Comfort issues in geriatric oncology

Comfort

Issues in Geriatric

Oncology

Constance Engelking

T

HE PROVISION of comfort has traditionally beenviewed as an integral part of the nursing role. In early writings, Nightingale indicated a need to observe the sick to find ways of increasing not only health but comfort. ’ Bodnar and Pederson describe nursing as a “ . . .nurturative practice oriented to providing comfort and care in the presence of illness,“2 and Leininger includes comfort as one of the componentsin her listing of twenty-five “Caring Constructs.“3 Accepting the role of comforter, nurses have developed and refined an extensive repertoire of knowledge and skills to alleviate the suffering of their patients at times of physical and emotional distress.4 With such definitiveness in designating the act of comforting as inherent to the art of nursing, it would seem a simple task to identify comfort issuesfaced by the elderly cancerpatient. However, two major gaps in the literature interfere with that task. First, a clear definition of what constitutes comfort is absent. Like caring, it remains a nebulous term open to many interpretations.5 Someauthors refer to comfort or comforting as an element of caring, while others use the two terms synonymously. Fleming et al6 state that although it is the focus of care for advanced cancer patients, the concept of comfort is not adequatelydescriptive of specific patient needsor easily translatedinto nursing behaviors. Examples of nursing interventions specifically described as comfort behaviors are listed in Table 1. While some nursing care themes do emerge, the range of interpretations is obvious. Secondly, literature addressingthe topic of geriatric oncology is limited. What does exist tends to have a global focus and to be empirically based. Scientific data regarding the unique problems of the elderly is not available since age frequently excludes them from participation in clinical trials. ’ Consequently, guidelines for differentiating between the problems of aging and those that are

From the Westchester County Medical Center, Valhalla, NY. Address reprint requests to Constance Engelking, RN, MS, OCN, 98 Armonk Rd, Mt Kisco, NY 10549. 0 1988 by Grune & Stratton, Inc. 0749-2081/88/0403-0005$05.00/0

198

sequelaeof cancer do not exist, and comfort issues specific to the geriatric cancer patient have not been articulated. The focus of this paper will be to establish a definition of comfort within the context of cancer nursing and to apply that definition in a discussion of potential comfort issues in geriatric oncology. Barriers to the achievement of comfort in the elderly cancer patient will also be identified. DEFINING COMFORT

Comfort is the fourth standardof the ten original Outcome Standardsfor Cancer Nursing Practice.’ Although images of physical suffering are readily called to mind when considering the concept of comfort, this nursing standard prescribes an expanded interpretation of the term. It identifies the cause of discomfort as psychological distress as well as pathophysiological change, and defines comfort as the minimization of psychobiologic distress. While selected physical manifestations of cancer including pain and sleep disturbances are highlighted in the content of this standard, specific referenceis made to both the emotional and interactive aspects of living. This is reflected in the outcome criteria which, in addition to identifying factors that influence comfort, notes that cancer patients and their families should be prepared to recognize those factors that “enhance the continuance of valued activities and relationships. “9 Rather than being presentedas an unidimensional physical experience, as it is often perceived to be, comfort is described in this standard as a biopsychosocial state of being or an intervention to achieve such a state of being. The multidimensional nature of comfort may be best understood by considering the opposite condition-discomfort. Using physical pain as the precipitating causeof discomfort, Fig 1 illustrates the interrelatedness of physical, psychological, and social forces in the total experience. On the fist level, pain may give rise to other physical problems such as altered nutrition and impaired mobility. If the patient is unaware of how to manage his or her pain and it persists, a certain psychological toll is paid in terms of the ability to cope

Seminars in Oncology Nursing, Vol4,

No 3 (August), 1988: pp 198-207

COMFORT

ISSUES

IN GERIATRIC

ONCOLOGY

199

Table 1. Nursing Interventions Author

Larson,

Described as Comfort Behaviors Comfort

19845

Behaviors

Listening Talking Sitting down with patient Being receptive to patient needs Touching patient when in need of comforting Showing patience even with difficult patients Using gentle approach

Fleming,

Scanlon,

and D’Agostino,

Paterson

and Zderad,

19767

1987s

Assisting with activities of daily living Acknowledging religious beliefs Listening, touching Calling a patient by name Maintaining privacy Minimizing symptoms Including significant others in care Using the expertise of other health team members Calling patients by name Giving honest information Accepting expressions of feelings Expressing authentic human tender

and the maintenanceof independence.If the pain and its attendantpsychological manifestationscontinue, an intensified psychological reaction (ie, fear) and social response (ie, withdrawal) may ensue.lo It should be noted that although a common physical problem associatedwith the concept of comfort has been used as an example, discomfort can also be the result of psychological or social etiologies. Further, the processdescribed may occur in reverse. That is, physical discomfort may be the result of emotional or social problems such as depression or loneliness. As an outcome, comfort is the stateof easearising in the individual when bodily wants are satisfied and both pain and anxiety are nonexistent. As an intervention, it may considered as an umbrella term encompassinga wide range of nursing behaviors aimed at eliminating pain and other discomforts, minimizing sadnessor sorrow, preventing the senseof abandonment,inspiring hope, and restoring a positive outlook. l1 Marino12 cites comfort as the major need of all patients with cancer, particularly those with advanced cancer and describesit as the concept that unifies all nursing interventions provided to this patient population. Since the elderly constitute the largest subset of the advancedcancer patient population, it is most appropriate to explore the comfort issues that may affect them.

feelings

when

appropriate

INHIBITORS TO COMFORT IN THE ELDERLY

Accepting the concept of comfort as multidimensional provides direction for suggestingpotential comfort issues unique to the physiologic and psychosocialareasof geriatric oncology. Since aging is characterized by declining physiological competence, psychological reserves, and social support network, it may be postulated that the elderly cancer patient faces more inhibitors to comfort than the healthy aged or the young in each of these different but integrated life dimensions. Physical Comfort Barriers

Perhapsthe first step in identifying barriers to physical comfort in the elderly is to recognize the possible physical discomforts that may arise as a result of aging and cancer. When cancer occurs late in life, the physical effects of a chronic illness are superimposedon the degenerativechangesassociatedwith the normal aging process. Additionally, intercurrent medical illness frequently complicates the elderly cancer patient’s physical picture.13 Potential symptoms and symptom complexes associated with cancer and its treatment have been describedelsewhere.14,15Similarly, the physiological effects of aging are well documented.l6 However, a comprehensivelisting of associatedphysical discomforts are not found in the

200

CONSTANCE

ETlOLOGV

~

GROWNG TUMOR, / ACTl”l”,EDE\

m : I

iu z

UNMET

_

SlGNS AND SYMPTOMS COMM”NlCATES THE PRESENCE OF PAIN J ,NAB,L,,Y TO CONCENTRATE FATIGUE DECREASED PHYSICAL ACTIVITY

INFLAMMATION,

NEED FOR PHYSICAL ALTERATION

AND PSYCHOLOGICAL

t IN COMFORT

CHRONIC

COMFORl

PAIN

2 z 0

NUTRlTlONAL

\

J DEFICIT

,MPAlRED

I

PHYSICAL

MOBILITY

4

9F- I

I

PAIN SELF-MANAGEMENT

DEFICIT

8 5 if fi

,NEFFECTl”E

\ SLEEP PATTERN DISTURBAL

J COPING

SELF-CARE TIT

1

t

REACTIVE DEPRESSION

DEPENDENCE-INDEPENDENCE CONFLICT \

\

+

FEAR OF CHRONIC

SOCIAL

PAIN

1

ISOLATION

Fig 1. Illustration of the interrelatedness and the impact to comfort.

of life dimensions

literature. Table 2 outlines physical effects of aging, selected physiological changes associated with cancer, and discomforts that may result. This listing does not imply that being old and having cancer automatically predispose to the potential discomforts outlined. It is intended, simply, to raise awarenessas to the possibilities. To provide a cancer-specific framework for considering these asproblems in the elderly cancerpatient, problems and associateddiscomforts are arranged according to ten of the 11 high-incidence problem areasidentified in the new Standardsfor Oncology Nursing Practice.‘7 Comfort has been omitted from the table since it pervades all other problem areas. Major comfort issues in this category are affectively based. Certain attitudes held by caregivers about elderly cancer patients and their capacity for rehabilitation or symptom control may seriously interfere with the achievement of comfort by and for these patients. Three attitudinal issues come immediately to mind. One issue is the appropriatenessof presuming that the elderly cancer patient is inherently fragile and, therefore, unable to face the physical challenge of this diseaseand its treatment. Becausethis patient is faced with the degenerativeforces of two or more separatephysiological phenomena, it is commonly assumedthat the negative physical effects of one will intensify those of the other, thus producing considerable symptom distress in the

ENGELKING

patient. While there is certainly a rational basis for the notion that the degenerative effects of aging can intensify the effects of cancer, the presumption of physiological fragility and heightened symptom distress on the basis of age alone is not always appropriate. For example, one might expect that a 70-year-old man with lung cancer would experience more intense breathing discomfort than his 40-year-old counterpart on the basis that the older man’s respiratory reserves are already compromised by age-induced weakening of respiratory muscles, reduced rib cage size, and loss of lung tissue elasticity. Cohen notes, however, that the elderly, more so than the young, are a heterogeneous group with a wide range of health profiles and varying physical reserves.” If that same 70year-old lung cancer patient had incorporated a program of vigorous physical exercise into his lifestyle at an early age, he may have experienced enhancement of baseline pulmonary function or slowed the effects of aging on his lung tissue and, hence, equalized his risk for respiratory deficiency to that of the 40-year-old. Generalizationsabout the physiological integrity of the aged can have a detrimental effect on the achievement of comfort in the elderly cancer patient. Planning patient care interventions in accordance with stereotypic perceptions may result in ineffective treatmentfor uncomfortable symptoms. In the caseof the 70-year-old lung cancer patient, the caregiver who automatically anticipates reduced breathing capacity subsequent to the patient’s age might underdose the patient with narcotic analgesics or hold back sleep medication becauseof concern about respiratory compromise. As a result of insufficient drug doses, this patient, who might easily have tolerated the potential respiratory effects of these drugs, may suffer needlessly from uncontrolled pain or sleep disturbance. This exampleunderscoresthe point that, while recognizing the potential for heightened symptom distress in the elderly cancer patient, caregivers must remain cautious about generalizing this perception to the entire population. A secondclosely related issuehas to do with the belief system that being old is synonymous with being dependent and frail. Panicucci” notes that age discrimination results in the attitude that the aged “do not have any reason for being rehabilitated or maintained at their present level of functioning.” The elderly cancer patient is doubly

COMFORT

ISSUES

IN GERIATRIC

Table 2. Potential

Impact

201

ONCOLOGY

of Age and Illness-Induced

Problems

Problems High

Levels

and detection

J i J t

DxlRx-Induced

+-Symptom concealment+ seeking medical advice articulating symptoms value in identifying and health problems reserves to pay for health care of signs and symptoms of cancer to old age

Sensory-perceptual acuity Short-term memory Information seeking Learning/decision-making time

in the Geriatric

Cancer Patient

to Age and Cancer

Aae-Induced

t Delay in t Difficulty 1 Perceived resolving J. Financial t Attribution Information

Comfort

Incidence

Problem Areas* Prevention

Related

on Physical

t Fear T Anxiety J Sense of control Information avoidance

Potential Impact on Physical Comfort Advanced disease diagnosis

at

1 t Symptomatology 4 J Chance for symptom resolution 1 Ability to comply with medical/nursing regimens L J Ability to prevent/minimize symptoms L t Duration symptom distress

J. J f t t

Support systems Repertoire coping Somatization Depression Mood alterations

t Fear t Anxiety t Guilt j. Sense of control Denial

skills

T Intensity physical symptomatology

+Weight loss+ +Malnutrition+

Nutrition

+Salivary +Hepatic 1 t t 4

Gastric motility Gastric pH Loss of teeth Basal metabolic

rate

(Continued

responses-t functionMechanical obstruction 2” to tumor Altered mucus membrane 2” to radiation chemotherapy Digestive dysfunction 2” to space-occupying tumor 4 Digestive surface 2” to surgical resection

on following

page)

Anorexia; nausea and/or vomiting; early satietv; J, energy levels: weakness; xerostomia; dysphagia; abdominal cramping; bloating; epigastric pain

202

CONSTANCE Table 2. Potential

Impact

of Age and Illness-Induced

Problems on Physical (Cont’d)

Problems High

Related

Comfort

Levels in the Geriatric

Age-Induced

Protective Mechanisms Immunity

Skin, mucous membranes

-J

DxlRx-Induced

Bone marrow function-, + 1 Cellular immunity-t

L + t Susceptibility to infection-+ (eg, pneumonia, herpes zoster, UTI) T Xerostomia Mucositis 2” to J Skin elasticity chemotherapy/radiation rx L Subcutaneous tissue Cutaneous lesions t Thinning Skin changes 2” to radiation dermis/epidermis

Central nervous system

+ 1 Psychomotor responses stimuli secondary

to noxious+ to:

J. Brain weight J Cerebral blood flow l Nerve conduction velocity

Primaryimetastatic tumor Cranial irradiation Neurotoxic drugs

Mobility

1 Bone density; f osteoarthritic changes J Muscle size/strength J Muscle coordination 1 Sensory/motor reflex response

Pathological fracture 2” to bone metastases Paralysis 2” to spinal cord compression Drug-induced neurotoxicity Lymphedema 2” to tumor obstruction Pain 2” to tumor invasion of bone; nerve plexus Electrolyte disturbances (eg, hypercalcemia)

Sexuality

-Altered hormone levels-* -Altered body image-, +Performance anxiety+ -Reduced IibidImpotence 2” to surgical t Time to erection J Ejaculation force disruption of nerve supply; J Vaginal lubrication neurotoxic drug Senile vaginitis Breast tissue atrophy

Elimination Urinary

brain

+-Altered drug absorption/elimination+ Renal blood flow Incontinence 2” to tumor invasion or surgical GFR f40-50%) Renal tubular function diversion Response to sodium Retention 2” to obstruction Drug-induced uric acid deficits 1 Ability to concentrate nephropathy; acute tubular urine necrosis 1 Bladder capacity/sphincter control

J J J 1

(Continued

Patient

to Age and Cancer

Incidence

Problem Areas*

Cancer

ENGELKING

on following

page)

Potential Impact on Physical Comfort

Constellation of infectious signs and symptoms ffebrile reaction -+ chills, swelling, local pain) Osteatosis, pruritis, xerostomia, local burning or pain

Headache; visual disturbances; tremors; vertigo; ataxia; traumatic physical injury 2” to falls; parasthesias; dysasthesias

Stiffness/heaviness of extremities or joints; pain on movement; muscle strain; tension; aching; cramping; t exhaustion; fatigue; J activity tolerance

Dyspareunia; inability to achieve orgasm; postintercourse urinary urgency/frequency

Dysuria; urgency; frequency; flank pain Skin irritation 2” to incontinence Abdominal discomfort 2” to bladder distension

COMFORT

ISSUES

IN GERIATRIC

Table 2. Potential

Impact

ONCOLOGY

203

of Age and Illness-Induced

Problems

on Physicel

Comfort

Levels

in the Geriatric

Cancer

Patient

(Cont’dl Problems Related to Age and Cancer High Incidence Problem Areas* Bowel

Age-induced

Dx/Rx-Induced

+--Altered pattern L Bowel motility; peristalsis 4 Sensory motor response to need for defecation L Anal sphincter control

Ventilation

+Altered

of bowel elimination-, Diarrhea or constipation due to: Bowel obstruction 2” tumor Bowel resection with ostomy Abdominal irradiation Hypercalcemia Narcotics or vinca alkaloids

Abdominal discomfort 2” to distension, flatulence, tenesmus, abdominal cramping,low back pain; proctitis, perirectal pain 2 to passage hard stool

drug elimination-t

J. Size thoracic cage t Weakening respiratory muscles J Vital capacity; respiratory reserve i Lung elasticity; breathing capacity J No. alveoli; J capacity for gasexchange

Perfusion

Potential Impact on Physical Comfort

Pulmonary fibrosis 2” to irradiation or cytotoxic drugs Malignant pleural effusion(s) Superior vena cava syndrome Respiratory function 2” space-occupying tumor i Respiratory capacity 2” to surgical resection

+Altered drug distribution+ Heart size Malignant pericardial Cardiac output effusion Organ perfusion Cardiac myopathy 2” to Vascular integrity anthracycline therapy; Peripheral resistance + chest irradiation Sclerosed vessels 2” t BP PPN, cytotoxic drugs

J 4 J J t

Shortness of breath; dyspnea on exertion; hunger”; chest pain; exhaustion

“air

Substernal chest pain; respiratory difficulty 2” to CHF; vertigo, lightheadedness 2” to orthostatic hypotension; phlebitic pain 2” to sclerosed vessels

Abbreviations: Dx, diagnosis; Rx, treatment; 2”. secondary to; UTI, urinary tract infection; PPN, peripheral parenteral nutrition, * As outlined in Standards of Oncology Nursing Practice, American Nurses’ Association and Oncology Nursing Society, Kansas City, MO, 1997.

stigmatized since he is not only over the age of 65 but is also afflicted with a chronic potentially terminal illness. Because death and dependency are the projected results of both ageand cancer, efforts at improving the functional ability of the aged patient with cancer are often thought to be in vain. This attitude supports a custodial approachto care in which treating the patient nicely is assigned greatervalue than treating his health care problems aggressively. A belief system that discouragesefforts to improve functioning in the elderly cancer patient can subsequently contribute to factors that directly or indirectly impair comfort levels. Consider the 78year-old previously active women with breastcancer which has metastasizedto ribs, pelvis, and other bony sites. Presumably this patient is experiencing some degree of pain and certainly at risk

for pathological fracture. Theserisks must be compared with the benefits of activity when deciding whether or not the patient should get out of bed to sit in a chair. It is likely that the caregiver who ascribes to the custodial patient care model will decide not to pursue those risks, reasoningthat the patient should be spared the chance of pain and fracture because it will not change the ultimate outcome of her illness. The consequenceof that caregiver’s “good intentions” and desire to protect the patient is, of course, that an important activity of daily living will be eliminated as a patient care option. Furthermore, since the patient remains bedbound, she is subsequently faced with the risk of developing other problems that may detract from her comfort level, ie, decubitus ulcer formation, contractures, and possibly, hypercalcemia. It is typical for patients like this to be caught

CONSTANCE ENGELKING

in a cycle of increasing vulnerability as the sequelae of impaired function build upon one another. As a result, comfort is sacrificed. The caregiver with foresight will anticipate those responses, will involve the patient in determining risks v benefits in care planning and will seek strategiesfor minimizing existing risks in order to prevent others. A third issue emerging from negative attitudes about the value of time and energy investment on behalf of the elderly cancer patient relates to the lack of clinical research in this area. Many unanswered questions reduce our ability to control physical symptoms that produce discomfort in thesepatients. Pain and sleep disturbances are two commonly reported physical discomforts in the older cancer patient. In a discussion of optimal pain management, Portenoy” notes that there is someevidence that elderly patients report less pain in response to noxious stimuli than younger patients. Whether the elderly actually experienceless pain due to changes in the composition of pain nociceptors or they simply report pain less frequently becauseof age-relatedstoicism or slowed responseto external stimuli is unknown. Questions regarding selection of analgesicsand dosing in relation to altered drug absorption in the elderly as well as the efficacy of nonpharmacological pain management strategies in the elderly also remain unanswered. Considering sleep/rest patterns in the elderly, Coiling” cites sleep disturbancesas a major problem. Compared with young adults, the elderly spend a longer period of time in bed before sleep onset, have more frequent awakenings during the night, and have an increasedtotal awaketime. Circadian asynchrony, physical illness, emotional stress,and drug exposure are all suggestedas possible etiologies. As in the case of pain, there is limited scientific data available upon which to base related assessmentsand interventions. The design and conduct of studies to answer the questions that prevent effective relief of these discomforts for the elderly cancer patient are needed. Other problems worthy of research include the phenomena of fatigue, immobility, malnutrition, and coping and learning patterns. Psychosocial Comfort Barriers

Comfort issues related to the psychological and social life dimensions are both affective and cognitive. Barriers to the achievement of emotional comfort include caregiver attitudes that frequently

block avenues to the resolution of psychological distress for the elderly. It is often assumed, for example, that having cancer is not as difficult for the elderly becausethey have “lived their lives,” and for them the prospect of death is not so frightening. Neugarten** suggestedthat serious illness has an age-dependentpsychologic impact and that for the elderly, a potentially terminal illness may be developmentally “on time” and, therefore, less psychologically disturbing. Ascribing to this philosophy, depression that arises in the presenceof cancer may be attributed to changesof aging such as organic brain syndrome rather than to the diagnosis itself. The elderly person faced with a diagnosis of cancer, however, is vulnerable to the same range of distressing psychological reactions commonly observed in younger adults. The constellation of emotional responses including fear, anxiety and panic, anger, disbelief, and despair are not unique to the young. These unsettling emotions surrounding the potential for disease-inducedloss of function, suffering, and death can be equally intense in the elderly and may be more intense when one considersthe compounding effects of aging. Comparing psychological reactions with cancer and responsesto counselling in young and old patients with advancedcancer, Linn and Linn23 found minor differences. Their findings support the notion that there are client-centered benefits associated with counselling the aged patient distressed by cancer. Yet, becauseof caregiver perceptions that death is less disturbing for the elderly and the myth that there would be little gain, psychotherapeutic interventions are rarely considered or attemptedin this population. Consequently, the elderly cancer patient is left in a state of psychological discomfort. Recognizing the natural extension of psychological responses into the social aspects of life, unresolved emotional turmoil can subsequently impair interpersonalrelationships and may contribute to the senseof isolation and abandonment so feared by the elderly. In addition to attitudes, a knowledge deficit on the part of those who care for the elderly cancer patient creates another barrier to psychosocial comfort. Those who do not work consistently with the aged often fail to recognize that these individuals have a unique set of tasks commensuratewith age that must be completed before death.24 The elderly are different from other age groups by virtue of the fact that they have entered the final de-

COMFORT

ISSUES

IN GERIATRIC

ONCOLOGY

205

Table 3. Cancer-Imposed Barriers to Completion of Devvelopmentel Tasks of Aging Theorist

Erikson,

1978’s

Butler and Lewis,

Peck, 196827

1973’s

Developmental

Tasks

Cancer-Imposed Barriers

Resolution integrity Y despair crisis (affirming in the face of death that life was meaningful)

Reflection on past life events interrupted by disease/treatment-induced depression and/or CNS dysfunction

Clarify significance of lifetime Conserve strength, physical, emotional reserves Adjust to changes and losses of age Enjoy achievement of becoming a complete human being

(Barrier cited above) Interferes with conservation of personal resources. Intensifies adaptational demands Achieve sense of life-completion blocked by physical illness.

Ego differentiation v work-role preoccupation (replacing work with a range of satisfying activities)

Interrupts role reorganization; interferes with planned lifestyie changes; prevents participation in satisfying activities. Creates heightened symptomatology which prevents refocusing from bodily deterioration: limits participation in satisfying activities. Limits interactions with younger family members; interferes with sharing of life experiences, insight and wisdom of age; prevents participation in community service.

Bodily transcendence v bodily preoccupation (refocusing from physical deterioration to participation in satisfying activities) Ego transcendense v ego preoccupation (extending significance beyond lifetime through children, contributions to society)

velopmental stage of life and, as such, are influencedby past life events that have occurred during all previous stages. The inability to complete the normal adaptation tasks of aging may result in heightened anxiety, depression, and a general senseof psychosocial discomfort. Limited awareness of the potential barriers posed by cancer to completion of the tasks of aging prevents the caregiver from facilitating interventions that could result in progress toward task completion and, ultimately, the achievement of psychosocial comfort. Table 3 outlines selected developmental theories and the potential impact of cancer on the completion of the tasks described.25-27 Erikson25 describes the primary emotional task of the elderly as the achievementof ego integrity. This entails reflection upon past life experiencesboth successesand failures-in an effort to come to terms with and validate the meaning of that life. Accomplishing this task paves the way toward the acceptanceof death as a natural outcome of living and, ultimately, freedom from psychological discomfort in relation to the threat of death. Dugan and Scallion28describe the cancer experience as a unique “marker event” in life which interferes with the ability to achieve ego integrity. The in-

hibiting effect is attributed to a variety of internal and external forces secondary to the diseaseprocess, treatment, and the individual’s responseto the illness experience. The patient who has succumbedto despondency over disease-inducedfunctional limitations and increasing dependenceon others may have little motivation to engage in the adaptive process of life review. Remembering, analyzing, and sharing the details of past life eventsmay require more psychic energy than this patient is able to generate. Outcomesof diseaseand treatmentplay a role in preventing the achievement of ego integrity as well. A patient who has brain metastasisor who is receiving therapy that requires frequent sedation to alleviate unpleasant side effects is not able- to spend time reminiscing about the past becauseof central nervous system dysfunction. The inability to achieve ego integrity may result in despair and a sensethat one’s life was without meaning.24Under these emotional circumstances, death can be a frightening prospect engendering intense emotional discomfort. There are additional developmental tasks that may be difficult to complete in the presence of cancer. Butler and Lewis26 identify the conserva-

CONSTANCE

Fig 2. Paradigm of factors that influence achievement biopsychosocial comfort in the geriatric center patient.

of

tion of personal resources and adaptation to the changes and losses that occur in life as priority tasks. The personal resources include healthy, physical and emotional strength. The negative impact of cancer and its treatment on the maintenance of physical resourcesand coping reserves is obvious. From the perspective of supply and demand, the greater the physical and emotional demandsof the illness experience, the smaller are the personal resources for meeting the demands of illness as well as those of normal aging. Further, this patient will have greater difficulty completing the tasks of refocusing from preoccupation with somatic concerns to participation in satisfying life activities or those activities that extend one’s significance beyond life.27 In terms of adjusting to changes and losses in life, the primary adaptational focus is on the individual’s social support network. The loss of loved ones (especially a spouse), affiliation with members of one’s peer group, adopting new social roles, retirement, reduced income, and establishing satisfying living arrangementsinvolve specific

ENGELKING

adjustments.29Cancer complicates life adjustment in all of these areas. The loss of a spouse, for example, may eliminate the presenceof a potential caregiver in the home setting. Without a family caregiver, the elderly cancer patient with complex care needsmay not be able to return home from the hospital and must, instead, enter a long-term care facility. Or, perhaps, family memberstake on the role of caregiversbut in doing so disrupt their own lives to the point of interpersonal tension and conflict. Similar family conflict may arise when a sibling or children are not willing to accommodatethe patient’s desire to remain at home. In both scenarios, guilt and anger may be overriding emotions that limit problem-solving abilities and preclude natural closure with the patient. Additionally, cancer may force premature retirement, interfere with economic solvency, and interrupt the development of new peer relationships. Any one of these problems can produce distress. Dealing with a combination of these psychosocial stressors, which is frequently the case with elderly cancer patients, can create dramatic levels of emotional and social discomfort. NURSING IMPLICATIONS

Facilitating the achievement of physical and psychosocial comfort in the elderly cancer patient is a major challenge to nursing. It is a challenge that cannot be met without recognition of the unique attitudinal and cognitive comfort inhibitors confronting thesepatients. Likening the processof comfort attainment to Aguilera and Messick’s3’ concept of crisis resolution, the overlapping impact of physical, psychological, and social forces as well as the role of comfort inhibitors and enhancerscan be appreciated(Fig 2). The nurse who is cognizant of these factors and alert to existing comfort barriers can focus her assessmentson the unique needs of the elderly and pursue ageappropriate interventions on their behalf. ACKNOWLEDGMENT The author wishes to acknowledge the support of colleagues Nancy Steele, RN, MSN and Paula Lestz, RN, MS during the preparation of this manuscript.

REFERENCES 1. Nightingale F: Notes on Nursing. New York, Dover, 1969 2. Bodnar B, Pederson S: The nursing process, in Edelman

C, Mandle C (eds): Health Promotion Throughout the Lifespan. St Louis, Mosby, 1986, pp 44-71 3. Leininger M: Caring: An essential human need. Proceed-

COMFORT ISSUES IN GERIATRIC ONCOLOGY

ings of Three National Caring Conferences. Thorofare, NJ, Slack, 1981, p 13 4. Battenfield BL: Suffering-A conceptual description and content analysis of an operational schema. Image 16:36-41, 1984 5. Larson P: Important nurse caring behaviors perceived by patients with cancer. Oncol Nurs Forum 11:46-50, 1984 6. Fleming C, ScanlonC, D’Agostino N: A study of comfort needs of patients with advanced cancer. Cancer Nurs 10:237243, 1987 7. PatersonJ, Zderdad L: Humanistic Nursing. New York, Wiley, 1976 8. Howard-Ruben J: Pharmacokineticconsiderationsof chemotherapy in the elderly, in Welch-McCaffrey D (ed): Nursing Considerations in Geriatric Oncology. Columbus, OH, Adria Laboratories, 1986, pp 9-22 9. Oncology Nursing Society and American Nurses’ Association: Outcome Standardsfor Cancer Nursing Practice. Kansas City, MO, 1979 10. Herberth L, GosnessDJ: Nursing diagnosisfor oncology nursing practice. Cancer Nurs 10:41-51, 1987 11. Stein J, Urdang L (eds): The Random House Dictionary of the English Language. New York, Random House, 1967, p 294 12. Marino LB: Control and comfort: Caring for the client who has advancedcancer, in Marino LB (ed): Cancer Nursing. St Louis, Mosby, 1981, pp 373-380 13. Neilan BA: Management of cancer in the elderly: Implications of the aging process. Postgrad Med 77:143-149, 1985 14. Yasko J: Guidelines for Cancer Care: Symptom Management. Reston, VA, Reston, 1983 15. McNally J, Stair JC, Sommerville ET: Guidelines for CancerNursing Practice. Philadelphia, Grune & Stratton, 1985

16. Dellefield ME: Caring for the elderly patient with cancer. Oncol Nurs Forum 13:19-27, 1986 17. American Nurses’ Association and Oncology Nursing Society: Standardsof Oncology Nursing Practice. KansasCity, MO, 1987 18. Cohen HJ: Cancer in the elderly patient: Special challenges in diagnosis and management.IssuesOncol2:2-7, 1985 19. Panicucci CL: Functional assessmentof the older adult in the acutecare setting. Nurs Clin North Am 18:355-363,1983 20. Portenoy RK: Optimal pain control in elderly cancer patients. Geriatrics 42:33-40, 1987 21. Colling J: Sleep disturbancesin aging: A theoretic and empiric analysis. Adv Nurs Sci 6:36-44, 1983 22. Neugarten BL: Dynamics of transition of middle age to old age. J Geriatr Psychiatry 4:71-87, 1970 23. Linn BS, Linn MW: Late stage cancer patients: Age differences in their psychophysical status and responses to counseling. J Gerontol 36:689-692, 1981 24. Aguilera DC: Stressorsin late adulthood, in Aguilera DC (ed): Family and Community Health, vol 2. Rockville, MD, Aspen, 1980, pp 61-69 25. Erickson EH: Adulthood. New York, Norton, 1978 26. Butler RN, Lewis MI: Aging and Mental Health. St Louis, Mosby, 1973 27. Peck RC: Psychological developmentsin the secondhalf of life, in NeugartenBL (ed): Middle Age and Aging. Chicago, University of Chicago, 1968 28. Dugan SO, Scallion LM: The older adult, in McIntire SN, Cioppa AL (eds): Cancer Nursing: A Developmental Approach. New York, Wiley, 1984, pp 225-253 29. Havighurst R: Developmental Tasks and Education (ed 3). New York, McKay, 1972 30. Aguilera DC, Messick J: Crisis Intervention: Theory and Methodology. (ed 3). St Louis, Mosby, 1978