Shared Decision-Making and Short-Course Radiotherapy for Operable Rectal Adenocarcinoma: A Patient's Right to Choose.

BACKGROUND: As new treatment options for colorectal cancer (CRC) emerge, physicians and WOC nurses must be prepared to assist patients to choose care that meets their needs and preferences. A patient with T2N0M0 rectal adenocarcinoma was offered the US current standard of practice; he was not offered alternative treatment options. This case study emphasizes the need to ensure patients are offered all reasonable options for treatment. Shared decision-making is a process that helps patients actively participate in their heath choices rather than exclusively relying on the judgment of a health care provider. CASE: Mr J was a 70-year-old man with operable CRC who sought care at a health care facility in his community. He was offered a single option, based on standard of care for this tumor stage: long-course neoadjuvant chemoradiotherapy followed by surgery and additional chemotherapy. After seeking a second opinion at a cancer care center in another state, Mr J chose to undergo a viable alternative treatment option (short-course radiotherapy, followed by surgery, with chemotherapy contingent on his nodal status post-surgery). No nodal involvement was found post- surgery (T2N0M0) enabling him to avoid postoperative chemotherapy. CONCLUSIONS: This case illustrates the need for all health care providers and carers to regularly engage in shared decision-making when choosing among treatment options. In this case, short-course radiotherapy offered Mr J a shorter duration of treatment and avoided the risk for adverse side effects associated with chemotherapy, resulting in improved health-related quality of life. Initial omission to disclose all treatment options to Mr J may have reflected the preferences of the surgeon, institutional financial pressures, or discomfort with shared decision-making, but it failed to provide him with full range of options, given his diagnosis and tumor stage. All members of the patient's care team, including the WOC nurse, play a pivotal role in ensuring transparency in medical care, including advocating for shared decision-making where patients are made aware of all viable treatments, followed by supporting the patient as they reach a decision.

Decreasing pressure ulcer risk during hospital procedures: a rapid process improvement workshop.

A 300-bed acute care community hospital used a 2-day "Rapid Process Improvement Workshop" to identify factors contributing to facility-acquired pressure ulcers (PU). The Rapid Process Improvement Workshop included key stakeholders from all procedural areas providing inpatient services and used standard components of rapid process improvement: data analysis, process flow charting, factor identification, and action plan development.On day 1, the discovery process revealed increased PU risk related to prolonged immobility when transporting patients for procedures, during imaging studies, and during the perioperative period. On day 2, action plans were developed that included communication of PU risk or presence of an ulcer,measures to shorten procedure times when clinically appropriate, implementation of prevention techniques during procedures, and recommendations for mattress upgrades. In addition, educational programs about PU prevention were developed, schedules for presentations were established, and an online power point presentation was completed and placed in a learning management system module. Finally, our nursing department amended a hospital wide handoff communication tool to include skin status and PU risk level. This tool is used in all patient handoff situations, including nonnursing departments such as radiology. Patients deemed at risk for ulcers were provided "Braden Risk" armbands to enhance interdepartmental awareness.

Prevention and management of incontinence-associated dermatitis.

Perineal dermatitis, recently relabelled 'incontinence-associated dermatitis' (IAD), is an inflammation of the skin that occurs when urine and/or stool comes into contact with the skin. It can range in severity from erythema with or without loss of skin integrity to infection. IAD affects as many as 41% of adults in long-term care; it is costly, painful and, for the most part, preventable. An effective plan of care for individuals with IAD must include assessment and management of incontinence aetiology, perineal skin and risk assessment, gentle cleansing and moisturization, application of skin barriers and treatment of secondary infection, and the use of containment devices if indicated.

Perioperative factors that affect long-term adjustment to an incontinent ostomy.

PURPOSE: We sought to identify perioperative factors associated with long-term adjustment to an incontinent ostomy. METHODOLOGY: The Ostomy Adjustment Scale (OAS), a demographic form, and a $5 gift certificate were mailed to 200 ostomates. Associations between items from the Survey of Perioperative Factors of Ostomy Adjustment, demographic forms, and total OAS scores were assessed using bivariate and multiple linear regression analysis. RESULTS: The survey response rate was 74%. About half (70/146, 49%) of the respondents were women, 99% (144/145) were Caucasian, and 74% (109/146) were married. Their mean age was 65+/-14 years. Fifty-six percent (79/141) of the respondents had an ileostomy, 28% (39/141) had a colostomy, and 15% (21/141) had a urostomy. The mean OAS score for all the respondents was 159.5+/-26.2, indicating a good overall adjustment to an incontinent ostomy. In bivariate analyses, the factor associated with a lower OAS score indicating poorer adjustment was distress related to affording and obtaining ostomy supplies. The more helpful the ostomates found the preoperative education provided by a wound, ostomy, and continence specialist nurse, the better was their adjustment as indicated by a higher OAS score. Having ongoing/recurrent illness and having an ostomy created by a specialty surgeon were also associated with better adjustment. When multiple factors were considered in a stepwise regression analysis, adjustment was lowered by distress about obtaining ostomy supplies. Adjustment was improved when preoperative education provided by a wound, ostomy, and continence specialist nurse was considered helpful for the ongoing/ recurrent illness. CONCLUSION: Many ostomates have a good long-term adjustment to ostomy surgery and value education provided by a wound, ostomy, and continence nurse. Perioperative patient education and addressing patient distress over obtaining supplies are areas that can benefit from wound, ostomy, and continence nurse intervention.