Colorectal Cancer: SPIKES protocol (Setting up, Perception, Invitation, Knowledge, Emotions, and Str

1 Colorectal Cancer Background Colorectal cancer (CRC) is a heterogeneous colon and rectum disease arising from adenomatous polyps (Saad et al., 2020). It is typified by the colon’s aberrant proliferation of glandular epithelial cells (Hossain, 2022). CRC is a serious health problem affecting young and older adults with cataclysmic consequences. This discussion explores the case of an individual with CRC. The client is Black and Minority Ethnic (BME) and has a significant history of cancer, including breast cancer, and a family history of cancer. The paper will investigate the demographic and broader contributing factors to health, illness, and wellbeing and determine how the epidemiology of CRC affects an individual and the wider community (Carethers & Doubeni, 2019). The clinical investigations will systematically evaluate the A-E assessment focusing on breathing, followed by an explanation of oxygen therapy (OT), an evidence-based treatment for CRC patients with respiratory symptoms.

Finally, the discussion will explore CRC's ongoing care, focusing on communication skills and a multidisciplinary team (MDT) approach. The paper will highlight how the healthcare team can uphold the SPIKES protocol (Setting up, Perception, Invitation, Knowledge, Emotions, and Strategy) in breaking the bad news (BBN) to terminally ill patients (Johani et al., 2022).

Disease Epidemiology Incidence of CRC Globally, CRC is the third most dominant cause of cancer and is responsible for high mortality rates (Siminoff et al., 2015). In the United Kingdom, CRC is the fourth most common cancer, with over 42,000 new cases diagnosed each year (Bromham, 2020). In the Western world, CRC is the most malignant and has 36,000 cases each year in the UK (Taylor

2 et al., 2010). In 2017, an estimated 19 million (18.5 -19.5) disability-adjusted life years (DALYs) were reported, demonstrating the high burden of BC on individuals and society (Guren, 2019).

Risk Factors for CRC Different factors, including environmental and genetic factors, contribute to the development of CRC (Yang et al., 2020). A family history of cancer is a significant risk for cancer, including CRC. Patients with a 50-70-year-old first-degree relative with CRC have almost a double risk of CRC than those without a family history of the disease (Song et al., 2021).

Similarly, Sena (2018) clarified that the risk is higher if the first-degree relative was <50 years old during diagnosis. The chances of having CRC are high if one of the parents or a sibling has a history of cancer.

Nonetheless, the risk of developing cancer due to heredity is minimal. For instance, William et al. (2022) noted that the risk of CRC is about 5% to 10% in individuals with a family history of the disease. Also, William et al. (2022) argued that inherited cancer is a less common cause of CRC. However, the risk is still significantly higher among individuals with a family history of cancer than those without.

Furthermore, patients with CRC may exhibit more non-modifiable risk factors than modifiable factors. Non-modifiable risk factors include personal medical history, age, history of adenomatous polyps, and inflammatory disease history. These factors are beyond the control of an individual. Age is the most significant non-modifiable risk of colorectal cancer (Sawicki, 2021). Although incidences of young persons with CRC are rising, individuals above 50 years exhibit greater CRC risk than younger people (Sawicki, 2021).

Lifestyle-related factors elevate the risk of CRC. Excessive consumption of alcohol, unhealthy diet, and cigarette smoking increase an individual risk of CRC. A population-based

3 case-control study by Lin et al. (2020) revealed that a significant proportion of the patients diagnosed with CRC had a history of excessive alcohol use. The researchers also noted that alcohol use and CRC had a time-dependent relationship. Individuals who consumed large quantities of alcohol for a long time had the highest risk. Alcohol metabolism involves the conversion of ethanol to its metabolites. These metabolites have carcinogenic effects on the colon (Rossi et al., 2018).

Health inequalities due to geographical location, ethnicity, and poverty are also significant risk factors for cancer (Baidoun et al., 2020). For instance, Semlyen et al. (2016) noted that heterosexuals, including Lesbian, gay, bisexual, and transgender (LGBT) adults, demonstrate a higher prevalence of mental health, low well-being, and an elevated risk of chronic disorders. These vulnerable groups experience stigma, making it hard to access preventive care (Hossain, 2022).

Inequalities hinder individuals from accessing timely healthcare services. Exarchakou et al.

(2022) noted that patients living in more socioeconomic deprived areas were found to have worse cancer outcomes than those in less deprived areas. Also, Dijkstra and Horstman (2021) added that individuals with poor socioeconomic status live unhealthier and shorter lives than those with more excellent social positions. Dijkstra and Horstman (2021) clarified that in high-income regions, cancer cases and outcomes like mortality rates are low due to more screening, early detection, and treatment improvement compared to low-income regions (Khan et al., 2019).

Disease Impact on Patient and Family Epidemiological studies depict CRC as a considerable burden for low-income individuals and families since it affects the financial base of these parties (Oakes & Kaufman, 2017). Treating cancer is costly, particularly for people without a health insurance plan. The systematic

4 review by Fitch et al. (2022) pointed out that cancer patients and their families face financial challenges searching for quality oncology services. These challenges are disproportionate in low-income individuals due to a lack of benefit schemes, social support, and poor income.

Also, CRC negatively affects the social and psychological systems of patients and families.

CRC patients are more likely to experience a broad scale of impact on their mental and physical health (Wickham et al., 2020). CRC patients lacking positive social interactions develop psychological symptoms like depressive thoughts, distress, and anxiety.

Besides the devastating financial impact on families, CRC disrupts the social roles in families. Fitch et al. (2022) reported that significant changes in social needs, intimacy, responsibility, and emotional needs change when a family member is diagnosed with CRC. These changes are attributable to the social, financial, and emotional demands of the patient.

In the UK, leaders have initiated reforms of various welfare programs, including Universal Credit, to support people with psychological distress, such as depression, which impacts the workload of general practitioners (Wickham et al., 2020a).

Disease Impact on Society A high mortality rate is one of the catastrophic consequences of CRC on society. Across the globe, CRC prevalence and death rates differ significantly (Macrea, 2022). The study by Hossain (2022) revealed that in 2020, almost 9.4% of cancer-related deaths were due to CRC. Approximately 930,000 died from colorectal cancer and related complications. A populationbased study also disclosed that patients with CRC died from non-cancer-related conditions (Feng et al., 2020). These findings show that CRC predisposes patients to the risk of complications like septicemia and cardiovascular diseases. Besides death, CRC reduces the productivity of individuals, thus depriving society of valuable economic resources and opportunities. The disease disrupts the social fabric since, as highlighted by Wickham et al.

5 (2020), patients and families cannot actively participate in social functions. Financial loss, reduced quality of life, morbidity, decreased productivity, and premature deaths are considerable blows to society.

Clinical Investigation and Assessments The A to E assessment is one of the approaches used in CRC patients. This assessment procedure highlights the vital signs and clinical investigation data of patients. This assessment helps clinicians gather valuable information about the patient’s state and plan their future nursing care needs. For this assignment, breathing is the chosen element since the patient presented with respiratory symptoms like an increased breathing rate.

The RR is a pivotal maker of deterioration and predicts the seriousness of a patient’s illness (Lister et al., 2021). Respiratory symptoms indicate that the disease or infections have spread to the lungs. For instance, CRC may spread to the lungs, leading to infections that affect breathing. The patient's breathing rate may increase from 20 to 26 breaths per minute, which is considerably high. The normal range RR for an adult at rest is 12 - 20 bpm. A change in the RR might indicate certain conditions, such as infection, pneumonia, and sepsis, which trigger inflammation, increased mucus production, and congestion (Chourpiliadis & Bhardwaj, 2022).

A normal RR plays a vital role in the body since it helps keep the balance of oxygen (02) and carbon dioxide (CO2) (Rowden, 2023). An infection, as highlighted by Rowden (2023), affects the molecular function of the lungs to facilitate the exchange of gases. Rapid breathing (Tachypnea) could be a symptom of sepsis and pleural effusion, indicating the spread of cancer to the lungs (Park & Khattar, 2022). Pneumonia, sepsis, and infections affect the respiratory system, generating severe symptoms like increased breathing rate.

6 Nova et al. (2019) clarified that gaseous exchange in the body occurs in the alveoli in the lungs and the cells in tissues. The alveoli contain thin membranes that allow the movement of oxygen and Carbon Dioxide (CO2) (Cook et al., 2020). The actual exchange of gases takes place via simple diffusion whereby gases do not require energy to move but can follow the gradient pressure to diffuse using high permeability, thin and large surface area, and the respiratory membrane, which can maximize gas diffusion.

Rossi et al. (2018) pointed out that colorectal cancer may undergo metastasis affecting different body parts, including the lungs. The symptoms of metastatic colon cancer in the lungs include difficulty breathing, shortness of breath, coughing, and chest pain.

Lung infections trigger immune reactions, leading to fluid build-up that disrupts gaseous exchange. For instance, the immune system generates macrophages that target defective cells, viruses, and bacteria. Macrophages engulf these foreign materials and recruit neutrophils to the infection site. These immune activities trigger humoral and cellular defense mechanisms, form antibodies against infectious organisms, and activate the complement system. These reactions cause lung parenchyma inflammation and make the lining capillaries leaky, leading to exudative congestion that typifies pneumonia (Nova et al., 2019). The increased secretions and inflammatory reactions caused by macrophages are responsible for the clinical findings in pneumonia. Gaseous exchange is almost impossible in clogged alveoli.

Rapid breathing is caused by a shortage of oxygen in the body. It is an intrinsic mechanism to increase the alveoli's gaseous exchange volume (Brinkman et al., 2022). This makes O 2 and CO2 movement across the membrane increase due to different partial pressures affecting the diffusion process (Williams, 2021). An increase in RR facilitates the supply of more O 2 into the blood and the subsequent reduction of CO2 in the body (Brinkman et al., 2022a).

7 Recommendation for Care Oxygen therapy is the most suitable intervention for CRC patients with severe respiratory symptoms. This intervention is supported by Zhang et al. (2012), who noted that ventilatory support is the primary intervention for adult pneumonia. In the systematic review of RTCs, Zhang et al. (2012) affirmed that oxygen therapy is extensively used in treating lung disorders like pneumonia. This intervention reduces the risk of death and shortens critical care unit stays. Zhang et al. (2012) employed a systematic review of the literature design to determine the effectiveness of applying oxygen therapy to treat pneumonia. The systematic review of RCTs is the highest level of evidence. The researchers used up-to-date evidence from electronic databases, including Cochrane and Medline. The resources were reviewed independently to ensure that only quality articles were included.

Also, Igarashi et al. (2020) supported using oxygen therapy in terminally ill patients with dyspnea. Igarashi et al. (2020) clarified that oxygen therapy has life-sustaining effects on patients with pneumonia and severe sepsis. However, oxygen use in patients with low oxygen saturation is controversial. Igarashi et al. (2020) noted that oxygen relieves dyspnea in patients whose oxygen saturation is below 95%. Further, randomized controlled clinical trials revealed that oxygen therapy reduced mortality in patients with hypoxemia due to COPD. However, oxygen therapy did not generate the intended therapeutic outcomes in patients with SpO2 below 94%. Igarashi et al. (2020) noted that oxygen therapy has not been experimented in patients with advanced cancer since it is presumed a risk factor for death.

Ongoing Care and Management Oxygen therapy was initiated to restore the patient's Oxygen saturation. Initially, I gained consent from Sarah and asked if she had any allergies, explained the O2 supplementation procedure, and provided her with reassurance and support on the safe delivery of O2

8 (Peate,2019). I assessed Sarah's RR, pattern, sounds, position, use of accessory muscles, and her new early warning score (NEWS2) (Ellis et al.,2020). Sarah's saturation was low (89%); therefore, I escalated the results to the doctor in charge.

The preparation included piped oxygen or an O2 cylinder, O2 tubing, prescription charts, and a nasal cannula as prescribed, considering the five rights (Cook et al., 2019). Since Sarah was prone to infections, I ensured I washed my hands and used personal protective equipment to prevent the spread of infection (Lister et al., 2021). Sarah was attached via O2 tubing to the flow meter connecting to the O2 cylinder. The nasal cannula was placed in Sarah’s nose and securely comfortably. The appropriate flow rate of 4L/min via nasal cannula was set up according to the prescription (NMC, 2018). Sarah’s skin color and perfusion, RR, respiration pattern, and O2 saturations were observed during OT (Blows, 2018). However, I monitored the rate constantly, encouraged her to increase fluid intake (water) and maintain oral hygiene using Vaseline regularly as O2 can dry the mucosa membrane. I continued to observe Sarah’s RR, monitored her saturation (Peate, 2019) in case of any change, and documented every procedure I carried out (NMC, 2018; Peate, 2019).

The Nursing and Midwifery Council (NMC, 2018) noted that nurses must be transparent and responsible in the care that they give to patients. However, in most cases, this is only sometimes the case, as errors are sometimes made when reading RR in clinical settings. For instance, anxious patient can alter their breathing when they are aware that their respiratory rate is taken (Kallioine et al., 2021).

The Multidisciplinary Team An oncology MDT is vital in delivering quality care to the patient. This team comprises surgeons, oncology nurses, hematologists, mental health nurses, clinical psychologists, occupational therapists, and nutritionists. This team’s primary role is to deliver holistic care

9 to oncology patients. The team employs a respectful, nonjudgmental, and mindful approach to delivering care to all patients (NMC, 2018). Teamwork is typified by delegation, prioritization, and collaboration. These elements of care are essential for improved outcomes.

Nurses collaborate with other professionals, ensuring adequate support for her and her family.

The MDT, as highlighted by Al-Johani et al. (2022), is aware of how patients react after receiving the BN. Therefore, the team uses psychosocial interventions to deal with reactions such as shock, isolation, and grief, resulting in the expression of tearful eyes, sadness, and silence. The article by Al-Johani et al. (2022) provides invaluable evidence concerning the role of the MDT. It clarifies the importance of MDT in delivering unwelcome news to patients and families. The researchers used a mixed-method approach to explore patients' perspectives on unwelcome news disclosure. They highlighted the research method and used recent evidence to support their findings. The study emphasized the significance of effective communication in managing cancer patients. Al-Johani et al. (2022) revealed how the MDT collaborates to disclose shocking news to patients, deliver patient-centered care, and address patient's needs.

Communication with Patients Nurse-patient communication is essential for improved care outcomes. Communication enables the nurse to understand the patient's values, preferences, and health needs. The nurse can then integrate these components into the care plan to achieve the projected health outcomes. The quality of care with patients can be improved through effective communication (Keutchafo et al., 2020). Unfortunately, in some cases, specific barriers, such as actions, behavior, language, attitude, and physical arrangement (such as room layout) that

10 make patients uncomfortable can prevent patient-nurse interactions, reducing their ability to communicate (Moss, 2020).

Further, verbal and non-verbal interactions can establish cultural separation between clinicians and patients (Gerchow et al., 2021). The article by Keutchafo et al. (2020) revealed how nurses and patients use non-verbal communication to pass crucial messages. Keutchafo et al. (2020) employed the scooping review of literature design, gathering valuable information about non-verbal communication in clinical settings. A scooping review is a reliable source of evidence since it maps the literature to critical topics, thus identifying practice gaps. Further, a scooping review design helps researchers understand the impact of an initiative.

The terminologies used to describe diverse groups and communities, such as BME residents and the pronouns used for LGBT individuals (Webb, 2019), are alienating and result in adverse care delivery outcomes. Thus, it is vital to promote patient-centered care and a communication continuum (PC4) model that encourages trust and mutual respect in nursing.

Family involvement is essential for end-of-life patients, as it can provide emotional support and help with decision-making regarding therapy (Laryionava et al., 2021). The article by Laryionava et al. (2021) provides sufficient information about family involvement in end-oflife care and decision-making. The findings were reliable since the researchers used qualitative semi-structured interviews to collect information directly from oncologists.

Breaking bad news Breaking Bad News (BBN) to the patient and the family could be challenging, especially if a clinician is inexperienced. However, ethical principles help achieve transparency and reduce anxiety associated with unexpected outcomes (Walter et al., 2008). Sad news generates a

11 feeling of “no hope” among patients and families. Therefore, inappropriately delivering BN is more likely to exacerbate distress and anger in individuals (Al-Johani et al., 2022).

Dos Santos (2021) suggests that delivering BN plays a vital role in the clinician-patient relationship. Therefore, consensus guidelines have been developed to support patients and their families. The SPIKES protocol, for instance, helps with BBN. This protocol was initiated by Baile and Buckman (2000). The SPIKES protocol incorporates the issues arising from BBN to patients (Moss, 2020a; Hashemi, 2020).

A great deal of professionalism, energy, and patience is crucial in BBN (Rosenzweig, 2012).

Hence, nurses involved in BBN can experience burnout and compassion fatigue. Also, BBN may stress professional performance and overall well-being (Bumb et al., 2017).

SPIKES protocol highlights a six-step protocol, including the focus on empathy to build the platform for the patient to respond to their feelings and reactions. Empathetic communication is a critical component of SPIKE. It includes active listening, promoting genuine interest, respect, and warmth during care (Monden, 2016).

In diagnosing, caring, and treating patients, communication helps establish and promote emotional intelligence, which is crucial for positive care outcomes (Grant & Goodman, 2018). Moreover, identifying and improving emotional intelligence is significant in health promotion (Khademi et al., 2021).

Emotions can be challenging for patients during BBN. Patients react differently, ranging from disbelief, crying, denial, or anger. Therefore, the nurse must consider the emotional aspect of their patients during this critical moment.

The impact of teamwork Teamwork is crucial since it makes patients feel valued. Patients who receive healthcare services from MDT with a higher level of mutual trust, information exchange, and role clarity

12 have low-stress levels. The team's approach to care helps improve care outcomes by eradicating errors and misunderstandings. Team members share information, which facilitates decision-making. Also, teamwork enhances patient safety since experienced professionals scrutinize care delivery.

Conclusion Bowel cancer is one the deadliest conditions worldwide, affecting both young and old. The risk factors of CRC include family medical history, diet, BME determinates of health, and health inequality. Physiology, pathophysiology, and pharmacology are highlighted in this assignment, alongside the effective treatment of O2. This paper has highlighted some of the impacts of CRC on the individual and broader community. Also, it explored how effective communication is using the SPIKES tool when delivering BN and how it can help deliver safe and effective quality care by consulting with the MDT to treat patients with CRC. The importance of confidentiality, dignity, and respect was maintained throughout the assignment.

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