
 Ixabepilone is indicated in combination with capecitabine (Xeloda) for the treatment of patients with metastatic or locally advanced breast cancer resistant to prior anthracycline and paclitaxel treatment (or for whom this treatment is contraindicated). Anthracycline resistance is defi ned as progression within 6 months of adjuvant therapy or 3 months of treatment for metastatic breast cancer; paclitaxel resistance is defi ned as progression on therapy or within 12 months of adjuvant therapy, or 4 months of treatment for metastatic breast cancer.


 Epothilones are a new class of antineoplastic agents which cause tubulin polymerization and stabilization, similar to paclitaxel. Epothilones are more soluble in water, however, so they do not require a solubilizing agent such as Cremaphor. There are three classes: epothilone A, B, and D. Ixabepilone (Ixempra) is a semisynthetic analog of epothilone B, and it binds to β-tubulin subunits on microtubules to suppress the changes of the microtubules during mitosis. Thus the cancer cell is unable to complete cell division, and it dies. In addition, ixabepilone has low susceptibility to tumor resistance mechanisms. This group of drugs is thought to have activity in tumor cell lines that are resistant to paclitaxel due to mutations in β-tubulin.

Ixabepilone Metabolism
 Ixabepilone is extensively metabolized in the liver via the CYP3A4 microenzyme system, forming at least 30 nonactive metabolites, which are then excreted within 7 days into the urine (21% of the dose) and feces (65%). Ixabepilone has a terminal half-life of 52 hours.

• The drug is given once every 3 weeks together with capecitabine (a pill taken twice daily for 14 days, then following a break for 7 days is repeated every 3 weeks).
 • Blood tests will be drawn to evaluate liver function, as the drug should not be taken if the patient has liver problems.
 • Blood tests also will be drawn to evaluate neutrophil and platelet counts, to make sure the counts are high enough to protect the body from infection and bleeding.
 • Patient should report any dizziness or difficulty thinking during drug administration, as the drug diluent contains alcohol.
 • Patient should avoid crowds and report any fever, chills, or signs and symptoms of infection or bleeding right away. • Patient should use effective contraception to prevent pregnancy during therapy.
 • Allergic reactions may occur during the infusion, so patient should tell the nurse right away if patient notices itching, flushing, difficulty breathing, feels dizzy or faint, or experiences anything different from usual.
 • Patient should report any numbness / tingling of the fingertips and toes and any difficulty with activities of daily living.
 • Patient should rinse the mouth after meals and at bedtime, and should report any pain or difficulty with eating or drinking.
 • Patient should not drink grapefruit juice or take St. John’s Wort, as they may affect the drug dose.

Interactions Strong CYP3A4 inhibitors may prevent metabolism of ixabepilone, thereby causing increased serum concentrations of ixabepilone; these drugs must be avoided, or the ixabepilone dose should be reduced to 20 mg/m2 if they mustbe coadministered. CYP3A4 inhibitors include ketoconazole, itraconazole, clarithromycin, tazanavir, nefazodone, saquinavir, telithromycin, ritonavir, amprenavir, indinavir, nelfinavir, delavirdine, or voriconazole; and grapefruit juice. If a reduced dose is used, then the CYP3A4 inhibitor is discontinued, wait 1 week before increasing the dose (washout period).

Strong CYP3A4 inducers may increase the metabolism of ixabepilone, thus reducing the serum level. These drugs should be avoided (dexamethasone, phenytoin, carbamazepine, rifampin, rifampicin, rifabutin, phenobarbital, St. John’s Wort).

When ixabepilone is given with capecitabine, there is an interaction resulting in a decreased ixabepilone serum level (by 19%) while the capecitabine serum level is decreased by 27%; 5-FU level is increased by 14% as compared to serum levels when ixabepilone and capecitabine are given separately.


 • Patients should be premedicated with H1 and H2 antagonists (eg, diphenhydramine at 50 mg PO, and ranitidine at 150 mg PO) 1 hour prior to drug administration.
 • Assess patient’s cognitive status during drug administration as drug diluent contains dehydrated alcohol (USP).
 • Monitor for hypersensitivity reactions, and stop drug if a hypersensitivity reaction is suspected (eg, fl ushing, rash, dyspnea, bronchospasm). Notify physician/nurse practitioner/physician assistant, and administer supportive treatment as needed (eg, epinephrine, corticosteroids).
 If reaction resolves, in subsequent cycles administer a corticosteroid in addition to the usual premedication, and extend infusion time.


 Ixabepilone together with capecitabine is contraindicated in patients with hepatic dysfunction (AST or ALT > 2.5 × upper limit of normal [ULN] or bilirubin > 1 × ULN) as there is increased risk of neutropenia-related death, and of other grade 3–4 toxicity. Drug is also contraindicated in patients with hypersensitivity to Cremaphor EL or polyoxyethylated castor oil (eg, prior paclitaxel), and patients with a baseline neutrophil count < 1,500 cells/mm3 or a platelet count < 100,000 cells/mm3.

Adverse Reactions to Ixabepilone, by System

 Rare cardiac ischemia, superventricular arrhythmia, ventricular dysfunction, myocardial infarction, angina pectoris, hypotension, embolism
 

 Nausea, vomiting, stomatitis, mucositis, diarrhea, anorexia,* abdominal pain,* constipation,* rare ileus, colitis, dysphagia, acute hepatic failure
 

 Urinary tract infection, rare nephrolithiasis, renal failure
 

Leukopenia, anemia, neutropenia, thrombocytopenia, rare coagulopathy
 

Musculoskeletal: Arthralgias, myalgias, pain, palmar-plantar erythrodysesthesia (hand-foot syndrome),* muscle weakness, spasm, trismus
 

 Peripheral sensory neuropathy, cognitive impairment (from dehydrated alcohol USP in diluent), syncope, lethargy
 

 Respiratory tract infection, rare pneumonitis, hypoxia
 Skin: Alopecia, nail disorders,* rare erythema multiforme
 

 Hypersensitivity reaction, fatigue, chills

Articles

Ixabepilone is indicated in combination with capecitabine (Xeloda) for the treatment of patients with metastatic or locally advanced breast cancer resistant to prior anthracycline and paclitaxel treatment (or for whom this treatment is contraindicated). Anthracycline resistance is defi ned as progression within 6 months of adjuvant therapy or 3 months of treatment for metastatic breast cancer; paclitaxel resistance is defi ned as progression on therapy or within 12 months of adjuvant therapy, or 4 months of treatment for metastatic breast cancer.

Epothilones

Palliative care for patients and their families across the cancer disease trajectory-from diagnosis, through survivorship, to end of life-is essential for quality cancer care. In their excellent article, Ferrell and Virani emphasize the important role of oncology nurses in providing palliative care, and they present the National Consensus Project (NCP) Guidelines[1] and the National Quality Forum (NQF)[2] preferred practices as a roadmap for all oncology nurses to use in their practice.

The authors succinctly condense the NCP guidelines and NQF preferred practices into a format that is readable and clinically applicable for both the generalist and the advanced oncology nurse.

They discuss the NCP’s eight domains of palliative care: (1) Structure and Process of Care; (2) Physical Aspects of Care; (3) Psychological and Psychiatric Aspects of Care; (4) Social Aspects of Care; (5) Spiritual, Religious, and Existential Aspects of Care; (6) Cultural Aspects of Care; (7) The Imminently Dying Patient; and (8) Ethical and Legal Aspects of Care. In their discussion, they present preferred practices within the context of oncology nursing practice.

For each domain, key recommendations are nicely summarized and examples of NQF Preferred Practices that correspond to the individual domains are provided. Finally, for each domain, the authors discuss implications specific to oncology nursing, making the guidelines and practices clinically relevant. Recommendations for Domain #3, Psychological and Psychiatric Aspects of Care, are especially well done.

For readers who are interested in the complete NCP Guidelines and NQF Preferred Practices, Ferrell and Virani direct them to appropriate web sites and a variety of helpful additional resources.

This is an exciting time to be an oncology nurse, with national efforts improving the practice of palliative care for our patients with cancer and their families. In the past 10 years, many educational programs have been developed and presented nationwide for health care team members, especially for professionals in oncology.

ELNEC (End of Life Nursing Education Consortium) programs, and in particular ELNEC-Oncology, are empowering nurses with the tools to improve the care of patients and families coping with cancer and other life-threatening illnesses across all health care settings.[3]

We are grateful to Betty Ferrell, Rose Virani, and colleagues at City of Hope and the American Association of Colleges of Nursing (AACN) for the ELNEC curriculum and for their dedication to improving palliative care through their research, publications, and national and international education efforts.

Now, with the educational tools provided, we as oncology nurses must advocate to integrate the NCP guidelines and the NQF preferred practices into our work settings. These guidelines and preferred practices set the benchmark to which we all should be held accountable. Ferrell and Virani give us the roadmap to follow, so that we can continue to make a difference in the quality of the life of our patients and families.

National Guidelines for Palliative Care: A Roadmap for Oncology Nurses

. National Consensus Project for Quality Palliative Care:Clinical practice guidelines for palliative care, 2004. Availableat: 

The Ferrell/Virani Article Reviewed

ABSTRACT: ABSTRACT: Patients with cancer have signifi cant needs for palliative care, including pain and symptom management and psychosocial and spiritual support. The experience of cancer has an impact on family caregivers as well, and palliative care needs exist from diagnosis through survivorship and end-of-life care. Oncology nurses have opportunities to integrate palliative care into disease-focused care. Clinical practice guidelines developed by the National Consensus Project for Quality Palliative Care and preferred practices defined by the National Quality Forum serve as a framework to guide nurses in this area. These national guidelines can serve as a roadmap to develop clinical services that will serve patients and families.

In the next decade, we will witness growing numbers of cancer survivors with ongoing needs for support, newly diagnosed patients whose cancer experience begins with uncontrolled symptoms and extreme psychological effects, and patients with recurrent or late-stage disease in need of high-quality care at the end of life. The concept of palliative care should be integrated throughout cancer care, with nurses primarily responsible for its delivery.

ONCOLOGY Nurse Edition has focused on the topic of palliative care at a pivotal time in the history of cancer care. This article is the fi rst of a four-part series on palliative care. It presents a general framework for quality improvement and is intended to present a global view of palliative care within oncology practice. Two national initiatives of major importance will be described: the National Consensus Project for Quality Palliative Care (NCP) and the National Quality Forum (NQF) framework for palliative care.

The three articles that will follow in this series will focus on specific priority topics: the newly diagnosed patient and palliative care, survivorship and palliative care, and fi nally, care at the end of life.

THE NATIONAL CONSENSUS PROJECT FOR QUALITY PALLIATIVE CARE 

The NCP published the Clinical Practice Guidelines for Quality Palliative Care in 2004.

 The NCP was initiated in 2001 and is a collaboration of four key national palliative care organizations: the American Academy of Hospice and Palliative Medicine (AAHPM), the Center to Advance Palliative Care (CAPC), the Hospice and Palliative Nurses Association (HPNA), and the National Hospice and Palliative Care Organization (NHPCO). These organizations worked to achieve consensus on elements defining quality palliative care.

The NCP goal was to promote growth and development of quality practices in clinical settings. NCP guidelines were created through a rigorous 3-year process consistent with other clinical practice guide-lines. Development included a comprehensive reviewof the research literature and extensive consensus by the leaders of the palliative care organizations. The consensus document was then reviewed by external peers and various organizations. These guidelines were endorsed as a timely and signifi cant advance for the field.

The NCP mission was "to create a set of voluntary clinical practice guidelines to guide the growth and expansion of palliative care in the United States."

 The NCP guidelines were initiated as a voluntary challenge to organizations.

But given the importance of the fi eld, many have speculated that this effort will lead to mandatory requirements for accreditation or licensure in the future. This is especially true in oncology as, even with treatment advances, more than 560,000 people will die from cancer this year and principles of palliative care need to be initiated from the moment of diagnosis.

NCP guidelines address needs for quality care for patients in hospice and palliative care. The guidelines are equally applicable to inpatient and outpatient oncology settings, to small and large oncology programs, and to rural and major urban cancer centers. Hospice in America has been a welcome advance in care, but unfortunately it is often limited to the last days or weeks of life. Palliative care aims to improve quality care through reduction of symptoms; improved communication between patients, families, and health professionals; and enhancing continuity of care across settings.

Reports by the Institute of Medicine and others have called for systemwide change to insure that palliative care begins at the time of diagnosis in serious illness.

 Palliative care should be seamlessly integrated within disease-focused care such as during radiation therapy, chemotherapy, in clinical trials, and also in survivorship care.

The NCP's Eight Broad Domains The NCP framework includes eight broad domains, and within each domain there are specific recommendations. The NCP guidelines address the structure and process of care important in building systems of quality palliative care. The other NCP domains address quality-of-life (QoL) concerns in the physical, psychological, social, and spiritual aspects of care. The NCP guidelines also address cultural considerations, a topic of increasing importance in our diverse society. The final domains include imminent death and ethical/legal aspects of care. NCP guidelines were developed for palliative care programs across all settings: hospital-based, ambulatory, and home care.

NATIONAL QUALITY FORUM EXTENDS NCP GUIDELINES 

The significance of national guidelines for palliative care was evidenced by the response by the NQF. The NQF framework was built directly on the NCP guidelines, and was a major achievement in the advancement of palliative care.

 The NQF extended the guidelines by developing a set of preferred practices for each of the eight domains. These 38 best practices are evidence- based and endorsed through expert opinion for a comprehensive quality measurement and reporting system across all settings to improve palliative care. The NQF and the NCP defi nition is that "palliative care is both a philosophy of care and an organized, highly structured system for delivering care."

 The goal of palliative care is to prevent and relieve suffering and to support the best possible QoL for patients and their families, regardless of the stage of the disease or the need for other therapies.

Palliative care expands traditional disease-model medical treatments to include the goals of enhancing QoL for patients and family members, helping with decision making, and providing opportunities for personal growth.

NCP DOMAINS: AN ONCOLOGY NURSING ROADMAP 

Following is a summary of each domain of the NCP guidelines with the recommendations for improving the quality of palliative care. Examples of some of the preferred practices from the NQF framework are also included to indicate where oncology nurse leaders can direct efforts at change.

A complete version of the NCP guidelines can be found on the NCP website, and a complete list of the NQF preferred practices can be found on that organization's website. (See 

Oncology nurses know that to improve care for patients in a consistent and reliable way, enduring structures must be developed and processes of care must be created. This has been demonstrated in other areas of oncology such as creation of structures and processes of chemotherapy administration, infection control precautions, and survivorship care planning. The key recommendations within Domain 1 include the following: 
• Conduct comprehensive interdisciplinary assessment of patient and family. 
• Address the identifi ed and expressed needs of patient and family. 
• Interdisciplinary team is consistent with the plan of care. 
• Implement education and training. 
• Recognize emotional impact of work. 
• Team develops relationship with hospices. 
• Physical environment meets needs of both patient and family.

Examples of NQF Preferred Practices for Domain 1 

Preferred Practice #2: Provide access to palliative and hospice care that is responsive to the patient and family 24 hours a day, 7 days a week.

Preferred Practice #3: Provide continuing education to all health-care professionals on the domains of palliative care and hospice care.

Preferred Practice #8: Health-care professionals should present hospice as an option to all patients and families when death within a year would not be surprising, and reintroduce the hospice option as the patient's health declines.

There are many opportunities to implement structures and processes that can integrate palliative care within disease-focused care. The aforementioned preferred practices are valuable contributions to oncology care.

Strengthening relationships with hospice and providing education to staff on topics such as symptom management, bereavement, and cultural issues at the end of life can have a signifi cant impact on the delivery of care to patients.

Quality care in cancer is not possible without attention to physical concerns. The key recommendations within Domain 2 include the following: • Manage pain, other symptoms, and treatment side effects using best practices. • Team documents and communicates treatment alternatives, permitting patient/family to make informed choices. • Educate and support the family to provide safe/appropriate comfort measures to patient.

Examples of NQF Preferred Practices for Domain 2 

Preferred Practice #12: Measure and document pain, dyspnea, constipation, and other symptoms using available standardized scales. Preferred Practice #13: Assess and manage symptoms and side effects in a timely, safe, and effective manner to a level that is acceptable both to the patient and to the patient's family members.

Over the past decade, oncology nurses have made substantial contributions to improving pain management. The impact of improved pain relief on QoL has been well documented. Often, symptoms are not well addressed, yet palliative care programs have demonstrated that routine procedures for treatment of physical and psychological symptoms can greatly improve QoL.

DOMAIN 3: PSYCHOLOGICAL AND PSYCHIATRIC ASPECTS OF CARE 

Attention to psychological aspects of cancer is as essential as the priority of physical care. These symptoms often are not assessed or aggressively treated, despite the prevalence of depression, anxiety, and other symptoms. Key Domain 3 recommendations include: 
• Assess and manage psychological/psychiatric issues. 
• Team employs pharmacologic, nonpharmacologic, and complementary therapies as appropriate. 
• Grief and bereavement program is available to patients and families.

Examples of NQF Preferred Practices for Domain 3 

Preferred Practice #14: Measure and document anxiety, depression, delirium, behavioral disturbances, and other common psychological symptoms using available standardized scales.

Preferred Practice #15: Manage anxiety, depression, delirium, behavioral disturbances, and other common psychological symptoms in a timely, safe, and effective manner to a level acceptable to the patient and family.

Preferred Practice #17: Develop and offer a grief and bereavement care plan to provide services to patients and families prior to and for at least 13 months after the death of the patient.

There is much to be done to improve the psychological aspects of palliative care in oncology. Preferred practice #17 can be a challenge for oncology settings given the high mortality in this clinical specialty. While hospice programs have modeled the provision of bereavement services, most other settings do not routinely provide bereavement support. Oncology nurses can develop collaborative relationships with hospices and community agencies to insure that bereavement services are available.

Oncology nurses have long recognized that quality care encompasses the family, not only the patient diagnosed with cancer. Needs for family support intensify as the disease progresses. The key recommendations within Domain 4 include the following: 
• Conduct interdisciplinary social assessment. 
• Develop care plan. 
• Make referrals to appropriate services.

Examples of NQF Preferred Practices for Domain 4 

Preferred Practice #18: Conduct regular patient and family care conferences with physicians and other appropriate members of the interdisciplinary team to provide information, discuss goals of care, disease prognosis, advanced care planning, and to offer support.

Preferred Practice #19: Develop and implement a comprehensive social care plan that addresses the social, practical, and legal needs of the patient and caregivers, including but not limited to relationships, communication, existing social and cultural networks, decision making, work and school settings, finances, sexuality/intimacy, caregiver availability/stress, and access to medicines and equipment.

This domain is indicative of the need for interdisciplinary collaboration. Implementing quality improvement strategies for many aspects of palliative care in oncology can be facilitated by partnership with social workers.

Preferred practice #18 regarding family conferences is often an area of needed improvement. Open communication with family members is particularly important in advanced disease when decisions about treatment discontinuation or hospice often occur. Implementing routine family conferencing can be key to promoting the best care.

DOMAIN 5: SPIRITUAL, RELIGIOUS, AND EXISTENTIAL ASPECTS OF CARE

Oncology nurses have long advocated for attention to spiritual care needs. Many of the advances in spiritual assessment and in addressing diverse religious preferences have been pioneered in oncology. The key recommendations within Domain 5 include the following: 
• Assess and address spiritual concerns. 
• Recognize and respect religious beliefs-provide religious support. 
• Make connections with community and spiritual/ religious groups or individuals as desired by patient/family.

Examples of NQF Preferred Practices for Domain 5 

Preferred Practice #20: Develop and document a plan based on assessment of religious, spiritual, and existential concerns using a structured instrument and integrate the information obtained from the assessment into the palliative care plan.

Preferred Practice #23: Specialized palliative and hospice spiritual care professionals should build partnerships with community clergy, and provide education and counseling related to end-of-life care.

In much the same way that structured assessment of pain or symptoms facilitates consistent care, this domain and its referred practices emphasizes the importance of routine practice related to spirituality. Many clinical settings have adopted standard spiritual assessments such as use of the FICA tool.

 Oncology nurses can be instrumental in promoting collaboration between chaplaincy and community clergy.

Oncology nurses have embraced the challenge to adapt cancer care to accommodate diverse cultures. Culturally based values, beliefs, traditions, and rituals impact greatly on QoL and take on added signifi cance in serious illness. The key recommendations within Domain 6 include the following: 
• Assess and attempt to meet the culture-specific needs of patients and families. 
• Respect and accommodate range of language, dietary, and ritual practices of patients and families. 
• Team has access to/uses translation resources. 
• Recruitment and hiring practices refl ect cultural diversity of community.

Example of NQF Preferred Practices for Domain 6

Preferred Practice #24: Incorporate cultural assessment as a component of comprehensive palliative and hospice care assessment, including but not limited to locus of decision making; preferences regarding disclosure of information, truth telling, and decision making; dietary preferences; language; family communication; desire for support measures such as palliative therapies and complementary and alternative medicine; perspectives on death, suffering, grieving, and funeral/burial rituals.

Respecting culturally based values and practices begins with assessment but must include quality improvement efforts to change practice. Cancer patients facing the end of life may have heightened needs for affi liation with cultural practices. Many ethical dilemmas stem from a lack of attention to this domain, such as confl icts in truth telling or decision making. Oncology professionals often need continuing education to enhance their own understanding in this domain.

Oncology nurses have often seen instances where the final days or hours of a patient's life were not peaceful and quality care unfortunately was not achieved. The NCP guidelines and NQF framework have recognized this area of need and thus designed the seventh domain to address the imminently dying. Key recommendations within Domain 7 include: • Recognize and communicate signs and symptoms of impending death. 
• As patients' health declines, team introduces or reintroduces hospice. 
• Signs/symptoms of approaching death are developmentally appropriate (age and culture).

Examples of NQF Preferred Practices for Domain 7 

Preferred Practice #26: Recognize and document the transition to the active dying phase and communicate to the patient, family, and staff the expectation of imminent death.

Preferred Practice #29: Provide adequate dosage of analgesics and sedatives as appropriate to achieve patient comfort during the active dying phase and address concerns and fears about using narcotics and of analgesics hastening death.

Preferred Practice #30: Treat the body after death with respect according to the cultural and religious practices of the family and in accordance with local law.

This domain has been an area of attention for hospices, palliative care programs, and acute oncology settings. Many programs have developed written materials for families addressing signs of impending death or practices to help support families in these critical times.

Attention to/management of physical symptoms such as delirium can help comfort the family. 

 While most busy oncology units have limited time to comfort families after a death, intentional practices to respect and care for the body after death is an important clinical area which often can be neglected.

DOMAIN 8: ETHICAL AND LEGAL ASPECTS OF CARE 

The final domain of quality palliative care is the ethical and legal aspects of care. Decisions regarding treatment preferences, life-sustaining treatments, decision making, and advance care planning are common in oncology and should be anticipated and treated in a reliable approach to facilitate ethical practice. The key recommendations within Domain 8 include the following: 
• Respect patient's goals, preferences, and choices when forming basis for plan of care. 
• Team is aware of and addresses complex ethical issues. 
• Team is knowledgeable about relevant federal and state statutes and regulations.

Examples of NQF Preferred Practices for Domain 8 

Preferred Practice #34: Convert the patient treatment goals into medical orders and ensure that the information is transferable and applicable across care settings, including long-term care, emergency medical services, and hospitals, such as the Physician Orders for Life-Sustaining Treatments Program.

Preferred Practice #35: Make advance directives and surrogacy designations available across care settings, while protecting patient privacy and adherence to Health Insurance Portability and Accountability Act regulations.

Preferred Practice #38: For minors with decision-making capacity, document the child's views and preferences for medical care, including assent for treatment, and give appropriate weight in decision making. Make appropriate professional staff members available to both the child and the adult decision maker for consultation and intervention when the child's wishes differ from those of the adult decision maker.

These preferred practices are likely areas of opportunity for improvement across all oncology settings. Ethical dilemmas are often heightened with children and older adults. Written documentation of decisions and preferences is extremely important and greatly enhances care.

This article is an introduction to a four-part series on palliative care to guide oncology nurses to initiate quality improvement efforts. People diagnosed with cancer deserve quality palliative care regardless of their stage of disease, and such care should not be reserved for the final days of life.

Educational projects such as the End of Life Nursing Education Consortium have made a concerted effort to prepare nurses to lead the charge. Ultimately, quality palliative care is aimed at insuring the best care each of us would expect if someone we cared about was seriously ill or dying.

 National Consensus Project for Quality Palliative Care: Clinical practice guidelines for palliative care, 2004. Available at 

 National Quality Forum. Available at www.qualityforum. org. Accessed December 12, 2007.
 

 Ferrell B: Overview of the domains of variables relevant to end-of-life care. J Palliat Med 8(suppl):22â25, 2005.
 

 American Cancer Society: Facts and figures, 2006. Available at 

http://www.cancer.org/docroot/STT/stt_0_2006.asp?sitearea=STT&level=1

Patients with cancer have significant needs for palliative care, including pain and symptom management and psychosocial and spiritual support. The experience of cancer has an impact on family caregivers as well, and palliative care needs exist from diagnosis through survivorship and end-of-life care. Oncology nurses have opportunities to integrate palliative care into disease-focused care.

ONCOLOGY Nurse Edition Vol 22 No 2 | Oncology Nurse Edition

Epothilones

The Ferrell/Virani Article Reviewed

National Guidelines for Palliative Care: A Roadmap for Oncology Nurses