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218
been noted to commonly manifest as adjustment disorders, major depressive
disorder, anxiety disorders, insomnia and pain where intervention can be
appropriately instituted at an early stage (Bonito et al. 2013 ; Derogatis et al. 1983 ;
Garland et al. 2013 ; Krok and Baker 2013 ). Such needs can be intervened through
early education, cognitive behavioural therapy, relaxation techniques and peer
support (Kilbourn et al. 2013 ).
Caregivers are an invaluable source of comfort to cancer patients and they devote
their time to take care of their loved ones. Multiple studies have proven the positive
effects of good care giving leading to better outcomes for patients (Wu et al.
2013 ).
Flowchart 14.2 Overview of palliative approaches to provide care to patients
Pain is perhaps one of the most important factors in the management of the
palliative patient. Pain is commonly experienced amongst patients with advanced
cancers, with studies reporting up to 80 % of patients with advanced cancer
experiencing severe pain (Breivik et al. 2009 ; Teunissen et al. 2007 ; Van den
Beuken-van Everdingen et al. 2007 ; Goudas et al. 2005 ; Larue et al. 1995 ). The
D.K.-H. Chan et al.
219
causes of pain in colorectal patients can originate from tumour infi ltration of nerves,
bowel obstruction and distension of Glisson’s capsule (Fisher et al. 2013 ). Cancer
pain management utilises the World Health Organization analgesic ladder, in which
opioids occupy the second and third steps of this ladder, and these are typically
recommended for moderate to severe pain. The use of opioids allows for patients to
undergo a peaceful death and reduce the anxiety amongst family members as they
go through the fi nal stages of their loved one’s life. Even at this stage when
the primary surgeon’s role in terms of surgical care is limited, being aware of
optimising pain control and prescribing the right dose and type of opioids is critical
not just for the patient but also for the patient’s relatives. Involvement of a pain
specialist or a palliative physician in the overall care of the patient is prudent at this
stage of disease.
Singapore Hospice Council ( 2014 ) is one such local organisation which looks
into improving the quality of life of patients at the tail end of terminal disease. Its
goal is to “alleviate suffering and maximise quality of life for patients and their
loved ones”. The Singapore Hospice Council is the umbrella body which coordi-
nates the services rendered by various hospices found in Singapore (Table 14.7 ).
Hospices provide a wide range of services available to the patient and caregivers.
This ranges from the loaning of medical equipment to religious support. Recreational
activities are also organised to drive home the important point that the end of life is
not a period of desolation and despair, but merely an extension of our human condi-
tion. A fullness of life can be lived close to death, just as with any other period of
that person’s life.
Conclusion
Metastatic colorectal cancers pose numerous challenges for the individual, family
and the attending physician. Each obstacle should be individually tackled while
considering the patients’ premorbid condition, extent of the primary cancer and
the metastatic disease. However, it is important to have a broader picture in mind,
and incorporating the inputs from various specialists in this multidisciplinary
approach is instrumental to ensuring the best possible outcomes in these patients.
Table 14.7 Hospices in
Singapore
Metta Hospice Care (MHC)
Agape Methodist Hospice (AMH)
Singapore Cancer Society (SCS)
St. Joseph’s Home & Hospice (SJH)
Assisi Hospice (AH)
Bright Vision Hospital (BVH)
Dover Park Hospice (DPH)
HCA Hospice Care (HCA)
14 Multidisciplinary Management in Metastatic Cancer
220
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© Springer-Verlag Berlin Heidelberg 2015
K.-Y. Tan (ed.), Transdisciplinary Perioperative Care in Colorectal Surgery:
An Integrative Approach, DOI 10.1007/978-3-662-44020-9_15
Take-Home Pearls
• Each member of the healthcare team plays a vital role in delivering
comprehensive stoma care through a transdisciplinary approach.
• Stoma care begins preoperatively and continues postoperatively and after
discharge in the rehabilitation phase.
• Common objectives shared by patients and the transdisciplinary team improve
recovery outcomes and increase acceptance of the stoma.
15.1 Introduction
Stoma, a Greek word also known as ‘ostomy’, is an artifi cial opening in the skin of
an individual created surgically to allow fl uid withdrawal. Stomas are fashioned in
different ways depending on their indications. Table 15.1 summarises the classifi ca-
tion of stoma and type of procedures. Creating a stoma may be temporary or perma-
nent, and the diversion of intra-abdominal fl uids aims to improve quality of life or
aid in recovery from the disease process. Table 15.2 illustrates the type of stoma and
description of output consistency.
The need for a stoma is often regarded as a drastic changing event which can be
traumatising for patients both psychologically and physically (Gesaro 2012 ). An
ostomist’s journey is apprehensive with many diffi culties to face, requiring
Y.-J. Ong (*) • L.-C. Chee
Nursing Administration , Khoo Teck Puat Hospital , Singapore , Singapore
e-mail:
ong.yu.jing@alexandrahealth.com.sg; chee.lay.choo@alexandrahealth.com.sg
C.-E. Ong
Nursing Administration , Singapore General Hospital , Singapore , Singapore
e-mail:
ong.choo.eng@sgh.com.sg
G. K. E. Heng
Department of General Surgery , Khoo Teck Puat Hospital , Singapore , Singapore
1 5
Transdisciplinary Stoma Care
Yu-Jing Ong , Choo-Eng Ong , Lay-Choo Chee ,
and Gregory K. E. Heng
228
signifi cant adaptation. Challenges encountered have an impact on all aspects of an
ostomist’s life, including psychosocial, spiritual, physical and sexual health and
cultural and religious beliefs. Thus, a transdisciplinary approach in the delivery of
stoma care would provide much benefi t in dealing with these challenges.
Transdisciplinary stoma care encompasses the collaborative input from various
healthcare professionals’ different specialties for holistic care. This team comprises a
colorectal nurse specialist, surgeon, oncologist, social worker, dietician, pharmacist,
caregiver and the patient (Fig. 15.1 ). Each member of the team plays an important
role with the common goals of improving an ostomist’s outcome, rehabilitation to the
premorbid status and achieving self-care. Effective communication between the
Table 15.2 Type of stoma and description of output consistency
Type of stoma
Ileostomy Colostomy
Urostomy
Description
of output
Watery to loose faecal matter Formed faecal matter Urine
End
Loop
Double-barrel
Table 15.1 Classifi cation
of stoma and procedures
Type of procedures
Ileostomy Colostomy
Urostomy
Abdominoperineal
resection (APR)
√
Hartmann’s √
Low anterior resection √
Ultra-low anterior
resection
√
Proctocolectomy √
Cystectomy √
Y.-J. Ong et al.