Guide for Residents and Fellows on Med E
Contents
1. Overview
2. Contact information
3. Hematology/Oncology Inpatient Curriculum per the ABIM
4. Discharge Planning reminders
5. Documentation Tips
6. Recreation Therapy
7. Living Spiritually with Cancer
8. Algorithm for patients with Bone metatases
9. Chemotherapy Concepts
10. Pharmacy Issues
a. Use of Acid Suppression in heme onc patients
b. Guideline for Antiemetics in Oncology. Kris M, Hesketh P, Somerfield M, et al
J Clin Oncol 24:2932-2947. 2006
c. White Blood Cell Growth Factors
i. Smith TJ, Khatcheressian J, Lyman G, et al. 2006 Update of recommendations for the use
of white blood cell growth factors: an evidence based clinical practice guideline. J Clin
Oncol 24: 1-19. 2006
d. Tumor Lysis Syndrome
Bertrand Coiffier, Arnold Altman, Ching-Hon Pui, Anas Younes, and Mitchell S. Cairo.
Guidelines for the Management of Pediatric and Adult Tumor Lysis Syndrome: An
Evidence-Based Review. J Clin Oncol 26:2767-2778. 2008
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Med E 4 Oncology
Overview
Goals for the Service
1. Provide excellent patient care
2. Learn from every patient
3. Learn about the interdisciplinary approach to Cancer Care
A few Highlights
 Form and talk about a discharge plan at the time of admission!
 Communications is Key!
o Expect and welcome nurses to join work rounds
o Update Rounds Report
o Interdisciplinary Rounds
 11:15 daily Monday – Friday
 Work Rounds
8:30 – 10:30
This time slot is split between the two attendings so decide before
you start how much time you need for each.
 Run the lists first
 Are they correct?
 Who is ready to go?
 Make rounds on all patients except super stable patients.
o Acknowledge the patient
 Knock before entering
 Eye contact
 TURN OFF THE TV!
 Ideally sit down by the bedside
 Switch attendings half way through
o Introduce yourself and everyone else entering the room – student or intern speak
 Explain everyone’s role
o Duration
 Set expectations for the encounter – how long will you be in the room?
o Explain plans
 Ask for questions
 Clarify the patient’s expectations
o Say “thank you” to the patient
o Use the White Board
 Teaching Rounds
o 2pm M-T-W-F
 Documentation
o Perform and document complete history and physicals
o It is not appropriate for housestaff or students to take short-cuts such as “no focal findings” on
neurology exam or “clear” on lung exam.
o Be sure to perform and document a complete Review of systems and family history
(noncontributory” is unacceptable)
 Presentations
o Goal of 3 minutes for even the most complicated patient. Focus only on pertinent positives and
negatives.
 Reading
o Everyone should be doing background reading on their patients (review articles UptoDate, Med E
handbook, www.NCCN.org, www.cancer.gov).
2
o
I.
II.
III.
Residents should PubMed select patients and share results/summarize for team
Communication
a. With the RN
i. Make sure to communicate plan of care with RN (ASAP with any discharges or stats meds)
ii.
Plan discharge as much as possible a day or several days in advance
b. With the Patient
i.
Discuss plan of care as much as possible
ii.
Ask if they have any questions or if there is anything else you can do for them
before
leaving the room.
c. With the Care Coordinators
i.
Any issues you know about need to be communicated ASAP to help avoid delays (IV
antibx, rides, change in living situation, etc)
Rounds
a. RN input during rounds
i.
The RN caring for the patient for the shift will attend rounds outside the room as able. If you
need to communicate directly with the RN their name is identified on the marker board on
each side of the unit and they carry individual phones to ease communication.
b. White boards (anyone can/should write on these)
i.
Make sure to put MD group
ii.
Plan of care for the day/dc goals/tentative date of dc
iii.
Markers-carry one with you or ask the HUC for one
Other
a. NO OVERHEAD PAGING
i.
Dedicated phone numbers in each work rooms
b. Rounds Report
c. There is an otoscope and portable Doppler in the A side team work area.
d. If you have questions or concerns about how the service runs please contact the nurse leader, Crista
Creedle or the service leader, Frances Collichio. Dr Collichio can be reached best by email.
fcollich@med.unc.edu
3
MDE Contact information.
4ONC A side 966-1661,
4ONC B side 966-1956,
BMTU 966-7792
Workroom A side
445-5426, fax 843-3890
Workroom B side
445-5421, fax 843-0299
Case Manager A side
Angela Greene 216-0599, 6-5504
Case Manager B side
Tonya Thompson 347-0210, 6-8102
Charge nurse, 4ONC
445-7542
Hematology Oncology
966-1672 Clinic, 966-4431 Office, 966-6735 Fax
Hem Onc appointments
966-0000 and follow the prompts
Appts for fellow pts
Sandy Smila 6-3093
Home Infusion/TPN
Fran Davis/ Linda McElveen/ Pam Miller 123-4280
Nurse Manager
Crista Creedle 347-1911, 6-4501
Assistant Nurse Manager
Ann Marie Walton 347-0023, 6-1696
Nutrition
Jennifer Spring 123-2431
Palliative Care Program
Chip Baker 216-1549, 3-3650
Pharmacy
Larry Buie 216-1144, Jill Bates 216-9497
Pastoral Care
Patricia Cadle 347-0942, 123-3288, 6-4021
Physical Therapist
Emily Lemons Sourisak 123-3410, 6-2056
Occupational Therapist
Tim Holmes 123-2766
Physician Assistant
John Strader 216-6420
Research Nurse
Rey Garcia 216-2763
Radiation Oncology
6-9060, 6-1101
Resident Assistant
Brenda Joyner 347-1770
Speech Therapist
62347
Surgical Oncology Consult Pager
123-7083
Utilization Manager
Claire Riggsbee 347-0706, 6-3938
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Hematology/Oncology Inpatient Curriculum
Updated 6/2008. Topic Information from the American Board of internal medicine web site.
1. Acute Leukemias
a. ALL
b. AML
i. Genetics of AML
c. Clinical Presentation of Acute Leukemias
i. Laboratory Diagnosis
ii. Bone Marrow Examination
D. General Therapy for Acute Leukemia’s
i. Therapy for ALL
ii. Therapy for AML
Tallman MS, Nabhan G: Acute promyelocytic leukemia: evolving therapeutic strategies. Blood. 2002 Feb
1;99(3):759-67.
2. Sickle Cell Disorders
3. Febrile Neutropenia and infected catheters
Mermel LA et al: Guidelines for the management of intravascular catheter related infections. Clin Infect Dis
32:1249, 2001
4. Thrombotic Disorders
a. Major Risk Factors
b. Laboratory testing in thrombotic disorders
c. Management of a thombotic defect
d. Treatment and prevention of Thrombosis
5. Breast Cancer
a. Risk Factors for breast cancer and risk reduction strategies
b. W/U of a suspicious breast mass
c. Primary therapy for a newly diagnosed breast cancer
d. Systemic therapy for breast cancer
e. Quality of life in breast cancer survivors
Fisher B et al: Twenty-year follow-up of a randomized trail comparing total mastectomy, lumpectomy, and
lumpectomy plus irradiation of the treatment of invasive breast cancer. N Engl J Med 347:1233, 2002
Wong ZW, Ellis MJ: First –line endocrine treatment of breast cancer: Aromatase inhibitor or antiestrogen? Br J
Cancer 90:20, 2004
Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an
overview of the randomized trails. Lancet 2005; 365, 1687
Ravdin PM et al: Computer program to assist in making decisions about adjuvant therapy for women with early
breast cancer. J Clin Oncol 2001; 19:980m
5
.
6. Colorectal Cancer
a. Risk factors for colorectal cancer
b. Clinical features of colorectal cancer
c. Staging of colorectal tumors
d. Management of resectable colorectal tumors
e. Post resection surveillance in colorectal cancer
f. Management of patients with metastatic colorectal cancer
Baron J et al: A randomized trial of aspirin to prevent colorectal adenomas. N Engl J Med 348:391, 2003
Walsh JME, Terdiman JP: Colorectal cancer screening; JAMA 289:1288, 2003
7. Lung Cancer
a. Clinical presentation of lung cancer
b. Diagnosis and treatment of lung cancer
c. Non-Small Cell Lung cancer
d. Small Cell Lung cancer
American College of Chest Physicians: Diagnosis and management of lung cancer: ACCP evidence based
guidelines. Chest, 123:1S, 2003
8. Cancer of Unknown Primary Site
a. Adenocarcinoma of Unknown primary site
b. Squamous cell carcinoma of unknown primary site
c. Poorly differentiated carcinoma of unknown primary site
Hainsworth JD, Greco FA: Management of patients with cancer of an unknown primary site. Oncology 14:563,
2000
9. Lymphadenopathy, lymphoma and Multiple Myeloma
Diehl V et al: Part II: Hodgkin’s lymphoma---Diagnosis and treatment. Lancet Oncol 5:19, 2004
Barlogie B et al: Treatment of multiple myeloma. Blood 103:20, 2004
10. Prostate Cancer
a. The screening controversy
b. Treatment of prostate cancer
c. The Gleason Score
d. Comparison of Treatment modalities
e. Sequelae of treatment in prostate cancer
f. Management of recurrent prostate cancer
Nelson WG et al: Prostate cancer. N Engl J Med 349:366, 2003
11. Testicular Cancer
Bosl GJ et al: Testicular germ-cell cancer. N Engl J Med 337:242, 1997
6
12. Oncologic Emergencies
a. Metabolic Emergences (Hypercalcemia, Hyperuricemia, and Hyponatremia)
b. Hematologic Emergency: DVT
c. Mechanical Emergencies (Spinal Cord Compression, SVC, Pericardial Effusión and Tamponade)
Strewler GJ: The parathryid hormone-related protein. Endocrinol Metab Clini North Am. 29:629,2000
Yim BT et al: Rasburicase for the treament and prevention of hyperuricemia. Ann Pharmacotherapy 37:1047,
2003
13. Chemotherapy, biotherapy and hematopoietic colony stimulate factors:
2000 update American Society of Clinical Oncology : Update of recommendations for use of hematopoietic colony
stimlating factors: Evidence-based clinical practice guidelines. J Clin Oncol. 2000 Oct 15;18(20):3558-85
14. Antiemetics
Wiser, W. Practical management of chemotherapy-induced nausea and vomiting.
Oncology (Williston Park). 2005 Apr;19(5):637-45. Review.
15. Pain Management
Levy MH: Pharmacologic treatment of cancer pain. N Engl J Med 335:1124, 1996
7
D/C Planning Reminders
*Case manager notes are in WEBCIS under Care management/discharge planning
*Nursing, Speech and Nutrition notes are in E Chart.
*PT/OT notes are in E Chart.
SNF/ ALF
FL2 signed by MD
Yellow DNR/DNI form signed if applicable
RX for narcotics
FULL DC summary
DOC
Resident/ Intern Call DOC at 733-0800
FULL DC Summary
HH/Home IV Infusion
Resident/ Intern to Notify PCP re: HH referral
BRIEF Discharge Summary
*If pt. lives out of state, confer with CM re: transport and out of state physician
to sign home health orders
Home Hospice
RX for all meds
Yellow DNR/DNI form signed if applicable
Verification of Hospice MD
FULL DC summary
Inpatient Hospice
RX for narcotics
Yellow DNR/DNI form signed
FULL Discharge Summary
New Dialysis
Order Hep B panel, Hep C, Albumin, EKG, CXR,
Vein Mapping, PPD
FULL DC Summary
CHECK W/ CASE MANAGER BEFORE SIGNING FULL D/C SUMMARY IF PT HAS ANY OF THE ABOVE!!!
DME
RX
Write RX with Diagnosis, height/weight, duration of need
Home Oxygen RX
Flow rate, Duration of need, RA sat of < 88% within 2 days of d/c, diagnosis,
“portable and concentrator”
Tube Feeds RX
Helpful to Copy recommendation from Nutrition consult. Include diagnosis,
height/weight
Flush RX for PICC line
(if not in use)
Dressing change kits (1/week)- may need additional
Prefilled Heparin Flush 100 units/ml (3ml in 10ml syringe)
Flush QD each Lumen, # refill
Change claves twice per week (4/week)
8
(if in use)
Flush RX for Hickman
(if not in use)
(if in use)
add Prefilled NS flush syringes, Flush each Lumen before and after each use, #
refills
Dressing change kits (1/week)- may need additional
Prefilled Heparin Flush 100 units/ml (3ml in 10ml syringe)
Flush Two Times/wk each Lumen, # refill
Change claves twice per week (6/week)
Add Prefilled NS flush syringes, Flush each Lumen before and after each use, #
refills
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Documentation Tips(it is anticipated that this section will be updated in July 2010):
Patient should be admitted with OBS orders unless they fit into one of these criteria:
Scheduled Chemo over 24 hours
Pulmonary Embolism
Cord Compression on imaging
Infection/fever (38.0) with Neutropenia – ANC < 0.5
Platelets < 10,000
Medical Intent/ Criteria
 Severity of signs and symptoms
 Differential diagnosis
 Clinical predictability of something adverse happening
 Plan for management that requires an inpatient setting
MDE General Documentation Tips










Name abnormal lab values
Give a diagnosis to symptoms, if possible
o Syncope due to….
o Chest pain due to….
o Altered mental status due to ….
Readdress treatment plans every day in the progress notes. Notes still appear to be “cut/pasted” at times
because they are not updated daily.
Include all active diagnoses in the progress notes and discharge summary
Avoid abbreviations
Be specific
If you chart morbid obesity, chart the BMI
If you chart malnutrition, tell us the severity and the BMI
Close the loops on all unresolved diagnoses
If patients are anemia, what’s the underlying cause
Principal Diagnosis: “that condition established after study to be chiefly responsible for occasioning the
admission of the patient to the hospital for care” (Uniform Hospital Discharge Data Set, UHDDS).
Secondary Diagnosis: “all conditions that coexist at the time of the admission, that develop subsequently, or
that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which
have no bearing on the current hospital stay are to be excluded” (Uniform Hospital Discharge Data Set, UHDDS).
Pneumonia
 Document the type if known
o i.e. Aspiration, Candidal, Lobar (pneumococcal)
 Link the pneumonia to the causative organism or post obstructive process (tumor or foreign body), if
known
 Coders cannot link positive cultures or chest x-ray results to the diagnosis of pneumonia
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Bacteremia
Coders will query for positive blood cultures to determine if bacteremia should be included as a diagnosis.
Coders cannot code the diagnosis of bacteremia on the lab result alone. A physician must write the diagnosis in
the chart
Complication/comorbidity:
“A condition when present leads to substantially increased hospital resource use such as intensive
monitoring, expensive and technically complex services, and extensive care requiring a greater number of
caregivers…..”
Examples: UTI
Cellulitis
Major complication/comorbidity:
“diagnosis codes that reflect the highest level of severity”
Examples: Acute respiratory failure
Acute renal failure
Acute on chronic systolic heart failure
Severe Malnutrition: Two or more indicators + clinical signs:
Inadequate intake greater than 7 days or less than 50% of estimated nutrient needs;
Weight less than 80%;
BMI less than 16%
Acute Respiratory Failure: arterial Pa O2 less than 60 mm Hg and/or arterial Pa CO2 greater than 50 mm Hg
and/or pH less than 7.35 and/or use of accessory muscles
Chronic Respiratory Failure: A persistent, non-severe decrease in pulmonary function with normal ph with
high pO2 and/or on home O2
Chronic Kidney Disease Stages
Document the stage of the CKD according to the National Kidney Foundation’s classification if known:
Stage
Description
GFR (mL/min/1.73m²)
I
Kidney damage with normal or high
GFR > 90
II
Kidney damage with mild decrease in GFR 60-89
III
Moderate decrease in
GFR 30-59
IV
Severe decrease in
GFR 15-29
V
Kidney failure
GFR >15
ESRD Kidney failure with dialysis
***12 Conditions - Present on Admission (POA) – Important documentation in the H & P***
Object left in surgery
Air embolism
Blood incompatibility
Hospital acquired injuries (falls, fractures, dislocations, head injuries, crush injuries, burns, etc)
Catheter associated infection
Decubitus ulcers Stage III & IV
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Vascular catheter associated infection
Surgical Site Infection (Mediastinitis after CABG)
Surgical Site infection following certain Orthopedic procedures (Spinal,shoulder, elbow fusions & reinfusions of
those sites)
Surgical Site infection following Bariatric surgery for Obesity
DVT and PE following total knee and hip replacements & partial hip replacements
Manifestations of poor glycemic control (DKA, Diabetic Hyperosmolality, Hypoglyecmia Coma secondary to
DKA< Secondary diabetic hyperosmolality)
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Chemotherapy concepts
Updated 2009
I. Alkylating Agents



DNA-binding drugs
all have reactive alkyl groups capable of forming covalent bond with DNA
impair DNA replication via substitution, crosslinking or strand breaking.
A. Nitrogen Mustard Class
1. Mechlorethamine – First NM, rarely used now
2. Chlorambucil (Leukeran) –
For CLL, lymphoma, Waldenstrom’s
Oral
Tox: myelosuppression, some N/V, reversible neurotoxicity, twitching, agitation, seizure, rash,
pulmonary toxicity, amenorrhea, 2nd malignancy
3. Melphalan –
myeloma, ovarian, breast (?)
usually oral
Tox: Neutropenia, mucositis, 2nd malignancy
4. Cyclophosphamide (Cytoxan) –
NHL, breast cancer, BMP
oral or IV
Tox: myelosuppression, N/V, SIADH, amenorrhea, hemorrhagic cystitis
5. Ifosfamide –
sarcomas, lymphomas, NSCLC, ovarian, germ cell
IV
tox: neurotoxicity, hemorrhagic cystitis (give with MESNA), alopecia, metabolic
acidosis K Mag and bicarb wasting, encephalopathy
Like Aziridium intermediate of NMs
Mitomycin-C –
gastric, anal, pancreatic
IV
tox: vesicant. delayed myelosuppression
Thiotepa
BMT prep (IV) or i.t. for breast, lung, carcinomatous meningitis
tox: Neutropenia, N, V, alopecia mucositis
Busulfan (Myleran)
BMT prep (oral)
B. Nitrosureas
1. Carmustine (BCNU) - IV
GBM, NHL, myeloma
delayed Heme tox,
2. Streptozocin – IV
islet cell
nausea, vomiting, nephrotox
C. Platinums
interstrand crosslinks
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1. Cisplatin (CDDP, Platinol) –
lung, bladder, head+neck, esoph, gastric, endomet
IV
Nephrotoxicity. K and Mag wasting (avoid other nephrotoxins like
dye or gent while giving Cisplatin) peripheral neuropathy
N/V ototoxicity , neutropenia
2. Carboplatin (CBDCA, paraplatin) –
Ovarian, Small Cell Lung Cancer, testicular, Head and Neck
dose according to target AUC = target thrombocytopenia
formula based on CrCl, BSA
tox: Thrombocytopenia (d 21, 25 may take 6 weeks)
D. Methylating Agents
1. Dacarbazine –
Hodgkin’s, ABVD, Sarcoma (MAID),
myelosuppression, N/V, flu like symptoms, vesicant
2. Procarbazine – Old Hodgkin’s, MOPP
II. Antimetabolites
all ultimately inhibit replication or repair of DNA either by:
inhibition of enzymes needed
incorporation into DNA
A. Folate Antagonist
Methotrexate – chorioca, breast, H&N, osteosarcoma, lymphoma, CNS lymphoma
oral or IV or i.t. Inhibits DHFR   FH4   thymidine
Leucovorin rescue – alternate source of reduced folates
14
Tox: myelosuppression, mucositis.
renal tox (alkalinize urine)
high dose: hepatic tox (usually acute and transient), and neurotox (encephalopathy, dementia
after 2-3 months or acutely seizures, aphasia, paresis)
B. Pyrimidine Antagonist (Analog)
1. 5FU – colon, H+N, Esoph, anal, gastric, breast
IV
GI tox mucositis diarrhea
2. Capecitabine – 5FU prodrug Breast, colorectal
oral
3. Cytarabine (AraC) – leukemia and lymphoma
neutropenia, N/V, diarrhea, stomatitis, rash, conjunctivitis, cerebellar
4. Gemcitabine – lung, pancreas
C. Purine Analogs
Primary tox is myelosuppression
6MP - ALL
2CDA - hairy cell leukemia
Fludarabine – CLL, Waldenstrom’s
 T cells –use Bactrim prophylaxis
III. Antitumor Antibiotics
Doxorubicin
Adriamycin
Intercalation into DNA and RNA
Daunorubicin Cerubidine
Inhibition of DAN , RNA polymerases
Dactinomycin Actinomycin D Intercalation
Idarubicin
Idamycin
Generation of oxygen free radicals
Bleomycin
Blenoxane
Intercalation, free radicals, ss breaks
Mitomycin C
free radicals, alkylator, crosslinking
Mitoxantrone
ss breaks
Tox:
Myelosuppression
Nausea vomiting
Stomatitis
Extravasation
Plumonary (bleo)
Renal tox ( mito)
Hepatic tox
MAHA (mito)
cardiac
IV. Spindle poisons
microtubule targeting drugs
A. Taxanes – stabilize microtubules
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Pacific Yew Tree
1. Paclitaxel (Taxol) –
breast, ovarian, lung
IV
tox: hypersensitivity, myelosuppression, peripheral neuropathy
2. Docetaxel (Taxotere) –
breast, lung
IV
tox: neutropenia, fluid retention, skin rash.
B. Vinca Class – prevent microtubule assembly
Periwinkle plant
1.Vincristine – Neuropathy – peripheral +autonomic, N/V, constipation
2. Vinblastine – myelosuppression, mucositis
3. Vinorelbine – neutropenia
V. Targeted therapies
I. Therapies targeted at ER/PR
Tamoxifen
Aromatase inhibitors
Fulvestrant
II. Therapies targeted at HER2
Herceptin
III. Therapies targeted at EGFR
Small molecules –
Iressa (gefitinib)
Tarceva (erlotinib)
GW572016
Human/mouse Ab Erbitux, cetuximab, C225- approved for use in combo with CPT-11 for colorectal ca . side effects :
3% infusion rxn, <1% pulm tox, rash 1%
IV. Other TK inhibitors
Gleevac (Imatinib ) approved in CML and GIST
BCR-abl TK- constitutively expressed abnl TK created by Ph chromosome translocation
V . Rituxan- anti CD20 Ab . refractory low grade B cell NHL – infusion rxn, tumor lysis, lymphopenia
Campath – anti CD52 CLL
Myelotarg- anti CD33 refractory leukemia
VI . targeting apoptosis-
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Velcade
General points
Don’t forget that many of these need to be dose-reduced for renal and hepatic dysfunction – best thing is
to look up the package insert for guidelines
Most of these are teratogenic, although some regimens can be given fairly safely in 2nd and 3rd trimester
17
LIVING SPIRITUALLY
WITH CANCER
A RESOURCE FROM
THE UNIVERSITY OF NORTH CAROLINA HOSPITALS
DEPARTMENT OF PASTORAL CARE
LIFE CHANGING ISSUES
Life can change in many ways when you or a loved one is diagnosed with cancer. Spiritually, you might find
yourself turning more often to your beliefs to help you cope. Or, you may find new questions concerning your
faith emerging. Both of these are natural as you try to reorient your life during this difficult time.
Life changing issues may include:
 Managing anxieties and frustrations about an unpredictable disease; dealing with the unknown
 Facing fears about pain, disfigurement, physical and emotional isolation, and/or imminent death
 Experiencing grief about the loss of hopes and dreams, independence, self-esteem, and/or self-image
 Worrying about the future (i.e., the possible spread or recurrence of the disease, the cost of medical
treatment, the well-being of loved ones)
 Experiencing concerns about your quality of life, your role in the family, and the condition of significant
relationships
 Living with judgement from society and dealing with the misconceptions and fears of others
 Experiencing strong emotions (i.e., denial, anger, despair, depression, loneliness, guilt)
 Re-examining your beliefs/philosophy and the meaning of life
SPIRITUAL BENEFITS
At times you and those who love you may feel deeply troubled spiritually by a diagnosis of cancer. It is important
to remember that you are not alone at this time. Many have walked this road of spiritual re-examination before
you.
Regardless of your religious background or spiritual practice, your faith can:
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Provide a sense of peace
Nurture hope and joy
Clarify the meaning and purpose of life
Offer strength for the journey
Allow connection with the Holy
Provide emotional support
Give direction and guidance
Impart wholeness
Afford a deepening sense of the sacred
Provide opportunities for self discovery
Allow for spiritual growth and development
Supply ways of coping
Present new/healthy perspectives
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SPIRITUAL DIRECTION
Each person’s spiritual beliefs may be nurtured in different ways. Whatever your spiritual practice, remember it
is a dimension of your life which can be strengthened and developed. The following ideas may be helpful as you
look inward for a stronger connection to what is most meaningful and sacred:

Meditate or pray daily. Through these practices peace and strength can be discovered and experienced.

Join a group for meditation, prayer and support. Sharing with others with similar difficulties brings about
understanding and hope.

Read sacred/religious texts and other inspirational writings. These writings can enlighten your spirit and
guide your path.

Speak with your chaplain, spiritual leader or counselor. Clergy and other spiritual leaders can be a source
of support, compassion and direction.

Attend worship and practice religious rituals. These practices allow for a sense of community and
connectedness.

Inform the members of your faith community of your situation and needs. Invite them to walk with you
on your journey to find wholeness. They can be helpful to you both practically and emotionally.

Retreat to spiritual spaces or natural settings.
connection with the Holy.

Express your thoughts, feelings and memories in a journal. This activity can contribute to your process of
self-discovery and spiritual development.

Open your heart, mind and spirit to divine presence. Allow yourself to be gently guided, nurtured and
supported.
In these sacred places you can experience a close
Above all, remember you are not a hopeless, powerless victim of cancer. There are many actions you can take to
fight for your own recovery and improve the quality of your life. Out of the turmoil of this difficult time, your
spiritual life may be strengthened and deepened; a sense of meaning, purpose and connection beyond yourself can
help you to have a higher quality of life while living with cancer.
CONTACTING THE DEPARTMENT OF
PASTORAL CARE
A chaplain is available 24 hours a day seven days a week. For pastoral needs Monday through Friday between
the hours of 8:00 AM and 5:00 PM call the following phone numbers to reach a staff chaplain:
General Oncology
Patricia Cadle
445-5400
Gynecological Oncology
Darryl Owens
966-7801
Hadley Kifner
966-5026
Pediatric Oncology
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After 5:00 PM, Monday through Friday, and on weekends, please call the hospital operator at 966-4131 and ask
for the On-Call Chaplain.
WORDS OF INSPIRATION
What is the meaning of life?…The great revelation…never did come. Instead there were little daily miracles,
illuminations, matches struck unexpectedly in the dark.
–Virginia Woolf
Truly, it is in the darkness that one finds the light, so when we are in sorrow there the light is nearest to all of us.
–Meister Eckhart
You have learned something. That always feels at first as if you had lost something.
–George Bernard Shaw
Life is ten percent what happens to us and ninety percent how we deal with it.
–Common Wisdom
The ultimate measure of a person is not where they stand in moments of comfort and convenience, but where
they stand in times of challenge and controversy.
–Martin Luther King, Jr.
Every tomorrow has two handles. We can take hold of it with the handle of anxiety or the handle of faith.
–Henry Ward Beecher
There is a light in this world—a healing spirit—more powerful than any darkness we may encounter. We
sometimes lose sight of this force when there is suffering and too much pain. Then suddenly, the spirit will
emerge, through the lives of ordinary people who hear a call and answer in extraordinary ways.
–Mother Teresa
Pain is a part of being alive, and we need to learn that. Pain does not last forever, nor is it necessarily unbearable,
and we need to be taught that.
--Rabbi Harold Kushner
We have what we seek. It is there all the time, and if we give it time, it will make itself known to us.
–Thomas Merton
It does not matter how slowly you go, so long as you do not stop.
--Confucius
Courage is one step ahead of fear.
–Coleman Young
In the midst of winter, I found there was within me an invincible summer.
–Albert Camus
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When you have come to the edge of all the light you know and are about to step off into the darkness of the
unknown, faith means knowing two things…there will be something to stand on or you will be taught to fly.
–Anonymous
The main thing in one’s own private world is to laugh as much as you cry.
--Maya Angelou
Let my hidden weeping arise and blossom.
--Rainer Marie Rilke
That which may be bitter to endure may be sweet to remember.
--Chinese Proverb
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Activity Level for Patients with Bone Metastases
A Guide for Physical and Occupational Therapists
Presence of
Bone Metastasis
Old Diagnosis
New Diagnosis
Location in spine
Bedrest until work-up
completed
Location in NWB bone
Location in WB bone
Bedrest until work-up
completed
Prior to mobility:
 General activity
orders
Location in WB bone or spine
Location in NWB bone
Prior to mobility:
 General
activity orders
(+) change in pain level
in area of bone
metastasis
(-) change in pain
level in area of
bone metastasis
Bedrest until work-up
completed
(+) impending fx
(+) pathologic fx
(+) impending fx
(+) pathological fx
(-) impending fx
(-) pathologic fx
(-) impending fx
(-) pathological fx
Treat as new
diagnosis
Prior to mobility:
 General activity
orders
 WB orders for
involved extremity
from orthopedics
Prior to mobility
 General activity
orders
 Spine clearance by
orthopedics or
neurosurgery consult
 Patient education on
spine precautions
Prior to mobility:
 General activity
orders
 Patient education
on spine
precautions
(+) pain
Prior to mobility:
 General activity orders
 Consider assistive
device if metastasis is
in lower extremities
(-) pain
Prior to mobility:
 General activity
orders
Research clinic
notes or previous
inpatient notes for
mobility
recommendations
and precautions
Guidelines for working with
patients with bone metastases:
 Patient and caregiver should
understand risks and benefits
of mobilization versus
bedrest
 Limit activity to pain-limited
active range of motion
 Do not perform manual
muscle testing or resistance
training to involved extremity
Evidence Table by Amy Kushner, PT
Flow chart created by Emily Sourisak, PT & Elizabeth Stauffer, SPT, MHS
References on page 2
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References
1. Bunting RW, Shea B. Bone metastasis and rehabilitation. Cancer Rehabilitation in the New
Millenium. Supplement to Cancer. 2001; 92(4):1020-1028
2. Bunting RW, Boublik M, Blevins FT, et al. Functional outcome of pathological fracture
secondary to malignant disease in a rehabilitation hospital. Cancer. 1992; 69:98-102.
3. Johnson, SK & Knobf MT. Surgical interventions for cancer patients with impending or actual
pathologic fractures. Orthopaedic Nursing. 2008; 27(3):160-171.
4. Mirels H. Metastatic disease in long bones: a proposed scoring system for diagnosis
impending pathological fractures. Clin Orthop 1989; 249:256-264.
5. Struthers C, Mayer D, Fisher G. Nursing management of the patient with bone metastases.
Seminars in Oncology Nursing. 1998; 14(3):199-209.
6. Weber KL, Randall RL, Grossman S, Parvizi J. Management of lower-extremity bone
metastasis. J Bone Joint Surg Am. 2006; 88:11-19.
Content of flow chart generated by Fran Collichio, MD and Emily Sourisak, PT in consultation with
Jordan Renner, MD, Eldad Hadar, MD, and Robert Escher, MD.
23
Recreational Therapy
Recreational Therapy is provided for patients on 4 ONC following initiation of services
through a physicians referral. As part of the interdisciplinary treatment plan for oncology
patients, RT strives to support the patient through goal directed emotional, social, physical
or cognitive interventions. Recreation therapy interventions are designed to have direct
impact upon the recuperative and rehabilitation process, and may take a variety of forms.
The role of the Licensed Recreational Therapist(LRT) is to provide the patient with
functional skills and resources for increasing independence and coping with hospitalization
and the disease process. The application of specific treatment interventions is based upon
the analysis of an individual's assessment and may include:







teaching strategies for coping with pain and anxiety
relaxation techniques, including biofeedback or hypnosis if indicated
physical and emotional coaching during medical procedures
mobility skills
emotional self regulation skills
reality orientation
legacy projects
Recreational Therapy in adult oncology is best viewed as a component of integrative
medicine. Patients most appropriate for RT referrals are those who will be in-house for long
periods of time, such as newly diagnosed leukemia patients, or for those patients who have
demonstrated or are anticipated to have difficulty coping with depression, anxiety, stress,
or pain, or those with functional deficits in need of additional ancillary services.
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Use of Acid Suppression Therapy in an Adult Hematology/Oncology Patient
Population
I.
Description
Describes the optimal use of acid suppression therapy in the hematology/oncology patient
population
II.
Rationale
Chronic therapy with proton pump inhibitors (PPI) or H2 antagonists is common in patients
with, or at risk for, chronic gastroesophageal reflux disease. In fact, their use is
recommended by the 2008 guidelines issued by the American College of Cardiology
Foundation, the American College of Gastroenterology, and the American Heart Association
entitled, Expert Consensus Document on Reducing the GI Risks of Antiplatelet Therapy and
NSAID Use. Acid suppression therapies are also prescribed short-term in the non-ICU,
hospitalized patients to prevent development of stress ulcers. Studies have shown that
approximately 50% of these patients did not receive this therapy prior to admission and
that almost half of those new patients will receive prescriptions to continue therapy once
discharged. Acid suppression therapies have traditionally been viewed as safe; however,
recent evidence suggests potential harm, including an increased risk of pneumonia,
Clostridium difficile-associated disease and hip fractures. As such, it is recommended to
follow the guidelines below when prescribing acid suppression therapy to a
hematology/oncology patient paying particular attention to appropriate discharge
prescribing practices.
III.
Clinical guideline
1. Indications for PPI therapy
 Gastric and duodenal ulcer
 Pathologic hypersecretory conditions
 GERD
 Indigestion symptoms (within the last 3 months)
 H. pylori eradication
 NSAID gastric ulcer prophylaxis (for scheduled therapy)
 Zollinger Ellison syndrome
 Mucositis or esophagitis
2. Studies looking at the safety and efficacy of PPIs focused on them being used to augment
healing of ulcers. Consequently, most patients only require 3 months of therapy
3. Patients that do not have any indication for PPI use or stress ulcer prophylaxis who may
benefit from the use of an H2 blocker:
 Coagulopathy
 Thrombocytopenia (platelets <50,000)
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4. For patients receiving steroid doses >250 mg hydrocortisone, 9 mg dexamethasone, 60
mg prednisone or equivalent daily, PPI should be prescribed concurrently with steroid
if:
 Thrombocytopenia (platelets <50,000) or other coagulopathy
 Receiving anticoagulation therapy
Since steroids can cause GI upset all other patients not meeting criteria for PPI use may
benefit from an H2 blocker while on steroids. Patient discharge or continuation on acid
suppression therapy after completion of steroid therapy should not occur.
5. PPI agents should be avoided in those individuals receiving concurrent: posaconazole,
erlotinib, atazanavir, clopidogrel and dasatinib
IV.
References
1. American Society of Health-system Pharmacists. ASHP therapeutic guidelines on
stress ulcer prophylaxis. Am J Health-Syst Pharm 1999;56:347-79.
2. Arther RR, May B. Stress ulcer prophylaxis in hospitalized patients not in intensive
care units. Am J Health-Syst Pharm 2007;64:1396-400.
3. Pham C, Regal RE, Bostwick TR, Knauf KS. Acid suppressive therapy use on an
inpatient internal medicine service. Ann Pharmacother 2006;40:1261-6.
4. Bhatt DL, Scheiman J, Abraham NS, Antman EM, Chan FKL, Furberg CD, Johnson DA,
Mahaffey KW, Quigley EM. ACCF/ACG/AHA 2008 expert consensus document on
reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of
the American College of Cardiology Foundation Task Force on Clinical Expert
Consensus Documents. Circulation 2008;118:0000-0000.
5. Aseeri M, Schroeder T, Kramer J, et al. Gastric acid suppression by proton pump
inhibitors as a risk factor for clostridium difficile-associated diarrhea in hospitalized
patients. Am J Gastroenterol. 2008;103:2308-13.
6. Dubberke ER, Reske KA, Yan Y, et al. Clostridium difficile-associated disease in a
setting of endemicity: identification of novel risk factors. Clin Infect Dis
2007;45:1543-9.
7. Dalton BR, Lye-Maccannell T, Henderson EA, Maccannell DR, Louie TJ. Proton pump
inhibitors increase significantly the risk of clostridium difficile infection in a low
endemicity, non-outbreak hospital setting. Aliment Pharmacol Ther 2009;29:62634.
8. Aseeri M, Schroeder T, Kramer J, et al. Gastric acid suppression by proton pump
inhibitors as a risk factor for clostridium difficile-associated diarrhea in hospitalized
patients. Am J Gastroenterol 2008;103:2308-13.
9. Jayatilaka S, Shakov R, Eddi R, et al. Clostridium difficile infection in an urban
medical center: five-year analysis of infection rates among adult admissions and
association with the use of proton pump inhibitors. Ann Clin Lab Sci 2007;37:241-7.
10. Dial S, Alrasadi K, Manoukian C, et al. Risk of clostridium difficile diarrhea among
hospital inpatients prescribed proton pump inhibitors: cohort and case-control
studies. CMAJ 2004;171:33-8.
11. Lahej RJ, Sturkenboom MC, Hassing RJ, et al. Risk of community-acquired
pneumonia and use of gastric acid suppressive drugs. JAMA 2004;292:1955-60.
12. Lowe DO, Mamdani MM, Kopp A, et al. Proton pump inhibitors and hospitalization
for clostridium difficile associated disease: a population based study. Clin Infect Dis
2006;43:1272-6.
26
13. Sarkar M, Hennessy S, Yang YX. Proton pump inhibitor use and the risk for
community-acquired pneumonia. Ann Intern Med 2008;149:391-8.
14. Latmer N, Lord J, Grant RL, O’Mahony R, Dickson J, Conaghan PG; National Institute
for Health and Clinical Excellence Osteoarthritis Guideline Development Group.
Cost effectiveness of COX2 selective inhibitors and traditional NSAIDs alone or in
combination with a proton pump inhibitor for people with osteoarthritis. BMJ
2009;339.
15. HO PM, Maddox TM, Wang L, et al. Risk of adverse outcomes associated with
concomitant use of clopidogrel and proton pump inhibitors following acute
coronary syndrome. JAMA 2009;301:937-44.
16. Dial S, Delaney JAC, Barkun AN, Suissa S. Use of gastric acid suppressive agents and
the risk of community acquired clostridium difficile associated disease. JAMA
2005;294:2989-95.
17. Yang YX, Lewis JD, Epstein S, Metz D. Long term proton pump inhibitor therapy and
risk of hip fracture. JAMA 2006;296:2947-53.
18. Laheij R, Sturkenboom M, Hassing R, et al. Risk of community acquired pneumonia
and use of gastric acid suppressive drugs. JAMA 2004;292:1955-1960.
19. Herzig S, Howell M, Ngo L, Marcantonio E. Acid suppressive medication use and the
risk of hospital acquired pneumonia. JAMA 2009;301:2120-8.
Written by: Jill Bates and Larry Buie
Reviewed by: Fran Collichio, Matt Foster, Stephen Park, Kristy Richards, Scott Savage,
Hank Van de Venter, John Valgus, Peter Voorhees
27