Coping mechanisms and depression in stage 5 pancreatic cancer patients

Ineffective Coping Mechanisms for Stress or Anxiety Due to Stage 5 Pancreatic Cancer Prognosis Morbidity

Pancreatic cancer is one of the most prevalent forms of terminal cancer. There has been great progress made in understanding the activation of Hedgehog (Hh) signaling pathway reportedly related to malignant biological behavior mechanism of pancreatic cancer; yet this progress is far from reaching a cure (Xu X, Guo C, Liu J, Yang W, Xia Y, Xu L, Yu Y, Wang X., 2009, found online). Like victims of other terminal forms of cancer, pancreatic cancer patients are faced with overwhelming choices that they must make on behalf of their selves, their families, and the people who care about them. In the face of the brevity of their situation, many patients suffer from depression, arising out of a sense of hopelessness, and begin to exhibit aberrant behaviors consistent with their diminished physical and mental abilities to cope with the stress and anxiety of their terminal prognosis.

Adenocarcinoma is the most common form of pancreatic cancer, accounting for 95% of the cases reported (Unversity of Texas, 2009, found online). It involves the cells that secrete digestive enzymes (2009), and, like other cancers, metastasizes to other related organs, like the pancreas. The symptoms include: jaundice, a noticeable change in the color of urine and, or, stool; pain, when tumors press against nerves; indigestion, nausea, lack of appetite and weight loss; sudden onset diabetes or a sudden change in blood sugar levels warranting intervention (2009). As the symptoms of pancreatic cancer manifest, it might be anticipated that the patient begins to look for coping mechanisms. The mechanisms are ineffective; perhaps because the most prevalent conditions linked with the disease is depression suffered by pancreatic cancer patients, which is not well understood (Makrilia, Indeck, Syrigos, and Wasif Saif, 2009, found online). If the side effect of the disease is poorly understood, then it would follow that therapeutic interventions designed to help pancreatic cancer patients cope with the disease are likewise poorly designed and ineffective.

Using the case study assigned for this essay, and relying upon published peer reviewed literature in journals, and some reprinted on various cited web sites; this brief essay is an exploration of the coping mechanisms for the manifestations of terminal cancer found in the literature. These mechanisms prove to be largely unsuccessful or ineffective for patients coping with the profound circumstances surrounding a terminal illness like pancreatic cancer.

The Case Study: History and Physical (H&P)

Mr. Pen is a 77 years old healthy Italian man. Past history of 60 years smoking, PVD. He lives with his wife in a two storey house. He has one son who does not live with them. He noticed his urine was darker and two weeks ago he became jaundice. The patient was admitted to St. Joseph Health Center on the general surgery floor. The admitting diagnosis was Pancreatic Adenocarcinoma. The patient underwent whipple, cholecystectomy, explanation major vessels on Sept. 15/09. He complains of abdominal pain and does want to go to rehab center.

The Nursing Element in Terminal Illness

The nursing element in this case is integral to both identifying the patient's onset of depression, and in providing guidance for interventions that could help this patient find ways to mitigate or even to delay the onset of depression. There are new and innovative and therapeutic ways that can be introduced to patients suffering a terminal illness that might help to counter depression. In an article found in the Journal of Palliative Medicine, Anne Horne-Thompson and Denise Grocke (2008) explore the ways in which music can be utilized as a therapy for depression, and improving the quality of life for end of life patients. Quantitative research yielded results that supported the hypothesis that music helps to manage anxiety, a precipitator to depression, in terminally ill patients, is alleviated with music therapy (2008). This is a therapy that might be explored with the patient in this case as it could bring the patient together with the family in a way that takes them away from the source of their anxiety and depression.

While palliative nursing is beginning to receive more attention, the Canadian Nurses Association has a position paper that speaks to nursing and terminally ill patients (CNA Position, 2008). The position paper states that end of life care must be a collaborative effort, and that it will include a mixture of nursing specialties: mental health, nutrition, and, in this case, oncology nursing.

Jacquie Peden, Carolyn Tayler, and Carleen Brenneis (

Terminal Illness, Patient and Family

In this case study, the patient is a 77 years old Italian, with one adult child who lives away from the home; and a wife living with him in the home. Carol Robinson and Karen Janes (2001), in an article published in the Cancer Oncology Nursing Journal, say that conscientious, systematic, and ongoing assessment of the family is as integral to the patient's care as is the direct nursing care given the patient. Interaction is created between the patient and the family by prompting the patient to have discussions with the family members about the patient's illness. While this patient's only child is an adult, there is no less a need for the patient to talk to his son, and to be open and forthright about the obstacles he is facing, and those they will encounter as a family. Robinson and Janes encourage patients to acknowledge that the disease has an effect each member of the family, albeit in different ways (p. 65). Ostensibly, redirecting the patient's focus to the needs of his family might help to alleviate the onset, and to counter the impact of his depression. Helping the patient focus on those things around him that he can have a positive impact on will help him to cope with his debilitating condition.

An article by E. Adali, a. Merkouris, E. Manoussou, and M. Priami found in the ICUS and Nursing Web Journal introduces a topic that is certain to come up in conversation between family members and even between the patient, the family, and the nursing and physicians professionals working the patient: end of life euthanasia (Adali, Merkouris, Manoussou, and Priami, 2004, found online). It is an emotional topic, and one that Adali et al. says comes about in the context of the patient's quality of life (p. 3 of 9). This is a subject that really is family members or the patient's first steps in acknowledging their mortality; and arises out of the desire to prevent the prolonged suffering of a loved one, or the patient's loved ones.

Even though many healthcare professionals support the idea of legalized euthanasia, it is, in the United States, not legal. Conversations with the family about euthanasia should be handed in a professional manner, recognizing the source of the conversation is a desire not to see a loved one suffer. Ending the suffering with drugs would indeed be an easy enough solution, but at this point in time it remains unethical and illegal. The nursing professional must be adept at dealing with these kinds of conversations, and without increasing the guilt that the family member or patient might be experiencing, and keeping in mind the patient's probable depression; it is the responsibility of the nursing professional to take the conversation back to the treatment and therapies that within the realm of the legal and ethical practices in delivering medical nursing care.

Jacquie Peden, Darlene Grantham, and Marie-Josee Paquin (2005) say that nursing standards in palliative care are based on the values of the nursing profession, and are developed by provincial and territorial regulatory bodies in Canada to guide the professional practice of nursing professionals (p. 2). The hospice palliative nurse, they write:

Believes in the intrinsic worth of others, the value of life, and that death is a natural process.

Establishes a therapeutic connection (relationship) with the person and family through making, sustaining, and closing the relationship.

Provides care in a manner that is empowering for the person and family.

Provides care based on best practice and/or evidence-based practice.

Assists the person and family to find meaning in their lives and their experience of illness.

Preserves the integrity of self, person, and family (p. 3).

These standards reflect caring, personal ethics, and industry professionalism. The nurse who holds these standards dear, is the nurse that is right for the patient suffering from terminal pancreatic cancer, and who help to sustain the family through this difficult and emotional ordeal.

Summary and Conclusion

The people who will be the closest to the patient and the family throughout his illness will be strangers; strangers who must be able to build a bridge between the emotional stress and depression that the patient will suffer, and the clinical therapeutic support and interventions to help the patient live with dignity, and to experience as high a quality of life as possible. Jacquie Peden, Carolyn Tayler, and Carleen Brenneis say that communicating openly, honestly, and with a consideration for the time of the patient and family is integral to the nursing support provided the patient.

The literature addressing hospice care, especially the articles by Peden et al., are the most useful in understanding and gaining a sense of nursing standards and what to expect in caring for the terminal ill patient. There is, however, a gap in the literature between the care that is administered according to the standards, and the condition of depression that is prevalent and, according to the literature, distinct to patients suffering from pancreatic cancer.

Jacquie Peden, Elizabeth Hill, and Daphne Powell (2005) speak to the myths of palliative hospice care. Addressing these myths from the experience and perspective of palliative nursing care enlarges the knowledge of the nursing community, and serves to inform patients and families in a way that resolves much of the fear of the unknown. This could go a long way to resolving the patient's depression, because it is the sense of helplessness, hopelessness, and the fear and anxiety of the unknown which would perpetuate the onset of depression.

All of the works cited here support the need for continued and expanded research involving the different specialties in nursing and oncology to better serve patients and their families. Also, there is little nursing information that is found in the professional peer reviewed journals that speak directly to the issue of pancreatic patients and depression. There is much more literature on the subject from the physician and researcher perspectives, but there is a void in nursing literature. At this point in time, the depression of pancreatic patients as it concerns nursing, has received little attention. Both the nursing profession and pancreatic patients would benefit from further research in this area.

The conclusion from the study of the literature available is that not only is pancreatic patient depression not well understood, it is also lacking in research that would help professionals to address depression in these patients. Also, because it is directly linked to pancreatic cancer, and because the research does support the fact that patients suffering depression and pancreatic cancer do not enjoy the quality of life as those patients who do not suffer from depression, then pancreatic cancer patients and depression should be a distinct and separate therapeutic intervention from other groups of depression.