Nurse practitioners play an important role in oncology pain, symptom management
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Patients with cancer often fear having uncontrolled pain, especially if it interferes with functioning, quality of life and mood.
I work on a palliative care team called Supportive Oncology and Survivorship, or SOS, comprised of five independent nurse practitioners who rotate coverage in both an inpatient consult service and outpatient clinics. Essentially, we provide pain and symptom management support for acutely ill patients with cancer in the hospital, as well as for stable yet chronically ill outpatients, whether they are actively receiving treatment, under surveillance or are cancer survivors. The nurse practitioners on the team have a mixture of experience and qualifications including certifications in oncology or palliative/hospice care, as well as work experience in the ED or ICU, oncology settings, home health and hospice care. Physicians are available as part of the team for consultation, referral and shared visits.
Inpatient consult service
In our National Comprehensive Cancer Network (NCCN) institution, we have 100 inpatient beds and receive referrals from all units, including medical oncology, bone marrow transplant, surgical oncology and the ICU (see Chart 1). There are always two nurse practitioners working the inpatient consult service 10 hours a day, 5 days a week. Last year we saw over 800 new inpatients, and pain is always either first or second in our top reasons for consult, with the other top reason being goals-of-care discussions for these patients (see Chart 2).
Our inpatient consults come from advance practice clinicians, interns, residents, fellows and attending physicians who request assistance and recommendations. Requests for pain management often involve patients with uncontrolled acute cancer-related pain in addition to chronic pain syndromes. Frequently, long-acting pain medications and patient-controlled analgesia pumps with either intermittent or continuous rates are already in place. Many patients are experiencing multiple types of pain, including nociceptive somatic, neuropathic, visceral and myofascial pain. Additionally, patients’ medication regimens often include complicating medications, such as benzodiazepines, that can increase sedation. These can make for difficult cases that take an extended amount of time and investment to help form a plan to improve the patient’s overall pain control and monitor its success.
Our goal is to improve quality of life by reducing symptom burden and distress. As nurse practitioners, we focus on understanding the whole patient and assessing physical, mental, emotional, spiritual and social aspects of each patient. This way, we can determine all possible factors contributing to a person’s distress. We may recommend changes to their pain regimen, including opioids, analgesics and other adjuvant medications. We put in orders for high-dose/high-concentration patient-controlled analgesia pumps when providers are not approved or not comfortable with the doses. We educate providers and nurses on the floor about dose equivalencies and proper dose increases and breakthrough pain dosing. When pain is difficult to control, we make daily or more frequent visits as required to manage the pain. We work closely with three anesthesiologists who specialize in chronic and interventional pain and are available for consult and referral when determined appropriate. In some cases, patients will benefit from nerve blocks, such as celiac plexus blocks for those patients suffering with abdominal pain from pancreatic cancer; kyphoplasties for pathologic or other compression fractures of the spine; or implanted intrathecal pain pumps when they are no longer able to tolerate side effects from oral and IV pain medications, or these medications are no longer effective.
Pain is often multifactorial, complex and difficult to manage. From our focus on the whole patient, we explore mood, coping and support needs, and we assess whether existential distress contributes to suffering. When patients have psychological problems or complex mental health histories, we consult with a psychiatrist on our team. If a patient is willing, we promote mindfulness techniques — such as meditation, breathing exercises and guided imagery — to reduce anxiety and stress that contribute to pain and suffering. Referrals to massage therapy, acupuncture and recreation therapy are a common part of our practice. We also work closely with social work and the spiritual care team, offering shared visits with patients and families, and we always communicate directly to optimize care coordination and promote spiritual and emotional well-being.
The outpatient SOS service is an excellent way to follow-up. It allows us to provide ongoing assessment of pain management needs and palliative care concerns. In our institution, we staff three outpatient clinics: one in the hospital and two community clinics, one located north of the city and one located south of the city. The nurse practitioners on our team practice independently in these clinics and rotate weeks between both inpatient and outpatient services.
We often have already met the patients by the time they come to clinic. However, outpatient oncology, hematology and surgery teams can refer new patients directly to our clinic. Patients also refer themselves. Referral reasons include the same as for inpatient and are most often pain and symptom management with anxiety, depression and goals of care following behind. Referrals to our consulting physicians are placed when appropriate. In some cases, we choose to alternate or piggyback visits between the nurse practitioners and psychiatrist or interventional pain physicians so that all symptoms affecting a patient’s quality of life can continue to be addressed.
Our NCCN institution has a wellness and integrative health center, and we encourage many of our patients to participate in the available services of acupuncture, massage and exercise therapy, all of which can potentially benefit patients as they cope with their cancer diagnosis and related treatments.
In my role as a palliative nurse practitioner, my goal is to help improve quality of life for patients with all types of cancer in a variety of settings and to continue to follow them throughout their cancer journey, from diagnosis and treatment into survivorship or, if needed, into end-of-life care. Unfortunately for patients with cancer, pain can be a complex and invasive problem with many different contributing factors — physical, emotional, psychological and spiritual — that often requires aggressive treatment with many modalities, including analgesics, opioids, adjuvant medications, interventional procedures and, for those open to it, complementary therapies. We are fortunate at our facility to be able to practice as independent providers with excellent referral and consultation relationships, and to be able to integrate all these options into our plan for pain and symptom control.
No matter what the reason for the consult to our team, by treating pain and other symptoms related to cancer and by addressing goals of care and helping patients identify their wishes, we reduce suffering and improve quality of life for our patients. I love my role as a nurse practitioner and find it rewarding to be able to offer specialized and compassionate palliative care to our patients with cancer.
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Brighton Loveday, ANP-BC, AOCNP, ACHPN, APRN, is a nurse practitioner with certifications in oncology and hospice and palliative care at Huntsman Cancer Institute of The University of Utah.
Disclosure: Loveday reports no relevant financial disclosures. Jennifer Shaw, ACHPN, APRN, helped edit and review this article.