Dying Process

Dying Process

Patient and Diagnosis

The person I have chosen to write about is a patient I took care of when I was a home health aide back in New York City. I got very close to this family, and they welcomed me the first day I walked into their home. Sadly, this man died of cancer exactly six months after being placed on hospice. This patient died of lung cancer, and that will be the disease process I will be researching. This person is of interest to me because I was really close to him and his family, and he was one of my favorite patients. Regarding the disease process, I have heard so much about cancer, especially lung cancer, and I would like to research more about this disease process or illness.

Possible Causes and Symptoms

Lung cancer is caused by a combination of genetic factors and environmental factors (Kumar, Abbas & Aster, 2018). Accumulation of driver mutations in certain genes results in the transformation of normal lung tissue into neoplastic tissue upon exposure to environmental factors. Environmental factors include tobacco smoke, air pollutants, and occupational respiratory carcinogens. Tobacco smoke is the most common cause of lung cancer, especially squamous cell carcinoma and small cell carcinoma (Kumar, Abbas & Aster, 2018). Tobacco smoke contains various substances, including nitrosamines, polynuclear hydrocarbons, benzene, and arsenic, all of which are carcinogenic. Passive smoking and other tobacco products apart from cigarettes also increase the risk of lung cancer. Occupational carcinogens that increase the risk of developing lung cancer include asbestos, coal, arsenic, and silica (Kumar, Abbas & Aster, 2018). These carcinogens also form a significant proportion of air pollutants. Radon is yet another common cause of lung cancer. It is a radioactive gas that emanates from uranium in soil and rocks and is sometimes found in buildings. Non-neoplastic lung diseases such as tuberculosis, chronic inflammatory diseases, and pulmonary fibrosis also increase the risk of developing lung cancer.

The symptoms of lung cancer depend on the sub-type of lung cancer and the part of the lungs affected. Early symptoms include a new worsening persistent cough, hemoptysis, chest pains that are exacerbated by coughing, dyspnea, wheezing, lung infections that are not relieved by treatment, unexplained weight loss, and lassitude (Kumar, Abbas & Aster, 2018). In advanced stages of lung cancer, new and more severe symptoms may develop, including jaundice, bone pain, edema of the face and limbs, headache, and dizziness. Lung cancer may also be associated with systemic symptoms that come as a result of metastasis. These include neurological changes such as paralysis, seizures, and numbness, paraneoplastic syndromes such as hypercalcemia and lymphatic changes such as lymphadenopathy (Kumar, Abbas & Aster, 2018).

Dying Trajectory and Metabolic Processes

The dying trajectory of lung cancer involves several processes. It begins with an increased tumor burden where the tumor spreads to extrapulmonary sites through the lymphatic system. The metastasized cancer cells use aerobic glycolysis to generate ATP molecules instead of mitochondrial oxidative phosphorylation (Nichols, Saunders, Knollmann, 2012). This is called the Warburg effect and serves to provide the cancer cells with metabolic intermediates required for the synthesis of cellular organelles. The cancer cells have increased metabolic demands where they consume the glucose of the host without producing a significant amount of energy due to the highly inefficient aerobic glycolysis. This prompts the host body to explore other metabolic pathways involving alternative substrates such as fat and proteins (Nichols, Saunders, Knollmann, 2012). The result is increased basal metabolic rate and high caloric expenditure leading to loss of body fat and lean body mass. This phenomenon is commonly referred to as cachexia and is accompanied by weakness, anorexia, and anemia. Cancer cells also cause the production of cytokines such as Tumor Necrosis Factor, which suppresses appetite centers in the hypothalamus and inhibits the action of enzymes involved in the production of energy such as lipoprotein lipase (Kumar, Abbas & Aster, 2018). These cytokines further contribute to cachexia, which is fatal. Tumor burden was the most common immediate cause of death.

The cancer cells metastasize to other body organs such as the brain, liver, bones, kidney, and heart. In the brain, these tumor cells may have a mass effect whereby they compress major structures, especially nerves and blood vessels (Nichols, Saunders, Knollmann, 2012). They cause seizures, headaches, changes in vision, changes in speech, nausea and vomiting, peripheral weakness, and memory loss. In the liver, cancer cells may obstruct bile ducts leading to obstructive jaundice. They may also interferer with the formation of bile, leading to the accumulation of bile salts in the skin and itching. Other metabolic functions of the liver, such as deamination, detoxification, and formation of proteins, may also be impaired (Nichols, Saunders, Knollmann, 2012). Toxic substances, especially chemotherapy drugs, are not going to be detoxified effectively and may accumulate to dangerous levels.

Lung cancer may also spread to the bones, especially the spine, pelvis, humerus, and femur. It compresses the spinal cord causing severe bone pain, weakness of the limbs, and inhibits bowel and bladder function (Nichols, Saunders, Knollmann, 2012). The patient often has difficulty emptying his bowels and bladder. Metastasis to the bone may also increase bone dissolution leading to hypercalcemia and interfering with bone integrity, which ultimately causes fractures. When calcium levels accumulate in the body above the normal range, the patient experiences abnormal heart rhythms, muscle weakness, fatigue, high blood pressure, frequent urination and feeling of thirst, confusion, fatigue, and digestive problems (Kumar, Abbas & Aster, 2018).

The kidney is an uncommon site of lung cancer metastasis. Renal metastases rarely present symptoms. However, it may lead to a decrease in the number of functioning nephrons in both or one kidney resulting in end-stage renal disease. In end-stage renal disease, the kidneys cease to function, leading to the accumulation of nitrogenous wastes in the body, impaired acid-base balance, and decreased production of certain hormones such as renin (Kumar, Abbas & Aster, 2018). All these changes are fatal and eventually lead to death. Lung cancer may metastasize to the heart and blood vessels. When it spreads to the heart, it causes dysrhythmias, which may result in death. It also causes occlusion of major blood vessels leading to decreased oxygen supply to vital organs, necrosis, and ultimately organ failure.

In the lungs, lung cancer causes respiratory failure. Respiratory failure is common in lung cancer patients with underlying lung disease (Nichols, Saunders, Knollmann, 2012). It leads to a reduction in functional lung tissue and a reduction in the number of alveoli. It also blocks the airways, especially bronchi, thus impeding the movement of air inside and outside the lungs. The lungs become less elastic and cannot expand to their full capacity (Kumar, Abbas & Aster, 2018). This leads to a reduction in the lung capacity, reduced oxygenation of the blood, and accumulation of carbon (IV) oxide in the blood.

It is important to note that lung cancer sets in motion a set of metabolic processes that ultimately lead to death. Most organs, especially the lungs and liver, fail due to increased tumor burden.

Treatment Options

Medications

Treatment of lung cancer depends on the stage and extent of spread. Medication involves chemotherapy, targeted therapy, and immunotherapy (Lemjabbar-Alaoui et al., 2015). Chemotherapy treatment is mainly used for small cell carcinoma of the lung because this type of lung cancer responds well to treatment. However, chemotherapy can also be used for non-small cell carcinoma. The chemotherapy drugs target and destroy metastasized cancer cells. For small cell carcinoma, cisplatin or carboplatin is combined with either etoposide or gemcitabine. For non-small cell carcinoma, cisplatin, or carboplatin, is combined with etoposide, paclitaxel, pemetrexed, vinorelbine, or gemcitabine (Lemjabbar-Alaoui et al., 2015). Chemotherapy is usually carried out in a cancer health facility. Targeted therapy is similar to chemotherapy, but it targets only cancerous cells without affecting healthy cells (Cagle & Chirieac, 2012). Immunotherapy is aimed at helping the patient’s immune system fight off cancer. Immunotherapy drugs include bevacizumab and atezolizumab.

Comfort Measures

Comfort is provided to lung cancer patients through palliative care. When a patient is under chemotherapy treatment, he often experiences numerous side effects such as nausea and vomiting, pain, fatigue, constipation, diarrhea, depression, and insomnia. Palliative care is used to relieve these symptoms and any other symptoms of lung cancer that lower the patient’s quality of life (Simoff et al., 2013). Palliative care involves drugs such as antiemetics, pain medications, thrombolytic agents, purgatives, antidiarrheal drugs, and antidepressive drugs. It may also include things such as massage and relaxation to improve the mental health of the patient (Simoff et al., 2013). Palliative care can be offered at a hospice facility or home by a trained palliative care team.

Role of other Medical Professionals in Treating the Disease

Apart from doctors and nurses, other medical professionals are also involved in the management of a patient with lung cancer. These include pharmacists, nutritionists, and mental health professionals (Levit et al., 2013). Pharmacists give out the drugs prescribed by the doctor and answer any questions about these drugs. Nutritionists are there to cater to dietary changes that are necessitated by lung cancer. They provide information on how to adequately meet the patient’s nutritional requirements without worsening the side effects of treatment (Levit et al., 2013). Mental health professionals such as psychiatrists, psychologists, and counselors cater to the mental health of the patient by guiding them towards a path of acceptance.

Point of no Return

When lung cancer proceeds to stage four, remission becomes a pipe dream. The fourth stage is considered the point of no return because, at this stage, death is imminent (Lim, 2016). As the patient nears his death, various noticeable changes take place. The patient becomes extremely weak and can barely move around on his own (Lim, 2016). His interest in foods and drinks depreciates, and he often experiences difficulty swallowing drugs. The patient’s pain increases and is not relieved by stronger pain medications such as opioids (Lim, 2016). The patient also experiences involuntary muscle movements, is confused, disoriented, and shows very little cooperation with caregivers.

Lessons Learnt

Taking this course puts me at a better place in assisting lung cancer patients and their families. I have acquired empathy, which enables me to understand the needs of the patients and their families. Patients with chronic diseases such as cancer are often in denial and, therefore, tend to be highly irritable. Their family members also experience significant mental torture due to financial strain and the fear of losing a loved one. Being empathetic makes me more compassionate to both the patient and the family. It also makes me a more holistic health care worker who not only focuses on alleviating pain but also on meeting the patient’s emotional, psychological, and spiritual needs.

References

Cagle, P. T., & Chirieac, L. R. (2012). Advances in Treatment of Lung Cancer with Targeted Therapy. Archives of pathology & laboratory medicine, 136(5), 504-509.

Kumar, V., Abbas, A., & Aster, J. (2018). Robbins Basic Pathology (10th ed., pp. 526-531). Philadelphia: Elsevier, Inc.

Lemjabbar-Alaoui, H., Hassan, O. U., Yang, Y. W. & Buchanan, P. (2015). Lung cancer: Biology and treatment options. Biochimica et Biophysica Acta (BBA)-Reviews on cancer, 1856(2), 189-210.

Levit, L. A., Balogh, E., Nass, S. J., & Ganz, P. (Eds.). (2013). Delivering high-quality cancer care: charting a new course for a system in crisis (pp. 7-8). Washington, DC: National Academies Press.

Lim, R. B. (2016). End-of-life care in patients with advanced lung cancer. Therapeutic advances in respiratory disease, 10(5), 455-467.

Nichols, L., Saunders, R., & Knollmann, F. D. (2012). Causes of Death of Patients with Lung Cancer. Archives of Pathology & Laboratory Medicine, 136(12), 1552-1557.

Simoff, M. J., Lally, B., Slade, M. G., Goldberg, W. G., Lee, P., Michaud, G. C., & Chawla, M. (2013). Symptom management in patients with lung cancer: diagnosis and management of lung cancer: American College of Chest Physicians. Evidence-Based Clinical Practice Guidelines. Chest, 143(5), e455S-e497S.