Nursing older patients with cancer

Older adults often present multiple chronic diseases, which can make treating cancer more complicated, and other challenges in accessing care, including losing agency over their health choices. Erin McLennan explains the importance of listening to their experiences and needs, and how education and advocacy are two areas where nurses can help improve cancer care for older adults.

We know populations are ageing around the world and that the incidence of cancer increases exponentially with advancing age. However, what we still do not know is how to best manage the individual needs of older persons with cancer to ensure that they receive the best care for the best possible outcome in terms of survival and/or quality of life.
 
There are a multitude of geriatric assessments used to clinically assess function, frailty and predict patient outcomes. Evidence suggests that a Comprehensive Geriatric Assessment (CGA) is the gold standard in decreasing patient length of stay, healthcare costs and mortality, while increasing a patient’s chance of returning to their normal home environment rather than requiring assisted living. A CGA is great when you have someone available to conduct it – but what if you don’t have a Geriatrician on staff? What can you do as a nurse?  
 
Older patients face health complications and challenges that change their experience of the healthcare system, from one where they had control and agency over their bodies to one where others often make decisions for them. Whether it’s many healthcare professionals in a multidisciplinary team (MDT) deciding who can and cannot have treatment, or a patient’s own family deciding where they’ll live now that they can’t live independently, older patients are often transformed into a two-dimensional proposition rather than considered for the vulnerable, multifaceted people that they are.

In my experience, older patients are indeed a complex cohort, but they are also robust individuals with a lifetime of history and stories. Often, all they want is for someone to listen. Education and advocacy are two areas where I believe nurses can impact change.  

Education 

Irrespective of age, all patients need to receive education about their disease before making informed decisions about their treatment. With older patients, there is a risk of others lovingly stepping forward to make decisions on their behalf. During consultations and assessments with a patient, it is not uncommon to hear whispers from loved ones directed at the treating team like “Oh don’t worry, they’re deaf,” “Mum’s a bit overwhelmed, I’ll tell her about it later,” or my personal favourite, “We don’t want Dad to know it’s spread because he’ll pull the pin.”

While the support of family and friends is invaluable for older patients, it is imperative that communicating with the patient as an individual remains the central priority even when it’s challenging. As the clinician often delivering the cancer treatment, nurses need to ascertain the patient’s understanding of their diagnosis and treatment, its likely side effects and, where appropriate, that they have a choice not to pursue active treatment. Starting a conversation with “Do you know much about the drugs you’re receiving today?” is often all it takes to expose any gaps that need to be filled and what information should be shared with their treating team.  

Advocacy  

As cancer care nurses, it is our job to be a voice and advocate for all patients, especially our frail and vulnerable older patients. Ensuring their wishes are heard and respected assists them to maintain their dignity. We must also champion the rights of fit, older patients who are often typecast by their chronological age, rather than their condition.  

We can start by challenging the negative terminology associated with older patients: senile, weak, out of it, crusty, hopeless, off with the fairies, on the way out, cranky. It is a sad indictment on our healthcare system to acknowledge this language is being used to describe those who have sought our help, but unfortunately it is the reality. While it is no small feat to stand up to our colleagues when we hear terminology being used that serves no purpose other than to disempower our patients, it is our responsibility to do so. By calling out this behaviour, we can empower other nurses to do the same.  

No matter what role you play in the journey of an older person with cancer, you have the ability to make an impact on their experience and encourage others to do the same. If you have a special interest in this patient population then I encourage you to explore avenues in your own healthcare system and tertiary institutions; the International Society of Geriatric Oncology (SIOG) is a great place to start. 

Through education and advocacy, you can give older patients a voice, help maintain their dignity, show them respect, and ensure they have agency over their treatment and a say in their outcomes. Just because we are told that our ageing population is a burden on the healthcare system, does not mean that our patients need to feel they are a burden to us.