Case Study - Walter

A patient’s experience of a stoma

following curative bowel surgery:

Opportunities for the acute therapy team

to enhance recovery and promote

quality of life

Beki Dellow

Occupational Therapist – Acute Therapy Team (Surgical Rotation) March 2012

Learning Outcomes

Brief explanation of the meaning of ‘stoma’ and causes of bowel cancer

Review bowel cancer statistics and importance of screening

Gain an overview of a specific patient’s experience pre/post operatively (bowel surgery)

Review guidelines and evidence to support practice in stoma care and assessment of quality of life

Consider opportunities for the acute therapy team to enhance the patient experience and their quality of life, promote recovery and decrease length of stay

Summary & conclusion

Questions

Stoma

From classical Greek meaning

‘Mouth’

‘Artificial opening’ (Black 2000)

There are approximately 100,000 people in the UK with a stoma

(Windsor and Conn 2008)

Causes of Bowel Cancer High intake of red and processed meat will increase the

chances of developing bowel cancer whereas a diet rich in fibre will reduce your risk

Around 13% of bowel cancers in the UK are linked to overweight or obesity

Research has shown that drinking as little as 10g/day of alcohol (around 1 unit) can increase the risk of bowel cancer

Smoking increases the risk of bowel cancer

People with a first-degree relative with bowel cancer are at twice the average risk of developing it themselves

People with diabetes, ulcerative colitis or Crohn's disease all have an increased risk of bowel cancer

Being physically active reduces risk of colon cancer (Cancer Research UK 2011)

Bowel Cancer UK Incidence Statistics

Approximately 110 new cases of colorectal cancer are diagnosed daily

The third most common cancer in women after breast and lung, third in males after prostate and lung

In 2008 - 39,991 new cases of large bowel cancer registered: two-thirds (25,551) in the colon and one-third (14,440) in the rectum

(Cancer Research UK 2011; NICE 2011)

Bowel Cancer UK Incidence Statistics

Bowel cancer is the third most common cause of cancer death among men (11% of all male cancer deaths). It is the third most common cause of death among women (10% of all female cancer deaths)

The lifetime risk for men of being diagnosed with colorectal cancer is estimated to be 1 in 15 and for women 1 in 19

In 2009, there were 15,908 deaths from bowel cancer

Bowel cancer mortality rates have overall decreased: For men, European age-standardised mortality rates were 35% lower in 2007-09 than in 1971-73. For women, rates were 47% lower in 2007-09 than in 1971-73

(Cancer Research UK 2011)

Average number of new cases per year and age-specific incidence rates per 100,000 population (UK)

The importance of bowel screening

Has been shown to reduce the risk of dying from bowel cancer by a quarter in people who are screened in England

Most cases of colorectal cancer develop slowly over a number of years from adenomas, or benign polyps, which can transform into malignant adenocarcinomas. This provides the opportunity for screening to detect and treat benign polyps before malignant transformation occurs

Can detect colorectal cancers at an early stage when survival rates are highest

Those who attend screening have a 25% reduction in their risk of dying from colorectal cancer

(Cancer Research UK 2011)

Survivorship

Five-year survival rates for male rectal cancer rose from 25% in the early 1970s to 51% in mid 2000s and from 27% to 55% for female rectal cancer

These improvements are a result of earlier diagnosis and better treatment but there is still much scope for further progress

Ten-year survival rates are only a little lower than those at five-years indicating that most patients who survive for five years are cured from this disease

Patients who are diagnosed at an early stage have a much better prognosis than those who present with more extensive disease

Bowel cancer incidence is generally higher in populations with ‘westernised’ diets and these populations also tend to have a higher proportion of overweight and obese people and lower levels of exercise

(Cancer Research UK 2011)

Case study - Walter

78-year-old male

Lives with supportive wife (retired nurse)

Short-term memory difficulties

Motivated and positive

Walter’s journey

28/10/11Visit to GP

2 – 3 months bleeding from rectum

Rectal examination(definite palpable mass)

2 week fast track referral for suspected colorectal cancer

11/11/11Letter received by consultant from GP

8cm mass on left lateral wall of rectum confirmed. Tumour likely

to be a carcinoma

Explained to Walter and his wife

14/11/11Colonoscopy

Biopsies of large bowel Mucosa taken

23/11/11CT &

Local staging of Primary tumour with MRI

Staging: The 1932 Dukes’ classification of tumours

     

UICC/TNM Modified Dukes'

Stage 0 Carcinoma in situ A

Stage I No nodal involvement, no distant metastasis  

  Tumour invades submucosa (T1, N0, M0)  

  Tumour invades muscularis propria (T2, N0, M0)  

Stage II No nodal involvement, no distant metastasis B

  Tumour invades into subserosa (T3, N0, M0)  

  Tumour invades into other organs (T4, N0, M0)  

Stage III Nodal involvement, no distant metastasis C

  1 to 3 regional lymph nodes involved (any T, N1, M0)  

  4 or more regional lymph nodes involved (Any T, N2, M0)

Stage IV Distant metastasis (any T, any N, M1) D

     

29/11/11MDT discussion

• Review of histology from colonoscopy • Biopsies from large bowel mucosa are infiltrated by poorly differentiated Adenocarcinoma• CT - no evidence of metastatic disease• MRI – low rectal adenoma or early invasion lesion (T2NO-LOREC Stage 1)

Stoma Care Nurses informed

09/12/11Reviewed at clinic by consultant in

colorectal and general surgeryDiagnosis of T2 carcinoma of the

Lower rectum

Walter advised of temporary diverting stomaPossible permanent colostomy

21/12/11Colorectal Enhanced Recovery

SURGERY 10.30 – 12.30Low Anterior Resection

& Loop Ileostomy

Wound coveredHigh volume epidural controlling pain

18.00 – Walter is reviewed by the surgeon (sit out and mobilise as able)

Walter mobilised in the eveningUrine output satisfactory

Walter’s surgery: Low anterior resection with loop ileostomy

23/12/11 – DAY TWO• Nursing staff - ‘IV & edpidural down’• Therapy assistant – ‘Mobile with supervision of one staff’• Stoma Nurse – 30 minute education session with

patient (wife present) – Diet, stoma self-care equipment supplier and kit, stoma care advice line• Occupational therapist - observing

Walter reports: ‘my pain is not too bad, just when I’m coughing’Walter’s wife reports: ‘ the fast track and enhanced recovery is fabulous. I’m particularly surprised that my husband is returning home at day three, all being well. I am happy with the service and pre-op preparation also’

Christmas Eve – DAY THREEWalter is discharged home

from hospital

ONE WEEK AFTER DISCHARGE• Stoma nurse – telephone contact

to arrange follow-up home visit

TWO WEEKS AFTER DISCHARGE• Stoma nurse – follow up visitWalter managing well with wife’ssupport

WEEK THREE• Occupational therapist – Telephone call – wife reports

Walter managing well, with min support

22/12/11 – DAY ONE08.20am – ‘doing fantastically, mobilising’

• Physiotherapist – ‘Independent with epidural stand. Taught deep breathing exercises and cough’• Stoma Nurse – First visit, education session with occupational therapist present. ‘Participated well, slightly muddled’

Acute therapy team role?

Assessment and enabling strategies

Education

Supporting role, rehabilitation and follow-up – collaboration with intermediate care teams and stoma nurses

Assessment and enabling strategies

Self-care

Quality of life

Mobility and exercise

Enabling engagement in stoma self-care occupation

Involves a complex interaction between

the occupation itself; Walter’s beliefs,

values and identity; and the

institutional, cultural, social and

physical environment in which the

occupation is performed(Van Huet et al, 2010)

Analysis of Walter’s occupational performance

‘Occupational performance analysis is a structured evaluation

process that uses observation of an individual to identify and

define factors that support or hinder occupational performance

and prevent that person from being a full participant in life’

(Chard, 2010 p161)

AssessmentObjective (observation)

Careful observation of Walter’s performance of the self-care occupation to determine:-

Capacities to complete the specific tasks

Degree and nature of assistance required

Need for support

Need for further targeted assessment of areas of difficulty

Causes of any activity limitations(Van Huet et al, 2010)

AssessmentSubjective (questionnaire)

Collect data that reflects Walter’s perspectives and perceptions of self-care (self-report)

Indicates what Walter believes is occurring during performance

Highlights what Walter believes is particularly problematic

Gain and in-depth picture of Walter’s self-care needs, abilities, choices and desires

(Van Huet et al, 2010)

Quality of life

Assessment tools

There are limited quality of life evaluation tools (Baxter et al 2006)

1994 – Major quality of life international study using the Quality of Life Index (QLI) developed by Padilla and Grant (1985) - 16 countries

5289 patients recruited by stoma care nurses

Patients completed a questionnaire 4 times in first year (discharge, 3, 6 & 12 months). The following year, one questionnaire at 18 & 24 months (voluntary basis)

Findings:

Showed change with time – biggest improvement between hospital discharge and 3 months (patients generally enjoyed a better quality of life)

Those with good relationship with a stoma nurse after discharge had a significantly higher QOL than those who had a poor relationship

Changing appliances - most patients had moderate confidence at hospital discharge. Those high in confidence had a higher QLI score. At 3 months, those with decreased confidence had a decrease in QLI score

Helping to increase patients’ confidence in changing their appliance has a positive effect on Quality of life (Black 2000)

Stoma-QoL questionnaire

Mobility and exercise

Education

Pre and post op physiotherapy

Information leaflet – exercises and

advice

Reinforcing stoma self-care in and

out of hospital – Occupational

therapists and therapy assistants

Supporting role & rehabilitation

On the road to rehabilitation, most patients go through at least three stages :-

1. Learn to basically care for their stoma and manage their equipment

2. Complete with stoma, engages in activities of daily living they regard as part of their normal lifestyle

3. Report feeling ‘back to normal’ or ‘being myself again’. The stoma is experienced as an integral part of the person instead of being separate or added onto them

Our care must be relevant to our patients’ needs and also promote their longer-term psychological and physical rehabilitation (Breckman 2005)

NICE Guideline Colorectal Cancer (2011)

Patient-centred care – Take into account their needs and wishes; involve family and carers with consent; informed decisions; good communication

Before surgery, offer all patients information about the likelihood of having a stoma, why it might be necessary and how long it might be needed for

Ensure a trained stoma professional gives specific information on the management and care of stomas

Quality of life - Colorectal cancer-specific patient-reported outcome measures (PROMs) should be developed for use in disease management and to inform outcome measures in future clinical trials

‘The essence of successful stoma care is knowing,

valuing and working with each patient as an individual

human being. Their physical and psychological needs,

goals capabilities and resources can then be used to

help them to move from feeling and acting as a ‘stoma

patient’ to being a person engaged in their normal

lifestyle who happens to have a stoma’

(Breckman 2005)

Summary: Getting the balance right

The quality of pre-operative preparation can contribute greatly to

patients quality of life and acceptance of their stoma

The presence of any stoma, either permanent or temporary, affects

patients’ lives, therefore carefully planned siting is critical to promote

independence in self-care

Psychological care is important to help patients to form positive

attitudes towards their new form of bowel elimination and changes to

their body image

Patients are discharged very soon after surgery and this restricts the

time available to help them gain adequate knowledge and skills to

manage self-care at home

(Black 2000, Borwell and Breckman 2005)

Conclusion

The impact of rectal surgery goes well beyond the physiological changes a person will experience

With the appropriate knowledge, skills and sensitivity, we as health care professionals can help our patients to make the transition from despair to adjustment and rehabilitation, ultimately enhancing their quality of life and promoting recovery

(Winney 2005)

Questions?

References Baxter NN, Novotny PJ, Jacobson T, Maidl LJ, Sloan J (2006) A stoma quality of life scale

Diseases of the Colon & Rectum 49(2): 205-12

Black PK (2000) Holistic Stoma Care London: Bailliere Tindall

Borwell B, Breckman B (2005) Types of bowel stoma and why they are created. In:

Breckman B (Ed) Stoma Care and Rehabilitation Oxford: Elsevier Churchill Livingstone

Breckman B (Ed) (2005) Stoma Care and Rehabilitation Oxford: Elsevier Churchill

Livingstone

Burch J (Ed) (2008) Stoma Care Chichester: John Wiley & Sons Ltd

Cancer Research UK (2011) Colorectal Cancer Fact Sheet London: Office for National

Statistics [Online]

Available from: http://info.cancerresearchuk.org/cancerstats/types/bowel/incidence/

[Accessed 25/02/2012]

References Chard G (2010) Analysis of Occupational Performance. In: Curtin M, Molineux M, Supyk-

Mellson (Eds) Occupational Therapy and Physical Dysfunction: Enabling Occupation (6th

Ed) London: Churchill Livingstone Elsevier

Curtin M (2010) Enabling Skills and Strategies. In: Curtin M, Molineux M, Supyk-Mellson

(Eds) Occupational Therapy and Physical Dysfunction: Enabling Occupation (6th Ed)

London: Churchill Livingstone Elsevier

Curtin M, Molineux M, Supyk-Mellson (Eds) (2010) Occupational Therapy and Physical

Dysfunction: Enabling Occupation (6th Ed) London: Churchill Livingstone Elsevier

Jones DJ (1999) ABC of Colorectal Diseases (2nd Ed) London: BMJ Books

NICE (2011) Colorectal Cancer: The Diagnosis and Management of Colorectal Cancer

Manchester: NICE

Padilla G, Grant M (1985) Quality of life as a cancer nursing outcome variable Advances in

Nursing Science 8: 45-60

References

Prieto L, Thorsen H, Juul K (2005) Development and Valdation of a Quality of Life Questionnaire for Patients with Colostomy or Iliostomy Health and Quality of Life Outcomes 3(62) [online]

Available from: http://www.hqlo.com/content/pdf/1477-7525-3-62.pdf [Accessed 04/12/2012]

Sumsion T (2010) The Art or Person-Centred Practice. In: Curtin M, Molineux M, Supyk-Mellson (Eds) Occupational Therapy and Physical Dysfunction: Enabling Occupation (6th Ed) London: Churchill Livingstone Elsevier

Van Huet H, Parnell T, Mitsch V, McLeod-Boyle A (2010) Enabling Engagement in Self-care Occupations. In: Curtin M, Molineux M, Supyk-Mellson (Eds) Occupational Therapy and Physical Dysfunction: Enabling Occupation (6th Ed) London: Churchill Livingstone Elsevier

Windsor A, Conn G (2008) Surgery. In: Burch J (Ed) Stoma Care Chichester: John Wiley & Sons Ltd

Winney J (2005) Consequences of rectal surgery. In: Swan E (Ed) Colorectal Cancer London: Whurr Publishers