Needs of Critically Ill Cancer Patients and their Relatives: Nursing Perspectives

Care of patients in intensive care units (ICUs) need highly qualified health care team including nurses. Critical care nurses provide high skilled evidence-based care for all admitted patients to critical care units. Patients are admitted to critical care units for many reasons as they have or at risk for life-threatening problems mainly; respiratory, circulatory, neurological and renal. Patients with cancer are exposed to different treatment modalities such as surgery, chemotherapy, radiation and others. Taccone et al. [1] studied the characteristics and outcomes of patients with cancer in CCUs and reported that a large proportion of patients in ICUs had cancer. It was reported that every sixth to eighth critical care unit patient admitted because of the underlying malignant disease [1,2]. Patients with cancer may be admitted to ICUs for treatment of the associated side effects of cancer management or for follow-up treatment [2]. Many cancer- related complications such as malignancy-related airway obstruction, hyperleukocytosis, tumor lysis syndrome, drug reactions to immune and/or chemotherapy, stem cell transplant-associated conditions, hemorrhage, electrolyte disturbances, and thrombotic microangiopathies are considered causes for admission of patients with cancer to ICUs. Cancer was not considered from the admission criteria to ICUs, in the past. However, patients with advanced complications related cancer may develop multiple distressing symptoms which result in admission to ICUs [3-5].
Despite the advances in technology and science which aid in prevention, early detection, management of cancer, the incidence, consequences of cancer on the patients, their families/relatives and the society still high. Studies reported that the mortality rate because of cancer is higher than all types of stroke and cardiovascular diseases. In addition, the mortality rate is high in hospitals especially in ICU [3-6]. Azoulay et al. [4], studied the prevalence and factors of ICU and found that conflicts care of critically ill patients with cancer may have a negative impact on the patient, their family, and the ICU team members. The nature of cancer & its consequences, and the uncertainty about the future, make the patients and their relatives suffer from a lot of physiological, and psychological problems. Therefore, they need extra-care to meet their physiological, psychological, and spiritual needs4. Nurses’ role for care of critically ill cancer patients focuses on assessing, educating the patients, coordination of care, provision of direct care, symptom management, and supportive care [7-9]. Critically ill cancer patients -despite the innovative therapies- may be near the end of life and can have several episodes of clinical deterioration because of increasing tumor burden or as a side-effect of therapies. Hillman [10] & Jones et al. [11] stated that aggressive interventions may not always be in the preferred measure. Similarly, Khan et al. [12] revealed that goals of care in the stage of life, should be focused on decreasing suffering and distress by alleviating the symptoms. These interventions are recognized as critical components of excellent end of life care for patients, family and nurses, and can be implemented in intensive care units. Care of patients with cancer require nurses to be expert in providing high quality care. It is essential to understand the needs of patients with cancer in order to provide effective ways of caring. Care of patients with cancer is based on many aspects of care such as emotional and the moral, cognitive aspect, perception, and knowledge. Cancer affects family members and relatives. The diagnosis of cancer precipitates complex feelings and changes in the lifestyle which become as overwhelming for patients ‘family and relatives. Relatives of critically ill cancer patients may have many physiological, psychological changes as they support, help, and provide care for their patients. The relatives were suffering from many unexpected bad experiences with these patients during their journey of treatment from cancer. When patients with cancer are admitted to ICUs, sufferings of their families increased as they may have little experience with life-threatening illness, they even feel don does not know how and what to do for their patients. Recognizing the relatives’ needs and meeting them will have an important role in improving the quality of patient care and the quality of their life [8-10].
Patients with cancer and their families often need to understand what is happening in the critical care unit, they discuss the reasons, advantages of being on mechanical ventilation, renal replacement therapy, vasoactive agents, or other life-sustaining treatments modalities in ICUs. They also have unsolved queries about whether part or all these supportive therapies can be administered with cancer-specific treatments, including chemotherapy at the same time. More recently, the lack of survival benefit in patient with cancer who is admitted to ICUs with multiple organ failure has raised concerns about the timing of ICUs’ admission [4,5]. Han et al. [13] investigating the coping styles and social support among relatives of patients with cancer and reported that both patients and their relatives need support in order care for patients during this challenging time and to cope with presence of this disease. Many studies reported that effective care of critically ill cancer patients rely on identifying and meeting their needs [14-16]. There are few studies examined the needs critically ill cancer patients and their relatives from the nursing perspectives. Therefore, this study was conducted to identify critically ill cancer patients and relatives’ needs from the nursing perspectives. In order to achieve this aim, the following research question was addressed; what are the needs of critically ill cancer patients and their relatives in intensive care units?

A. Study design: A descriptive study design was used in this study.

B. Setting: The study was conducted in 10 intensive care units in Alexandria (2 ICUs in a university teaching hospital, 2 ICUs of a health insurance hospital, 6 ICUs in private hospitals).

C. Participants: the participants were chosen through the purposive sampling technique who were providing care for critically ill cancer patients and communicating with their relatives. Sixty critical care nurses working in the previously mentioned ICUs agreed to participate in the study. Nurses were distributed as their working ICU; 9 from ICUs of the university teaching hospital, 6 from ICUs of the Health Insurance Hospital, and 45 nurses from ICUs of the private hospitals.

D. Tool: Care needs of Critically ill cancer patients and their relatives semi-structured interview schedule”, this tool was developed by the researchers based on reviewing the related literature [14-20]. It was used to describe the needs of critically ill patients and their families in intensive care units. This tool covered 26 items geared towards caring of critically ill cancer patients and 30 items related to relatives’ needs in ICUs. These items were distributed into six main broad categories of (CANCER) including the following: (C) Criteria and causes for admitting cancer patients to ICUs, (A) Action; the medical/surgical actions performed to the critically ill cancer patients in ICUs, (N) Nursing; nursing interventions performed to the critically ill cancer patients in ICUs, (C) Communication needs for the critically ill cancer patients in ICUs, the (E) End of life care performed to the critically ill cancer patients in ICUs, and (R) Relative’ needs; this part measured nurses’ perceptions of the needs of relatives of critically ill cancer patients. All parts were scored using 5 points Likert scale ranging from 0 to 4 (0=not important at all to 4=Absolutely Essential). The tool also includes open questions to make nurses express their perceptions freely and strengthen the data collected. Tool preparation, validity, and reliability: The tool of the study was developed by the researcher based on reviewing the related literature [14-20] and tested by five academic experts (three from the Faculty of Nursing and two from the Faculty of Medicine of University of Alexandria), and 10 nurses from hospitals for content related validity and the necessary modifications were done accordingly. The tool was tested for its reliability using interrater reliability. The reliability coefficient was (r) =0.83). A pilot study was conducted on 5 nurses to test the clarity, applicability and feasibility of the tool (those nurses were not included in the study). Appropriate modifications were performed prior to data collection for the actual study.

To collect data, semi-structured interviews were held from the beginning of June to the end of August 2018. Each nurse was interviewed individually once by the researchers using the tool. Nurses were interviewed in the morning, afternoon, and at the beginning of the night shift during their break time. Each interview lasted from 20 to 30 minutes. Data were coded and entered in statistical program to be analyzed. Administrative design and Ethical considerations: A letter was submitted to the ethical committee and hospitals directors contains the purpose, the required participants, the tool, and methods of data collection of the study to obtain their approval. Before starting the interviews, an explanation of the study aim was done and the confidentiality, anonymity, right, refuse to participate, or withdraw from the study were emphasized to them. Consent was taken from nurses who agreed to participate in the study.

The data were entered into SPSS system files (SPSS package version 20) using personal computer. Output drafts were checked against the revised coded data for typing and spelling mistakes. Finally, analysis and interpretation of data were conducted. Descriptive statistics including frequency and distribution were used to describe different characteristics.

The results of the study are illustrated in two parts: nurses’ perception of care of critically ill patients with cancer and regarding their role toward relatives of critically ill patients with cancer. Part I: Nurses’ perception of care of critically ill patients with cancer Nurses stated that ICUs accept admission of critically ill cancer patients. Regarding criteria/reasons of admission to ICUs; the more common reason is performing surgery (80%) followed by respiratory emergencies (70%), shock (50%), bleeding 40% and electrolyte disturbance (30%). As for the medical/surgical actions performed to the critically ill cancer patients in ICUs; the most performed actions were administration of analgesics (70%), initiation of mechanical ventilation (60%), and monitoring effects of chemotherapy & radiotherapy (50%) as shown in (Table 1).

Table 1:Criteria for ICU admission and Medical/surgical actions performed to critically ill cancer patients in ICUs as reported by nurses.

Table 2: Nursing interventions performed to the critically ill cancer patients in ICUs.

Regarding the nursing interventions performed to the critically ill cancer patients in ICUs (Table 2); nurses agreed that care of cancer patients is the same care for any critically ill patient in general as they provide care of mechanically ventilated patients (100%), oxygen administration (60%), blood transfusion (40%), in addition to cancer-related care such as monitoring during chemotherapy & radiotherapy (50%), and they need psychological support (60%). There are special considerations for care of critically ill cancer patients as reported by nurses such as psychological/spiritual care and communication and information (100%), strict infection control measures (70%), and control of bleeding (30%). As for the end-of-life care, many aspects are performed for critically ill cancer patients such as administration of pain relief medications and termination of CPR (100%), basic nursing care (80%), psychological/spiritual care (60%), and allowing extra visits for relatives (70%) were provided to the critically ill cancer patients in ICUs as end-of-life care measures. Part II: Nurses’ perception regarding their role toward relatives of critically ill patients with cancer: nurses stated that admitting cancer patients to the ICUs means a lot of cost, stress, and depression to their relatives. As stated by nurses, relatives had feelings of sadness, depression and were crying and over-caring of their patients.
Nurses reported that relatives of critically ill cancer patients have many needs; all nurses (100%) reported that relatives’ needs to have questions answered honestly, know how the patient was being treated, frequently see their patient, and feel that the ICU health care team cared about their patient, are essential for relatives from their point of view. Most nurses reported that the essential relatives’ needs are to know the prognosis, talk with the nurse each day (98.33%) followed by; understand the reasons behind the especial management performed for their patient, be informed about any changes in the patient’s condition even they are at home, and their patient is receiving the best possible care (96.67%) and receive information daily regarding the condition of their patient, have adequate explanations of understandable terms related to their patient that are and talk to the doctor every day (90%). However, some relatives’ needs are of little importance or not important at all from the nurses’ perspectives such as have a telephone in the waiting room (13.33% and 48.33%), regarding social support; relatives need to be told about other hospital staff who could help with their problems (20 &30%), know types of ICU staff who is taking care of their patient (20 &30%), and have explanations/orientation of the ICU environment before admission (18.33 &20%) as shown in (Table 3).

Table 3: Needs of critical cancer patients as perceived by nurses.

Intensive care unit admission of critically ill cancer patients had many challenges in the past two decades. Many ICUs were refusing the admission of cancer patients because many their chronic disease, options of treatment are limited, patients spend a little time in ICU& die before ICU discharge. In-hospital mortality rates for cancer patients are less than mortality rates of critically ill patients [3]. However, the survival rates of critically ill cancer patients are less than other critically ill patients. In this study, nurses accepted the rights of critically ill cancer patients to be admitted to ICUs and have the required care. This is in line with Azoulay et al. [9] who reported acceptance of critically ill cancer patients’ admission to the ICUs which lead to improvement in the survival rates of these critical ill patients. This improvement in survival rate was reported in many studies for patients who needed management with vasopressors, mechanical ventilation, and renal replacement therapy. Studies found that appropriate admission of critically ill cancer patients help improving their disorders and their survival rate [2,4,5].
The findings of this study revealed that the criteria for admitting cancer patients to ICUs from nurses’ point of view are surgery, respiratory emergencies, shock, bleeding, and electrolyte disturbance. Several studies agreed with our results and revealed that managing cancer patients in ICUs through using of more targeted therapeutic regime, providing intensive chemotherapy treatments and innovative therapeutic approaches especially for cancerrelated complications resulted in improving the cancer cure rate. Cancer-related complications can lead to organ dysfunction mainly respiratory failure which necessitates ICU admission. Management of cancer patients with organ dysfunction requires specialized skills and holistic care which is received in ICUs [3]. Critically ill cancer patients receive many ICU actions as they conditions require. In this study, nurses stated that critically ill cancer patients admitted to ICUs to receive analgesics, intubation, chemotherapy & radiotherapy, and blood transfusion. This was also reported by many studies, who is stated that cancer patients admitted to ICUs for mechanical ventilation support, renal replacement therapy, and vasopressors and monitoring for chemotherapy & radiotherapy [5-13]. In this regard, a general improvement in CCUs mortality of cancer patients was reported over time, the reason for this improvement may because of improvement of ICU management, development of more targeted therapies, using more intensive chemotherapeutic treatments, and advances in supportive care [3,12,20]. Soares et al. [4], stated that advances in oncology and intensive care are probably being translated into a better outcome [21].
Care of critically ill cancer patients as care for any critically ill patients as nurses stated in this study and added that those patients need more psychological support and communication. Critically ill cancer patients most important needs include management of manifestations, psychological, emotional, and social spiritual needs. Meticulous care of these patients during the ICU period is essential to ensure successful outcomes. Critical care nurses must identify and interpret patients’ manifestations for formulating the required plan of care [22-24]. Critically ill cancer patients may be admitted post-operative, and intubated, have multiple connections need continuous monitoring and high-quality nursing care. Nurses reported that, cancer patients have many aspects of care in ICU such as management for the artificial airway, care for patients with mechanical ventilation, management of pain, electrolyte disturbances and others. Critically ill patients have many psychological and emotional problems such as anxiety, fear, and depression. Therefore, they need support and reassurance [24,25]. Relief of pain, providing emotional and psychological support are main aspects of care of critically ill cancer patients as perceived by nurses. Collins et al. [17] stated that the five important roles of care of critically ill cancer patients are being with the patient, vigilant respiratory system assessment, patient education and support of family or caregivers, care coordination, and pain management. There are significant communication exchanges between patients and non-physician health professionals [26]. Critically ill patients in general have a low immunity because of many factors; such as their disorders, age, invasive lines and machines, and malnutrition. Critically ill cancer patients may be under chemotherapy which make them at-risk for many complications. Critical care nurses present all the time with patients and see their sufferings and the effects of therapy on them which result in alterations in their selfesteem and body images [3,25,26]. Therefore, nurses reported that there are special considerations for their care, which are infection control measures, communication/information spiritual care, psychological support, and end of life care.
These considerations were assured by many studies. Communication needs are essential for critically ill cancer patients because they suffered a lot from cancer and cancerrelated management & complications. These patients be afraid, anxiety, depression and may lose their hope to retain to their lives. ICUs are full of machines, noise, life-threatening conditions, and resuscitation efforts, which precipitate stress for patients. In addition, ICU admission make them think that the life will end in the ICU. All patients need to have explanation for everything done for them, they need to practice their right to decide what will be done for them if they can, they can participate in their care and need everyone to dealt with them with trust of their power and respect [3,25-28]. Nurses allow the critically ill cancer patients to express their thoughts, and talk freely about their fear, sadness, and anxiety. Critically ill cancer patients need to have the care provider to be with them in all their suffers and help them to combat their disease and cancer related- complications [25].
Termination of CPR is performed for terminally ill cancer patients as our results revealed. This agrees with Gendt et al. [27] who reported that nurses may decide not to start cardiopulmonary resuscitation (CPR) for a patient without DNR status as it is considered a futile procedure for them. Providing a good death was the major theme of the result of Beckstrand [28] study and specific suggestions were offered to ensure death with dignity and peace. His study listed critical care nurses’ suggestions to improve endof- life care in ICUs which are; management of pain & discomfort, recognizing and following the patient’s wishes regarding end-oflife care, promoting of earlier termination of aggressive treatment, not allowing the patient to die alone, communicating effectively as a healthcare team, and educating others about quality end-oflife care [28]. a major ethical issue facing nurses in ICUs is donot- resuscitate (DNR). Many critically ill cancer patients have DNR order which means providing care including all medical interventions except vasopressors, and CPR but providing spiritual care, pain relief management, comfort measures, and other basic patients’ needs [29-31].
The most technologically sophisticated care is provided for patients in ICU, to manage their life-threatening problems, while restoring the quality to their lives. Many studies have reported that nurses participate in end-of-life decision making with the other health care team and provide care for patients and their relatives in this stage. In this study, nurses reported that patients’ needs for spiritual and psychological care. They need to feel that all people care of them, they need to see their relatives and closed ones. Nurses stated that they try to allow more flexible visiting hours. In the same line, Carlson et al. [32] reported that nurses allow more free visiting hours as they can and, in some cases, nurses tend to decrease the visiting time as the patients ‘condition allow. Some studies revealed that nurses may restrict relatives visit if the ICU is busy [33-35]. However, in other studies, nurses insist on restrictions in the visiting hours because they see that ICU is a busy work area, too small to care for patient and allow for extra-visitation at the same time. Pediatric nurses were very resistant to allow parents to visit their children despite they perceived themselves as family friends [36]. Relatives of critically ill cancer patients have many emotional and psychological problems. They are with their patients in all the disease process. Relatives of critically ill cancer patients are always presenting and share in making crucial decisions about the patients’ care & management. Studies found that the most important relatives needs are; to be present with their patients as they can, information needs, and can ventilate their feelings. The top important relatives’ needs as reported by Ghabeesh et al. [31], are being certain that the care given for their patients is the best, health team members are caring about their patients, and the health team members answer their questions honestly. In our study nurses’ perceived relatives’ needs are more than important for them, they express their understanding of their sufferings with their patients. Nurses demonstrated that the most important relatives’ needs are; information needs {answering the questions honestly, know the progress of their patients frequently, can be informed about any changes in their patients’ conditions even if they are at home, security& assurance needs such as know how their patients was being treated and managed in the ICU, assure that the health care team care about their patients, can talk with the health care team as they need, and have adequate explanation for what is being done for their patients, and support & comfort needs such as {can see the patient frequently, and have support from others, and can express their feeling.
Results of the study are consistent with many studies. Maxwell et al., revealed that the most important relatives’ needs are, assurance, and information regarding management of patients in ICU. Safety and information needs are the most important relatives’ needs as reported by Padilla-Fortunatti et al. [29]. Ashrafian et al. [30] described the relatives’ needs as social, cognitive, and psychological needs and stated that relatives’ needs are important. However, some of these needs are not perceived valuable by the health care team and not met effectively, such as giving the relatives the needed explanation and information, understanding of the heath care team of their feelings and sufferings, and communication needs. Many important decisions are taken by the critically ill cancer patients ‘relatives in ICUs, therefore, relatives of these patients need enough information, explanation of difficult complex medical issues, empathy, psychological support to relieve their anxiety and help them to have at least a comfortable life while their patients in the ICU [37-42]. This study raises the issues of needs of critically ill cancer patients and their relatives in ICU regarding support either through giving adequate clear information, effective communication and psychological support. This study described the needs of critically ill cancer patients and their relatives from the nursing perspectives. Data collection in this study was conducted in different hospitals including private, health insurance and university hospitals which is considered a strength for this study. However, there are some limitations of this study, identifying critically ill cancer patients and relatives’ needs from only the nurses’ perspectives, it may be more relevant to take the perceptions of critically ill cancer patients and their relatives to determine their needs. In addition, limited studies performed regarding needs of critically ill cancer patients and their relatives made the discussion difficult.

Management of critically ill cancer patients is a challenging task. Nurses stated that the criteria for admitting cancer patients to ICUs are surgery, respiratory emergencies, shock, & bleeding and electrolyte disturbance. Critically ill cancer patients admitted to ICUs to receive analgesics, intubation, chemotherapy & radiotherapy, and blood transfusion. Care of critically ill cancer patients is the same care of any critically ill patient. Critically ill cancer patients need special approaches for communication. Relatives of critically ill cancer patients have many needs include information, communication, and psychological needs.

The researchers are grateful to nurses of the selected critical care units for their cooperation and participation in this study. Special thanks to all hospital’s administrators for their cooperation.

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