectomy. For women, in particular, it is an important indicator of attractiveness, femininity and body image (Rosman 2004). Batchelor (2001) further suggested that it is perhaps not surprising that chemotherapy induced alopecia has traditionally been associated with loss of individuality, unattractiveness and a state of disgrace and illness.
Another aspect of body image that greatly affects a patient is the prospect of hair loss following chemotherapy. Also known as chemotherapy induced alopecia. There are interventions available to try and prevent or minimise hair loss. Scalp cooling is an uncomfortable procedure and there is no guarantee that it will work, so it should be discussed with patients before treatment is commenced (Grevelman et al.2005). Dougherty (2006) further suggested that the prospect of the uncomfortable procedure did not deter some patients. He highlighted that patients are often willing to endure the uncomfortable side effects associated with scalp cooling, such as headaches, nausea or sensations of severe coldness, in an effort to avoid chemotherapy induced alopecia.
Perhaps the most predominant technique is scalp cooling. This method causes vasoconstriction of the blood vessels in the scalp, which reduces the uptake of drugs into hair follicles, thus decreasing the amount of hair loss (Randall and Ream 2005). The cold cap can possibly prevent hair loss but it doesn’t prevent facial and body hair loss. Kath had been informed of this treatment but had decided against it. Kath was very positive about the prospect of her hair loss, and embraced the fact that it would grow back when her treatment had finished. Kath’s positive attitude had a good effect on her family when she mentioned to them that she had decided to refuse the treatment. It appeared that her family was a little shocked at first as they were all aware of how important their mums’ appearance was to her.
Kath had been visited by specialist nurses on the ward following Kath’s rejection of the scalp cooling to give Kath advice on other alternatives for her hair loss. They advised Kath about the availability of wigs for cancer patients. Kath again decided against this option and expressed that at the time she had no body image concerns. Kath further mentioned that she felt that this was again due to her multiple sclerosis giving her, her positive attitude towards her impending body image. Kath felt that as she had had to contend with so many body image issues over a period of time in relation to her multiple sclerosis, eg; her mobility, this new body image issue was just another adaptation.
Evidence suggests that women with breast cancer are more likely than those in the general population to develop anxiety or depression. For the patient receiving a diagnosis of breast cancer it would be valid to think that the diagnosis will have permanent physical and psychological effects on both the patient’s life and that of their family and friends. Kath’s attitude towards her diagnosis was admirable; it appeared to be the opposite of the described anxiety and depression.
Maguire (2000) suggested that as with anxiety depression is another common psychological reaction to a diagnosis of breast cancer. It is known that up to one third of women develop severe anxiety or a depressive illness within a year of diagnosis of breast cancer. Psychological support must therefore be an integral part of the management of the disease. Alongside the physiological effects of cancer treatment there are also psychological aspects which can also contribute to the patients side effects. (Dibble et al 2000) in addition to the physiological effects of chemotherapy that can produce gastric irritation and trigger the emetic centres of the brain, emotional stressors such as anxiety contribute to nausea. This only further demonstrates the necessity to manage all bio-psychosocial aspects of the patients needs.
Sneddon et al (2007) found that healthcare professionals acknowledge the importance of aftercare following breast cancer surgery to reduce potential physical and psychological complications, and patients increasingly express a need for access to timely preventative information. This desire for information is endorsed widely by professionals, who agree that patients should be empowered, and encouraged to be active participants in their care.
It has been recognised that patients being involved with the decision making of their treatment options have a positive effect on their long term well being. The concept of allowing a patient to be involved in decision making of their care is ideal. It allows the patient to be as involved or uninvolved as they want to be. (National Institute for Clinical Excellence) (NICE) (2002) pointed out that there was strong evidence that breast cancer patients benefit from involvement in treatment decisions, but women vary considerably in the amount of responsibility they wish to take and clinicians need to be sensitive to the degree to which individual patients want to become involved in decision making. This proved to be highly beneficial to Kath as her constant positive attitude enabled her to make what she felt was the best choices for herself. Kath remained actively involved with the decision making process from the point of diagnosis to treatment.
Kath remained to be a very active member in society. It became clear that Kath had no social problems and she was not going to allow her illness to affect her social life either. From the point of diagnosis to surgery and treatment Kath had remained optimistic. Although Kath had strongly acknowledged that she was a little worried about the fatigue that would follow her chemotherapy. Kath was concerned that having the treatment would interfere with her social life, and she was willing to accept any help available to suppress the fatigue, therefore enabling her to continue with her life before her breast cancer diagnosis.
Another important attribute to the patients’ recovery of breast cancer is their social support. Sormanti et al. (2000) found that numerous studies have examined how social support is associated with psychosocial functioning during breast cancer treatment and recovery; these studies have found that social support improves adjustment to breast cancer.
Kath continually expressed the importance of breast awareness to all 4 of her daughters due to the high family history and the hereditary aspects it appeared to have. Kath felt that it was important her daughters were actively breast aware as she was, for the earliest possible diagnosis. Kath remained extremely motivated throughout her diagnosis and treatment and wanted to prove to her family that this diagnosis of breast cancer was not the end of the world it was merely a stepping stone, and a learning curve which had been priceless to both herself and her family.
The attitude of each individual is recognised as being important for the patients’ experience of their disease and their recovery process as well. Many difficulties remain and new ones may arise during treatment and/or recovery (e.g., psychological distress; relationship, social, and occupational disruption; loss of physical stamina and fatigue; financial problems Bleiker et al.(2000). It is important that all of these aspects are recognised with each diagnosis as forgetting just one of them could impact a patients recovery process. Carver et al (200) suggested that optimism is a personality trait that can be thought of as the generalized expectancy of good outcomes, even in the face of adversity. Kath showed nothing more than intent optimism to overcome this and get back home and continue with life as it was before. Kath and her family strongly believe that Kath’s extremely positive attitude was a massive factor in aiding Kath’s recovery both physically and mentally.
Kath had an extremely close family who would do anything for their mum. Despite the fact the Kath had lost her husband, her daughters and other members of her family remained extremely active in their support. Kath was fully aware of her family’s support and accepted it when she knew it was required. Kath often spoke of the importance that she wanted to remain as independent following this diagnosis as she was before. Kath’s family were very loving and spent a great deal of time with Kath during her time in hospital to provide as much support as Kath required. Kath was also a great support to her family and often helped them when they felt unable to come to terms with her diagnosis.
In conclusion Kath’s health was considered by many as being compromised by her Multiple Sclerosis. Kath found it extremely important that she focused on the things that she found were of importance to her, this being her independence, her social life, her family and being in control. Kath was able to enjoy life and considered herself to have a good level of health and well being. When Kath developed further health problems when diagnosed with breast cancer she had the ability to accept and adjust to her altered circumstances in a way that was atypical of other patients diagnosed with breast cancer.
Kath had an exceptionally positive attitude. Kath continued to have a very outgoing personality from the onset and never felt a ‘victim’ to her diagnosis. Kath often mentioned there was always somebody worse off than herself, to which her daughters agreed that this was a continual view their mum had had throughout her previous diagnosis of multiple sclerosis and her general deteriorating health in recent years.
It remains important to recognise that the psychological and social factors are addressed as they are just as important as the biological factors in determining the outcome of the patient. Lindop et al. 2001 suggests that the psychosocial needs of women with breast cancer will vary throughout the stages of the disease from diagnosis to treatment. As well as the suggestion made by Lindop et al. (2001) it is also important that the psychosocial needs continue for however long required after treatment has ended. This became evident while speaking to Kath that the illness itself was not the great issue, it was how to enable Kath to maintain her life following treatment. Psychologically Kath was very strong and positive as she had already adapted to living with a chronic illness, and this diagnosis to Kath was merely another life adaptation. Kath’s biggest fear was her social life and independence.
From the literature it is clear that as the years have progressed the individual needs of patients have become more the issue then the actual treatment of the disease. It is important that at present and in the future healthcare professionals continue to drive towards the psychosocial needs of the patient as opposed to solely dealing with the biological issues. It has also been made clear that the bio-psychosocial model is an invaluable tool in meeting the needs of all patients’ individual needs. It provides a common ground that both health care professionals and patients can work alongside.
The diagnosis of breast cancer is often regarded as the end of life. It is suggested that the patients’ recovery and life expectancy is reflected in their attitude towards their illness. Brown et al. (2003) suggested that those who have high levels of hopelessness and depression do not survive as long as others do. However there is opposing literature arguing this, Chow et al. (2004) found that psychosocial interventions did not prolong cancer patients’ survival. Kath herself admitted that if it was not for her own positive attitude she doubted that she would have had such a remarkable recovery. Kath had continued to mention that although at the point of diagnosis her family were distraught, their attitude eventually changed to that of her own.
This assignment has highlighted how negative an experience the diagnosis of breast cancer is. It has been made obvious to the reader that although breast cancer can be medically destructive, it also affects a person greatly psychologically and sociologically. It appears to be a disease that although when dealt with medically, continues to affect the person for many years afterwards.
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THIS IS WHAT I HAVE LEFT OVER. ANY IDEAS WHERE I CAN PUT IT OR DO YOU THINK IT NEEDS TO GO?
It was important to explore why the reaction of Kath’s was unlike any other I had seen before. Kath had explained that this diagnosis was something that she had been expecting for a great number of years. Kath is a 64 year old breast cancer patient who regularly attended breast screening when recalled to, and was also breast aware.
Kath was treated on a surgical ward and continually showed optimism and a positive attitude in relation to her health, from the point of diagnosis through to surgery and chemotherapy. Kath herself felt that her positive outlook helped her greatly to deal with her illness, and also felt that the positive approach helped with the healing process. Kath often mentioned that the immense amount of support from her family also encouraged her to remain as positive as she was.
I will be looking at a bio-psychosocial model to use within this assignment as a holistic perspective in relation to my patient. It is my intention to use the model to critically evaluate the bio psychosocial factors in relation to my chosen patient. It remains important to recognise that both the psychological factors and social factors are addressed as they are just as important as the biological factors in determining the outcome of the patient.
Consent of the patient has been gained prior to this assignment being written. A consent form has been signed and included with this assignment. For the purpose of this assignment I shall name my patient Kath in order to remain within the confidentiality clause of the Nursing and Midwifery Council (NMC) (2008). The area of practice shall also remain undisclosed.
Kath is a 64 year old lady who has been widowed for 6 years following the loss of her husband, Kath also has 4 daughters. Kath was already living with a chronic illness, secondary progressive multiple sclerosis, with which she had been diagnosed with at the age of 18. Shering (2000) states that “secondary progressive multiple sclerosis being that of MS diagnosed in a young adult in which the severity and frequency of the relapses decreases yet disability slowly increases". Kath admitted that her general health had slowly deteriorated over the years and her mobility had been affected, and she was now confined to a wheelchair. Despite this Kath was determined to continue her life as normal. Kath continued to live alone and lived independently with the ability to continue to look after herself with very little assistance. Her family remained extremely supportive and continued to aid Kath with anything she may need assistance with. Kath mentioned that it was very important to her that she continued to take pride in her appearance. Her relationship with her family was that of a very strong unit and Kath often expressed the closeness she has with her daughters. Kath also spoke about the very active social life she led and was a bit concerned that this hospital admission would interfere with it, this just made Kath all the more determined to sustain a positive attitude towards a swift recovery.
The World Health Organisation (WHO, 1946) defined health “as a state of complete physical, mental and social – well being, and not merely the absence of disease and infirmity” (Cowley) (2002, p.45). According to this definition it would deem that Kath had not been healthy since her diagnosis of multiple sclerosis at the age of 18. However, Kath’s perception of health was unlike this described definition. Therefore proving that each individual does not have the same perception of idealistic health, each person has their own definition of health and what makes them feel ‘healthy’.
This definition has been heavily criticised by Dubos (1979) who intimated that the definition eliminates a numerous amount of people from achieving this exclusive state of health perfection. Dubos (1979) further insists that health and disease cannot be defined solely in terms of anatomical, physiological or mental elements. This definition was also criticised by Seedhouse (1986) who stated that this definition did not take into consideration the social, psychological, spiritual and environmental factors, which are highly significant to each individual’s notions of health. Pike and Foster (1995) further support the opinions expressed by both Dubos (1979) and Seedhouse (1986) by sharing the same opinion with their criticism and further draws attention to the importance of realising that people have their own individual notions of health. Cowley (2002) supports this theory and further argues that it is perplexing to identify the significance of what the notion of health is to any one individual, as we all have different perceptions of what health should be to us.
Although Kath was living with a chronic illness which to others may have appeared to be unhealthy, Kath’s perception of herself and her health was that of being extremely healthy. Kath often concluded that although she was living with a chronic illness this did not deem her unhealthy. Kath felt healthy as she was able to continue to live independently at home and participate in social activities with her friends and family. To Kath her health was not diminished by being disabled through multiple sclerosis as some may have imagined it to be.
Despite Kath’s health problems it was highly important to Kath to maintain her idealistic state of health. Kath was a non-smoker and only consumed alcohol socially at major events. Kath attended multiple sclerosis clinics twice annually unless an unforeseen problem may have occurred, which Kath mentioned rarely happened. Kath felt it to be important that she kept fit and active as she knew the risks of becoming overweight and had therefore learnt exercises that she was able to do despite her lack of mobility.
In particular Kath was aware that she had an increased risk of developing breast cancer. Kath explained that she had a large family history of breast cancer and she felt her chances of getting the disease was much higher as cancer was not only concurrent in her mother’s side of the family but that of her father’s as well. Kath mentioned that there were genetic links for the disease being inherited. Kath made it clear that the feelings she had were more of relief as opposed to dread and worry. It was something that she said she had just been waiting for to come into her life.
Cancer is a term used for diseases in which abnormal cells divide without control and have the ability to invade other tissues, via the blood and lymph systems. Cancer is not just one disease but many diseases. There are more than 100 different types of cancer. Most cancers are named for the organ or type of cell in which they start (National Cancer Institute, 2008).
Cancer progresses by enlarging and spreading to different sites within the body. Its growth at each site interferes with normal development and functioning. Tortora et al (2003) wrote that cancer is an irregularity in the normal pattern of tissue growth. These irregularities cause unrestricted cell growth, usually forming a tumour called a neoplasm. Although a dated piece of research. Souhami et al. (1995) similarly described that a common characteristic of cancer cells is their uncontrolled division (mitosis) which produces an expanding mass of disorganised cells known as a tumour. Tortora et al (2003) continued to define that cancer is a disease of the cells characterised by uncontrolled cell proliferation that usually forms a malignant neoplasm. There are many forms of cancer, and the large majority can be classified into five types based on the kind of tissue in which it develops. The American Medical Association (AMA) (2003) described further that an important characteristic cancer cells is that they do not adhere to each other as strongly as normal cells do.
Morgan (2001) defined that “cancer is a Latin term meaning crab, a word that aptly describes the appearance of a malignant tumour which is irregular in outline and uncontained. Crabs move in a seemingly erratic manner, sideways, often with sudden bursts of movement: cancer appears to grow in a similar way”.
The reported incidence of breast cancer has increased over the past 30 years. This is probably the result of better statistical reporting, better screening methods, increased life expectancy and increased exposure to carcinogens, changes in lifestyle and decreasing mortality rates, which reflects the benefits of early detection, screening and improvements in treatment (Chapman et al. 2000).
Breast cancer is one of the most common cancers in the UK with more than 44,000 people diagnosed each year (Cancer Research UK (CRUK) 2008). With one million new cases in the world each year, breast cancer is the most common malignancy in women and accounts for 18 per cent of all female cancers (McPherson et al 2000). McPherson et al (2000) also suggested that it has been recognised that age remains the greatest risk factor, with most breast cancers occurring in the post-menopausal age group.
It is important to identify which risk factors greatly contributed to Kath’s increased chances of developing breast cancer. Chapman et al. (2000) found that family history plays a significant part in breast cancer development. Between 5 and 10 per cent of breast cancers in Western countries are attributable to genetic predisposition. BRCA 1 & BRCA 2 are human genes that belong to a class of genes known as tumour suppressors mutation of these genes have been linked to hereditary breast cancer. The risk of developing breast cancer is greatly increased if a woman inherits a deleterious BRCA 1 or BRCA 2 mutation. It is estimated that 60% of women who have inherited the BRCA 1 or BRCA 2 mutation will develop breast cancer as opposed to 12% of women who have not inherited the mutation, National Cancer Institute (2009). In normal cells, these genes help prevent cancer by making proteins that help keep the cells from growing abnormally. If you have inherited a mutated copy of either gene from a parent, you have a high risk of developing breast cancer during your lifetime. The risk may be as high as 80% for members of some families with BRCA mutations, American Cancer Society (2009).
Kath was aware of the significance of family history and as she had 4 daughters herself, as well as granddaughters, knew that this would be beneficial not only for her own health but in the event of detecting something while being screened, this would enable her to educate her daughters into being more breast aware themselves.
Age is also recognised as a primary contributing risk factor studies showed that 85% of breast cancer cases had occurred in women over the age of 50 and older Fletcher (2008). Mcpherson et al (2000) also found that women were at greater risk if they were at a post-menopausal age. It is also found that gender is another primary contributing factor to developing breast cancer. Women are more likely to develop breast cancer then men as women have more estrogens and progesterone in their body then that of a man. These hormones stimulate breast cell growth both normal and abnormal, Breastcancer.org (2008). Kath was aware of all the risk factors and was very self aware of the amount of categories she fell into. Breast screening has become more widely used in the UK, with the service being used by an ever increasing number of women. The increase in the reported incidence of the disease may be the result of increased detection through the NHS screening programme, (McPherson et al 2006). Although there is an increase in the incidences of the disease it is proven that the detection of screening is saving more lives. Gøtzsche et al. (2006) reported a 15% risk reduction in mortality in individuals who attended a mammographic screening programme. Another study also proves this by suggesting that the UK breast screening programme is estimated to save 1,400 lives each year (Advisory Committee on Breast Cancer Screening 2006). Another study also showed that a case-control study from East Anglia demonstrated a 48% reduction in breast cancer mortality rates in women who attended the breast screening programme (Allgood et al 2008).
It has become more evident that the majority of women are referred to the NHS via their GP by themselves being breast aware. GPs are usually the first point of contact for individuals with concerns regarding changes in their breasts. Guidelines produced by the National Institute for Clinical Excellence (NICE) (2005) assists the GP to make accurate referrals. (National Institute for Clinical Excellence) (NICE) (2002) also recorded that the majority of women who attended breast clinics for investigation of suspected breast cancer are referred by their General Practitioner. These women are symptomatic, they have themselves discovered the lump or have other symptoms and have been concerned enough to seek the opinion and advice of their General Practitioner.
Bailey (2000) continues to emphasise that the advantages of breast self-examination is that it is a simple, cost-free, non-invasive technique that has a good chance of discovering changes in breast tissue.
Kath had remained active within the breast cancer screening programme, which had always had negative results for her. Kath had a high level of family history of breast cancer which she referred to many times. Kath felt that this was one of the key points that encouraged her to use this service. (National Institute for Clinical Excellence) (NICE) (2002) also noted that a small minority of women are referred to breast clinics from the National Health Service (NHS) Breast Screening Programme.
It has become evident that women in the community are not breast aware. Although more women consult earlier with breast cancer than with other cancers, there is evidence that women in general are still not breast aware (Bailey 2000). Austoker (2003) stressed that the importance of being breast aware and reporting changes without delay cannot be over-emphasised. It is important that women are breast aware and inform their GP immediately if they identify any abnormality.
Although Kath always had negative results from her breast screening, Kath remained breast aware and regularly checked herself. It was during this intervention that Kath found the lump herself. Kath immediately sought the appropriate medical help that was required, and was therefore sent for the relevant treatment required. Kath felt that her immediate response aided her positive attitude. Kath explained that as she was already living with a chronic illness she had often found herself dealing with situations of her health changing all the time sometimes day by day. Research showed that 35% of a study carried out delayed seeking medical assistance for over 4 weeks for various reasons. Often people thought that the symptom would go away, the symptom was not serious and more commonly they delayed as they were too scared to seek medical help, British Journal of Cancer (1999). Kath felt that she was not scared to seek the help that was required as she knew it would be of benefit for herself.
The diagnosis of cancer fills most people with dread Love (2000) stated that the first thing a woman thinks when diagnosed with breast cancer is, ‘Will I die?’ This is quickly followed by ‘Will I lose my breast?’ However, whilst on a recent clinical placement I came across Kath, a patient whose reaction was quite different to her cancer diagnosis. Throughout the entire process of diagnosis, surgery, chemotherapy and recovery Kath remained positive and continued to be determined to sustain everything that she could to recover.
To most women the diagnosis of breast cancer is completely devastating although this was not the case with Kath. Her reaction to her diagnosis was admirable and exemplary. The diagnosis of breast cancer is often seen as a genuinely bad diagnosis which fills people with dread. It is often thought that when diagnosed with cancer their life is over, there is ‘no light at the end of the tunnel’. The NHS has recognised the pressure waiting has on people “Waiting for treatment of any kind is worrying and it is often painful and debilitating. Waiting for diagnosis and treatment for cancer is also potentially life threatening. The drive to end waiting is central to the Cancer Plan.” (NHS Cancer Plan, September 2000). Although dated the relevance is prevalent that Stanton et al. (1998) recognised that cancer creates unique stressors for patients and their families. These patients have a disease they recognise as a ‘real killer’, and one that can lead to intense pain, disfigurement and disability. It appears from literature that cancer diagnosis is generally a very negative experience. Maguire et al. 2006 wrote that once diagnosed, women face the prospect of potentially disfiguring surgery and ongoing treatment, which may continue for up to five years. Kath explained that as this diagnosis was something that she had been expecting for a great number of years. Kath made it clear that the feelings she had were more of relief as opposed to dread and worry. Kath seemed relieved by her diagnosis of breast cancer due to her high family history of the disease. Kath mentioned that she had just ‘been waiting’ for it to happen and felt a great deal of relief when she found the lump and she felt she could now move forwards. Kath highlighted that the uncertainty of when the cancer was going to emerge and what point in her life had finally been taken away with her diagnosis. Therefore, Kath was extremely eager for treatment to begin.
There are many forms of treatment for breast cancer. I shall concentrate on chemotherapy and mastectomy as this is relevant to that of my chosen patient. The term chemotherapy was used to describe the use of chemicals or drugs to treat microbial and later neoplastic diseases McCoy (2003). It has been acclaimed that chemotherapy has been certified as one of the significant therapeutic modalities, and that chemotherapy has assumed an increasing importance. Cytotoxic drugs are defined as ‘cell killing drugs’ and they act against cancer cells McCoy (2003). Chemotherapy unfortunately does not distinguish the difference between normal and malignant cells. McCoy (2003) further suggests that when the cytotoxic drug is introduced into the body it will not only attack cancerous cells but also normal cells proliferating as part of the normal physiological process repair and replacement.
Kath was given chemotherapy following her mastectomy; this is generally known as adjuvant chemotherapy. The purpose of this was to decrease the possibility of metastatic disease and also to enhance the chances of survival.
Often cancer of the breast is too advanced to have breast conservation. About one third of breast cancers are not suitable for breast conservation and mastectomy is performed (Sainsbury et al 2000). Harmer (2000) further highlighted that most management plans for breast cancer will involve some form of surgery for local control of the disease. If the cancer of the breast requires the removal of a large amount of tissue to completely excise the cancer within good margins then this is when a mastectomy is recommended. Harmer (2003) found that about 30% of all cancers require a mastectomy. The most common mastectomy is the total mastectomy. This refers to the total removal of the breast tissue, including the tail of Spence, which extends into the axillary space (Roses, 1999). It is recommended that mastectomy for invasive breast cancer should always be combined with some axillary node surgery.
Body image is a term which may refer to a person’s perception of their own physical appearance, or the interpretation of the body by the brain. Body image is often a barrier when it comes to patients making decisions about their treatment. As such, the loss of a breast for some women can result in negative consequences to body image and self-concept (Frost et al. 2000). Women undergoing mastectomy might have greater post-operative body image problems than those undergoing breast-conserving surgery (Maguire 2000).
In modern-day society, breasts are often regarded as symbols of beauty and femininity, and part of a woman’s sexuality and role as a mother. For this reason, disease of the breast and its treatment may cause great anxiety, and a woman may fear both for her life and her womanhood (The Royal Marsden 2002). Having a mastectomy often leaves a woman grieving for the loss of her breast. Breast cancer can be viewed as a life-changing event and that patients may need to reconcile alterations in body image following surgery, cope with feelings of being a different person and handle the prospect of potential social isolation. These emotions can lead women to distance themselves from family and friends (Lawton 2000).
White (2000) explores the issue of clinically significant body image problems and summarises that they exist when there is a marked discrepancy between body reality and body ideal. This results in negative emotions and behaviour, and interferes in all aspects of an individual’s life. (Dixon 2000) found that 23 per cent of psychological problems following breast surgery related to body image and sexuality. However Potts (2000) takes a feminist perspective and explains that some patients believe that by opting for prosthetics or reconstruction, they are hiding the problem, perhaps in an attempt to shelter other people from the reality of the disease. For most people it would be their first time having surgery that altered their body and therefore would be the first time that they would have had to think about their body image. However, this was not the case with Kath as she had been living with the effects of a chronic illness on her body for a vast amount of years.
MSSociety (2009) define “Multiple Sclerosis as an inflammatory disease of the Central Nervous System. Predominantly, it is a disease of the "white matter" tissue. The white matter is made up of nerve fibres which are responsible for transmitting communication signals both internally within the Central Nervous System and between the Central Nervous System and the nerves supplying rest of the body. In people affected by Multiple Sclerosis, patches of damage called plaques or lesions appear in seemingly random areas of the Central Nervous System white matter. At the site of a lesion, a nerve insulating material, called myelin, is lost”.
Speech can be widely affected by Multiple Sclerosis. It is known as a term called dysarthria. This is where damage is caused in different parts of the brain which affects the way in which speech is produced. Damage in one part of the brain affects the muscles of the tongue and lips making it difficult to pronounce precise words, Multiple Sclerosis Society (2009). Another common symptom of multiple sclerosis is some form of muscular paralysis. Paralysis is more accurately described as paresis which is a medical term meaning partial or mild muscle weakness. Paresis is common in Multiple Sclerosis sufferers but it is not exact as to what extent the paresis will affect them, McFox’s Multiple Sclerosis Pages (2009). Kath suffered paresis of both her legs, better known as paraparesis.
The body image factors cause many women great distress and depression, although this was not the case with Kath, Kath felt that she had the ability to adapt quickly to her new challenge in life. It was admirable that Kath felt it was a new challenge to overcome as opposed to developing an illness that could potentially be life ending. Kate always put forward that her attitude to illness came from the fact that she had been living with secondary progressive multiple sclerosis for the past 46 years. As the years had progressed Kath had adapted to her ever changing symptoms, which eventually affected her mobility and speech. Kath eventually ended up in a wheelchair. Kath mentioned that it was very important to her that she continued to take pride in her appearance. Kath also felt that given all the other problems she had overcome of the years on a daily basis due to her multiple sclerosis, losing her breast was relatively minor. Kath took a great deal of care in her appearance she wanted to look smart but made sure it was practical for her as well. Kath would wear loose comfortable clothing to enable her to transfer from her wheelchair to her chair/bed with ease. Kath wanted to make sure her clothes were smart but fashion and tight fitting clothes were not essential or practical for her. Kath had taken all this into consideration, and Kath also mentioned that this was something she had adapted to and learnt over the years to ensure her independence was not hindered.
It has been suggested that when a woman is diagnosed with breast cancer she goes through all or some of the 5 stages of grief, denial and shock, anger and rage, stress and depression, grief and fear, acceptance and adjustment. Kath felt that she was immediately at the stage of acceptance and adjustment as Kath had already been through this whole process when initially diagnosed with multiple sclerosis. This was just another issue to adapt to. Kath also briefly mentioned that she felt that as she had been living with secondary progressive multiple sclerosis for 46 years she had learnt to adapt and felt that having lived with this illness for so long this diagnosis had not been as much of a hurdle to overcome. Furthermore Kath felt that as she was continually adapting to live with her existing illness she found that she had felt it had been beneficial to cope with the new adaptation she had just encountered.
Following surgery most women have chemotherapy. Kath had a total mastectomy of her left breast. Following this she then went for adjuvant chemotherapy following a rapid healing of her mastectomy to mop up any cancer cells that may have been left behind post mastectomy.
It remains important to be familiar with the side effects that cancer treatments have on women being treated for breast cancer. These side effects are devastating to the patient and the lack of treatment of them can hinder the patients’ recovery. The most frequently reported symptom of cancer and cancer treatment is fatigue (Nail 2002). This was one of the issues which were one of Kath’s greatest concerns as she was so independent and held a very active social life. It has also been noted that it is one of the most difficult symptoms to manage so it is of high importance that health care professionals dealing with these patients are educated to effectively manage the varied symptoms. A dated piece of research also regards fatigue as being the most challenging symptom to manage (Clark et al. 1998).
The fact that the symptoms of repeated chemotherapy or radiotherapy have ongoing effects has been highlighted as it would be easily thought that symptoms end when the treatment ends. Jacobsen et al. (2003) found that most people who undergo repeated radiation and chemotherapy experience severe and long-lasting fatigue that often gets worse after the treatment ends. It was important to Kath to find information on ways to deal with the fatigue to prevent it from interfering with her everyday life. The expectant nausea that Kath had been made aware of during her chemotherapy was again a worry of Kath’s as she felt that this again would impact on her social life as she would be unable to go out as often as she did prior to her admission. It was important to Kath that this was controlled.
Fatigue is a major debilitating and unpredictable symptom in multiple sclerosis. Fatigue is one of the earliest, most common and troubling symptoms of multiple sclerosis, Multiple Sclerosis (2009). Kath mentioned that she had spent years adapting her days to combat the fatigue she suffered on a regular basis and found that the ways she dealt with it worked effectively. Kath felt that she would be able to adjust and learn new coping strategies to fight the increasing fatigue she would suffer from her cancer treatment.
Alopecia is one of the most distressing and visually noticeable effects of cancer treatment.
For some patients, the fear of treatment induced alopecia is so significant that some women may refuse potentially curative chemotherapy (Pruzinsky 2004).
It is apparent that the prospect of hair loss affects a persons’ body image just as greatly as that of mastectomy. For women, in particular, it is an important indicator of attractiveness, femininity and body image (Rosman 2004). Batchelor (2001) further suggested that it is perhaps not surprising that chemotherapy induced alopecia has traditionally been associated with loss of individuality, unattractiveness and a state of disgrace and illness.
Another aspect of body image that greatly affects a patient is the prospect of hair loss following chemotherapy. Also known as chemotherapy induced alopecia. There are interventions available to try and prevent or minimise hair loss. Scalp cooling is an uncomfortable procedure and there is no guarantee that it will work, so it should be discussed with patients before treatment is commenced (Grevelman et al.2005). Dougherty (2006) further suggested that the prospect of the uncomfortable procedure did not deter some patients. He highlighted that patients are often willing to endure the uncomfortable side effects associated with scalp cooling, such as headaches, nausea or sensations of severe coldness, in an effort to avoid chemotherapy induced alopecia.
Perhaps the most predominant technique is scalp cooling. This method causes vasoconstriction of the blood vessels in the scalp, which reduces the uptake of drugs into hair follicles, thus decreasing the amount of hair loss (Randall and Ream 2005). The cold cap can possibly prevent hair loss but it doesn’t prevent facial and body hair loss. Kath had been informed of this treatment but had decided against it. Kath was very positive about the prospect of her hair loss, and embraced the fact that it would grow back when her treatment had finished. Kath’s positive attitude had a good effect on her family when she mentioned to them that she had decided to refuse the treatment. It appeared that her family was a little shocked at first as they were all aware of how important their mums’ appearance was to her.
Kath had been visited by specialist nurses on the ward following Kath’s rejection of the scalp cooling to give Kath advice on other alternatives for her hair loss. They advised Kath about the availability of wigs for cancer patients. Kath again decided against this option and expressed that at the time she had no body image concerns. Kath further mentioned that she felt that this was again due to her multiple sclerosis giving her, her positive attitude towards her impending body image. Kath felt that as she had had to contend with so many body image issues over a period of time in relation to her multiple sclerosis, eg; her mobility, this new body image issue was just another adaptation.
Evidence suggests that women with breast cancer are more likely than those in the general population to develop anxiety or depression. For the patient receiving a diagnosis of breast cancer it would be valid to think that the diagnosis will have permanent physical and psychological effects on both the patient’s life and that of their family and friends. Kath’s attitude towards her diagnosis was admirable; it appeared to be the opposite of the described anxiety and depression.
Maguire (2000) suggested that as with anxiety depression is another common psychological reaction to a diagnosis of breast cancer. It is known that up to one third of women develop severe anxiety or a depressive illness within a year of diagnosis of breast cancer. Psychological support must therefore be an integral part of the management of the disease. Alongside the physiological effects of cancer treatment there are also psychological aspects which can also contribute to the patients side effects. (Dibble et al 2000) in addition to the physiological effects of chemotherapy that can produce gastric irritation and trigger the emetic centres of the brain, emotional stressors such as anxiety contribute to nausea. This only further demonstrates the necessity to manage all bio-psychosocial aspects of the patients needs.
Sneddon et al (2007) found that healthcare professionals acknowledge the importance of aftercare following breast cancer surgery to reduce potential physical and psychological complications, and patients increasingly express a need for access to timely preventative information. This desire for information is endorsed widely by professionals, who agree that patients should be empowered, and encouraged to be active participants in their care.
It has been recognised that patients being involved with the decision making of their treatment options have a positive effect on their long term well being. The concept of allowing a patient to be involved in decision making of their care is ideal. It allows the patient to be as involved or uninvolved as they want to be. (National Institute for Clinical Excellence) (NICE) (2002) pointed out that there was strong evidence that breast cancer patients benefit from involvement in treatment decisions, but women vary considerably in the amount of responsibility they wish to take and clinicians need to be sensitive to the degree to which individual patients want to become involved in decision making. This proved to be highly beneficial to Kath as her constant positive attitude enabled her to make what she felt was the best choices for herself. Kath remained actively involved with the decision making process from the point of diagnosis to treatment.
Kath remained to be a very active member in society. It became clear that Kath had no social problems and she was not going to allow her illness to affect her social life either. From the point of diagnosis to surgery and treatment Kath had remained optimistic. Although Kath had strongly acknowledged that she was a little worried about the fatigue that would follow her chemotherapy. Kath was concerned that having the treatment would interfere with her social life, and she was willing to accept any help available to suppress the fatigue, therefore enabling her to continue with her life before her breast cancer diagnosis.
Another important attribute to the patients’ recovery of breast cancer is their social support. Sormanti et al. (2000) found that numerous studies have examined how social support is associated with psychosocial functioning during breast cancer treatment and recovery; these studies have found that social support improves adjustment to breast cancer.
Kath continually expressed the importance of breast awareness to all 4 of her daughters due to the high family history and the hereditary aspects it appeared to have. Kath felt that it was important her daughters were actively breast aware as she was, for the earliest possible diagnosis. Kath remained extremely motivated throughout her diagnosis and treatment and wanted to prove to her family that this diagnosis of breast cancer was not the end of the world it was merely a stepping stone, and a learning curve which had been priceless to both herself and her family.
The attitude of each individual is recognised as being important for the patients’ experience of their disease and their recovery process as well. Many difficulties remain and new ones may arise during treatment and/or recovery (e.g., psychological distress; relationship, social, and occupational disruption; loss of physical stamina and fatigue; financial problems Bleiker et al.(2000). It is important that all of these aspects are recognised with each diagnosis as forgetting just one of them could impact a patients recovery process. Carver et al (200) suggested that optimism is a personality trait that can be thought of as the generalized expectancy of good outcomes, even in the face of adversity. Kath showed nothing more than intent optimism to overcome this and get back home and continue with life as it was before. Kath and her family strongly believe that Kath’s extremely positive attitude was a massive factor in aiding Kath’s recovery both physically and mentally.
Kath had an extremely close family who would do anything for their mum. Despite the fact the Kath had lost her husband, her daughters and other members of her family remained extremely active in their support. Kath was fully aware of her family’s support and accepted it when she knew it was required. Kath often spoke of the importance that she wanted to remain as independent following this diagnosis as she was before. Kath’s family were very loving and spent a great deal of time with Kath during her time in hospital to provide as much support as Kath required. Kath was also a great support to her family and often helped them when they felt unable to come to terms with her diagnosis.
In conclusion Kath’s health was considered by many as being compromised by her Multiple Sclerosis. Kath found it extremely important that she focused on the things that she found were of importance to her, this being her independence, her social life, her family and being in control. Kath was able to enjoy life and considered herself to have a good level of health and well being. When Kath developed further health problems when diagnosed with breast cancer she had the ability to accept and adjust to her altered circumstances in a way that was atypical of other patients diagnosed with breast cancer.
Kath had an exceptionally positive attitude. Kath continued to have a very outgoing personality from the onset and never felt a ‘victim’ to her diagnosis. Kath often mentioned there was always somebody worse off than herself, to which her daughters agreed that this was a continual view their mum had had throughout her previous diagnosis of multiple sclerosis and her general deteriorating health in recent years.
It remains important to recognise that the psychological and social factors are addressed as they are just as important as the biological factors in determining the outcome of the patient. Lindop et al. 2001 suggests that the psychosocial needs of women with breast cancer will vary throughout the stages of the disease from diagnosis to treatment. As well as the suggestion made by Lindop et al. (2001) it is also important that the psychosocial needs continue for however long required after treatment has ended. This became evident while speaking to Kath that the illness itself was not the great issue, it was how to enable Kath to maintain her life following treatment. Psychologically Kath was very strong and positive as she had already adapted to living with a chronic illness, and this diagnosis to Kath was merely another life adaptation. Kath’s biggest fear was her social life and independence.
From the literature it is clear that as the years have progressed the individual needs of patients have become more the issue then the actual treatment of the disease. It is important that at present and in the future healthcare professionals continue to drive towards the psychosocial needs of the patient as opposed to solely dealing with the biological issues. It has also been made clear that the bio-psychosocial model is an invaluable tool in meeting the needs of all patients’ individual needs. It provides a common ground that both health care professionals and patients can work alongside.
The diagnosis of breast cancer is often regarded as the end of life. It is suggested that the patients’ recovery and life expectancy is reflected in their attitude towards their illness. Brown et al. (2003) suggested that those who have high levels of hopelessness and depression do not survive as long as others do. However there is opposing literature arguing this, Chow et al. (2004) found that psychosocial interventions did not prolong cancer patients’ survival. Kath herself admitted that if it was not for her own positive attitude she doubted that she would have had such a remarkable recovery. Kath had continued to mention that although at the point of diagnosis her family were distraught, their attitude eventually changed to that of her own.
This assignment has highlighted how negative an experience the diagnosis of breast cancer is. It has been made obvious to the reader that although breast cancer can be medically destructive, it also affects a person greatly psychologically and sociologically. It appears to be a disease that although when dealt with medically, continues to affect the person for many years afterwards.
6697
THIS IS WHAT I HAVE LEFT OVER. ANY IDEAS WHERE I CAN PUT IT OR DO YOU THINK IT NEEDS TO GO?
It was important to explore why the reaction of Kath’s was unlike any other I had seen before. Kath had explained that this diagnosis was something that she had been expecting for a great number of years. Kath is a 64 year old breast cancer patient who regularly attended breast screening when recalled to, and was also breast aware.
Kath was treated on a surgical ward and continually showed optimism and a positive attitude in relation to her health, from the point of diagnosis through to surgery and chemotherapy. Kath herself felt that her positive outlook helped her greatly to deal with her illness, and also felt that the positive approach helped with the healing process. Kath often mentioned that the immense amount of support from her family also encouraged her to remain as positive as she was.
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The biopsychosocial model describes the concept that biological, psychological, and social factors interact as complex networks that influence one’s health and illness (Suls & Rothman, 2004; Gatchel, 2007). One of the main goals of health psychology is to understand the relationship and interaction between these factors. Health psychologists examine treatment effects on a person’s health by applying interventions that modifies the three factors that comprise the biopsychosocial model (Suls & Rothman, 2004; MacKinnon & Luecken, 2008). Numerous studies and interventions have been designed to improve physical and psychological health based on the biopsychosocial model (cite some of these). Among these interventions, the use of mindfulness-based…
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Capstone Assignment 1: Biopsychosocial Assessment Identifying Information The client is a 10 year old, heterosexual, cisgender, black, male, student who is unemployed and unmarried. The client lives in an urban community with his mother, stepfather, and younger sisters. The assessment is informed by the client and his mother.…
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FCA1: Student answer reflects accurate knowledge of the sequence of events that construct a nerve signal (message sent from where and going where?).…
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Clients who live with wellness in the foreground make an effort to balance their illness and their daily lives. They don’t see themselves as being ‘victims of circumstance’ but as ‘creators of circumstance’ (Paterson, B., 2001). Those living this way focus their emotional, psychosocial state. Clients who live with illness in the foreground focus on the pathological aspect of their illness. They research the illness and attempt to learn as much as they can. This lifestyle gives them the opportunity to come to terms with their illness and is typically seen in those who are newly diagnosed (Paterson, B.,…
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12: Biopsychosocial approach- A general model or approach positing that biological, psychological and social factors, all play a significant role in human functioning in the context of disease…
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The key drive of this assignment is to discover through narratives the mental, ethnic and sociological viewpoint of a patient journey with a long-term illness (asthma). Patient narrative is a means towards achieving more understanding about the individual, accepting patient-specific implication of a sickness and managing strategies (Kalitzkus and Matthiessen, 2009). The acceptance of sickness and wellbeing conduct models has been renowned to bear substantial effect on the care given to specific patients and the health care provision organisation (Wade and Halligan, 2004). The traditional theory that embraces that sickness is different from the usual has been a topic of discussion and the biomedical model of wellbeing which has long been the…
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The biopsychosocial approaches to treatment are broadly speaking holistic. Biological psychological and social factors are all incorporated into individual patient assessment. The biopsychosocial model of medicine is a way of looking at the mind and body of a patient as two important systems that are interlinked. The biopsychosocial model is also a technical term for the popular concept of the mind-body connection. This is in contrast to the traditional biomedical model of medicine. The biopsychosocial model draws a distinction between the actual pathological processes that cause 'disease ', and the patient 's perception of their health and the effects on it, called the illness. As well as a separate existence of disease and illness, the biopsychosocial model states that the workings of the body can affect the mind, and the workings of the mind can affect the body. Gilbert.P (2002) stated…
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Bibliography: Dougherty L, Lister S (2011), The Royal Marsden Hospital Manual of Clinical Nursing Procedures, Eighth Edition, Oxford: Wiley-Blackwell.…
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2. E-Notes.com (2011). Encyclopedia of Nursing and Allied Health. Patient Confidentiality. Retrieved June 10, 2011, from http://www.e-notes.com…
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Matthew is a 9 year-old Caucasian, fourth grader who is currently attending James Caldwell Elementary School, Springfield, NJ. His parents are divorced and share his custody. He primarily lives with his mother Ms. Lauren Share and his 7 year-old sister Olivia in Springfield, NJ and visits his father Mr. Marc Whitken on weekends and some weekdays. His mother is a learning specialist with New Jersey Blue Cross Blue Shield. His father works as a Senior System Engineer. He has remarried and lives in Fanwood, NJ. Matthew has an older step-bother Jake.…
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This model helps to establish a trusting rapport between you and the patient. When dealing with patients on an everyday basis the nurse is the one who interacts with the patient the most and sets the tone for the relationship. Compassion and human touch are necessary for positive patient outcomes. Following this module reminds me and helps me to improve my delivery of care by allowing patients to communicate feelings while I actively listen to their needs. When I enter a patient’s room I survey the scene or take a holistic approach. I want to let this patient know I care about all of their needs and not just the medical concerns. The theory states “interconnectedness of one human touching or caring for another is a carative factor which promotes restoration of health and equilibrium” (Cherry & Jacob, 2011). After I introduce myself to the patient I immediately ask them how they are feeling or if there is anything that they are concerned about. I feel this gives the patient the opportunity to discuss concerns and allows time for therapeutic communication establishing a trusting nurse to patient environment. Watson’s carative factors help with caring or maintaining health even when a patient is terminal. I instill this theory through offering chaplin services to patients or assistance finding mental support for those that are terminal. I come in contact with many different cultures…
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Cynthia is a divorced 47 year old mother of two sons, Stanley age 27 and George age19. Both of her sons live at home with her. Stanley, who is trainable mentally impaired, requires a lot of Cynthia’s attention. George attends Oakland Community College with plans on transferring to a four year university in his junior year. Cynthia has a great relationship with both of her children.…
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In line with clause 5 of the nursing and midwifery council (NMC) (2004) code of professional conduct details of the service user will be confidential I certify that confidentiality has been maintained by use of pseudonyms. For purposes of this assignment the service user will be known as Winifred Clark.…
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