Introduction
Medicine has quickly moved from a physician-centered to a patient-centered evidence-based model. Patient-centered care requires a multidisciplinary input with various health professionals playing their specific roles in ensuring that the patient receives holistic care that covers all their needs. The multidisciplinary team is usually led by the patient’s primary physician. In recent times, palliation has become a key area of patient-centered care. With an increase in the diagnosis of terminal illnesses, palliation has become an increasingly important aspect of modern medicine. One of the most commonly diagnosed terminal illnesses that require palliation is cancer. Considering the fact that up to 52% of all cancer patients require radiotherapy and almost all cancer patients require some form of radiography (Lutz, 2014 p.2914), the role of radiographers in palliation of cancer patients is becoming increasingly important. Therapeutic radiographers who directly contribute to the palliative process are more important compared to diagnostic radiographers in this case. This paper examines the importance of therapeutic radiographers in palliation of cancer patients and how therapeutic radiographers have worked with other health professionals to improve palliation. The focus of this paper is on how advanced practice in radiography can help to improve the care of cancer patients.
Advanced Practice in Radiotherapy and its Importance in Palliation
In the past, the role of radiographers in cancer management and in palliation has been seemingly maligned. However, therapeutic radiographers are extremely important in the management of cancer (White, 2017 p.3). As earlier alluded to, more than half of all cancer patients require the services of radiographers. Again, by the time of diagnosis, most cancer patients have their disease in advanced stages thus requiring palliation. Even those whose disease is caught at earlier stages, in some cases the disease may continue to progress to the advanced stages which require palliation. This thus affirms the importance of radiographers in palliation. In fact, radiotherapy has been used in palliation to help relieve the symptoms of patients (Lutz, 2014 p.2914).
Advanced practice in therapeutic radiography refers to the professional development where radiographers can perform specialized roles that contribute towards holistic patient care (Eddy, 2015 p.1). Traditionally, radiographers have had to play as understudies to physicians in cancer care; in this case, oncologists. Radiographers have been thought of as the individuals who only run machines as instructed by the physician and the medical engineer. In this case, the physician, the oncologist, prescribes radiotherapy to a patient and directs them to a radiotherapy unit, where a therapeutic radiographer reads the prescription and does as it instructs without interacting much with the patient (Eddy, 2015 p.1). The medical engineer, on the other side, is the person who regulates the amount of radiation that is safe for human health and is there to deal with any breakdown of the radiotherapy machine. As such, the role of the radiographer is only limited to controlling the machine. However, advanced practice is meant to enable radiographers to perform more than just operating machines (Eddy, 2008 p. 25). In fact, some areas of advanced practice require the radiographer to interact with the patients more.
One such area of advanced practice in therapeutic radiography is the ability to care for patients after they have had radiotherapy. In as much as radiotherapy is a mainstay in the management of cancer, it has numerous side effects to the body (Lutz, 2014 p.2915). The most important of these side effects is the ability to cause secondary malignancies. There are, however, other immediate side effects which are much more important to the patient after the procedure. These side effects include skin reactions, fatigue, post-radiation pneumonitis and post-radiation gastritis (Lutz, 2014 p.2915). These side effects can be severe enough to add on to the morbidity of the patient. It is, therefore, important to have these side effects managed promptly. This is where advanced practice in therapeutic radiography comes in; radiographers can advance their profession by learning the art of managing for patients with this reactions or preventing the reactions in patients who have had radiotherapy even before they are seen by the physician (Martino and Odle, 2007 p. 157).
In terms of palliation, it is important for patients who have radiotherapy as part of their palliative care to have these side effects controlled promptly. Advanced practice radiographers will have the time and expertise to review patients and help to control their symptoms or prevent occurrence of such symptoms (Martino and Odle, 2007 p. 157). Apart from better control of physical issues, advanced practice in therapeutic radiography will offer the patient many other advantages.
First, such expertise in radiography will make the therapeutic radiographer a very important member of the patient review team. This means that radiographers will directly participate in the process of choosing the best treatment plan for a patient, especially for patients who have undergone radiotherapy (Alfieri et al., 2009 p.45). This move will be advantageous to the patient in the sense that the expertise of the radiographer in radiation and its effects on the body can aid oncologists and the rest of the team in determining whether to subject the patient to radiation or not and how soon to do so. The fact that the radiographer was with the patient during the procedure and immediately after the procedure makes them the healthcare personnel who understand best how the patient reacted to radiation. Moreover, many oncologists are concerned with the late side effects of radiation like malignancies or radiation gastritis, the inclusion of a therapeutic radiographer in the team will ensure that the immediate side effects of radiation like pain are managed well (Alfieri et al., 2009 p.45).
Furthermore, the inclusion of a therapeutic radiographer in the patient care team will help to meet the psychological needs of the patient. This will be even more beneficial to the patient if the radiographer is one who has furthered their practice and have expertise in caring for patients in palliation. In the past, stories of patients with unmet emotional needs breaking down before diagnostic and therapeutic radiographers have emerged; unfortunately for such patients, the radiographers might not have done much since emotional support for patients was thought to be the duty of nurses (Lawrence et al., 2011, p.1). Advanced practice in therapeutic radiography and inclusion of the radiographers in the care team will help to alleviate such problems in future. Patients need emotional support while they go through radiotherapy (Halkett and Kristjanson, 2007 p.79). Having therapeutic radiographers who can listen to patients say their fears and hopes and support them through the procedure can be much more helpful. Additionally, this will allow the radiographer time to address patients’ issues which might be raised late or were not addressed satisfactorily by the oncologists. It is common for oncologists and other physicians prescribing radiotherapy to insist to patients the importance of the procedure without addressing the patients other issues like the period of time the procedure will take and the possible complications of the procedure. Alfieri and colleagues (2009 p.44) also assert that oncologists sometimes decide to omit the non-medical side of patient care claiming that it is not their direct responsibility. As such, having therapeutic radiographers with extra expertise in palliation and patient care can give the patients an expert that can address their other issues and a person they can vent in their worst fears and their highest hopes (Alfieri et al., 2009 p.45).
Additionally, radiographers are generally more accessible and approachable by patients compared to oncologists and medical engineers ((Alfieri et al., 2009 p.45). In fact, most cancer patients see oncologists just as prescribers and interpreters of their scans and radiographs. Medical engineers, on the other hand, do not even interact with patients and are not part of the patient care team. Having therapeutic radiographers who have the expertise and poses the skill to help patients emotionally. Even though nurses are closer to patients and the patients have far more time with the nurse, most patients find nurses to have less expertise in matters radiography. The patients and their families can thus benefit from speaking to therapeutic radiographers. As Alfieri and colleagues (2009 p.45) suggest, the radiographers themselves have a perception that they have more time with the patients than the oncologists do. This gives the radiographers the knowledge that there are some needs of the patient that have not been addressed and can thus aid them in identifying those needs and addressing them accordingly. In the past. Patients have utilized the little time they have with the therapeutic radiographer in the radiotherapy room to form a bond with the radiographer and have some of their issues addressed (Eddy, 2008 p. 27). This is an evidence of unmet psychosocial needs of the patients. Advanced practice will allow therapeutic radiographers more time to talk to patients and address their issues better.
In terms of palliation, the American guidelines for palliative care require all health professional to contribute towards the palliative care of patients (National Consensus Project for Quality Palliative Care, 2004 p. 3). In essence, patients on palliative care are likely to benefit more from having therapeutic radiographers with the expertise of giving them the best palliative care. In order to achieve the various aspects of palliative care that are proposed by the guidelines, contribution by all radiographers will be of utmost importance (White, 2017 p.3).
Past studies have shown that patients do not necessarily prefer to be reviewed by their oncologists (Alfieri et al., 2009 p.45). The studies show that patients had no problems with being reviewed by nurses. This means that therapeutic radiographers reviewing patients should be welcomed. In fact, it is better for a patient to be reviewed with a therapeutic radiographer who has expertise in palliation than for the patient to be reviewed with a nurse. The radiographer has arguably more knowledge about cancer as a disease, radiotherapy, and the possible complications of radiotherapy hence will be more helpful to the patient in addressing the medical concerns of the patient (Alfieri et al., 2009 p.45). A radiographer who has expertise in palliation will have equal competence to a nurse in addressing the patients’ non-medical concerns. Moreover, as earlier alluded to, radiographers will have more time for the patient than what the oncologist would afford hence better addressing of the non-medical concerns of the patient. Poor identification and address of non-medical concerns of the patient by oncologists could be the major reason why patients do not mind being reviewed by anyone else rather than the oncologist (Alfieri et al., 2009 p.45). In fact, the American guidelines for quality palliative care rank psychological and psychiatric issues in patients on palliation as far more important that the physical concerns of the patients (National Consensus Project for Quality Palliative Care, 2004 p.49). However, these psychological concerns are concealed and require skill to identify them; this is where advanced practice in therapeutic radiography comes in, it gives the radiographers the skill to identify and address the psychological, psychiatric, spiritual, and cultural aspects of the patient.
Additionally, having therapeutic radiographers review patients will reduce the time the patients have to wait to see oncologists so as to be reviewed (Alfieri et al., 2009 p.45). Only the patients who will have complications or medical issues which cannot be addressed satisfactorily by the therapeutic radiographers will be sent to the oncologist. Because the oncologist will be having lesser patients to review and few issues to address in the patients they are reviewing, the waiting time will be considerably reduced.
Advanced practice in radiotherapy has massive benefits for the patients as already seen. In places where advanced practice in therapeutic radiography has been used, the practice has had several effects on the interaction between the radiographers and other stakeholders including the patients, oncologists, and nurses. Here, the impacts of this advanced practice on other members of the healthcare team are considered.
As earlier alluded to, advanced practice in therapeutic radiography and heavier involvement of radiation therapists in the process of patient care has reduced the workload of physicians (Alfieri et al., 2009 p.46). The oncologists have lesser patients to review as advanced radiography practitioners are able to review patients. Moreover, even in the patients that the oncologists may be required to review, their job is made easier since they only have to review specific issues which could not be addressed satisfactorily by the radiographers (Alfieri et al., 2009 p.46). A reduced workload is likely to help the oncologists perform even better in their work. Definitely, the lessened workload will allow the oncologist to interact with their patients for longer times hence the identification of pertinent issues in the process of patient care.
Additionally, the fact that advanced radiography practitioners can help in the prompt control of the adverse effects of radiation therapy on the body will help to improve the quality of care to the patient (Eddy, 2008 p. 28). Improved quality of care is likely to translate into lesser patient mortality. Less patient mortality is a big plus for the oncologist. Anything which is likely to lower the mortality of their patients is, therefore, beneficial to the oncologist.
Advanced radiography practitioners are also beneficial to the system as a whole. For instance, having therapeutic radiographers who are competent enough to review patients nullifies the need to employ more oncologists who can review patients (Alfieri et al., 2009 p.46). As such, a hospital can work by hiring just a few oncologists who can make the initial diagnosis of cancer, prescribe the preferred treatment modality for the patients, and only the patients whose medical issues cannot be addressed satisfactorily by the radiographers. Considering the high cost of hiring oncologists when compared to that of hiring radiographers makes it economic to employ advanced radiography practitioners who can handle the lesser roles of oncologists and hire fewer oncologists (Alfieri et al., 2009 p.46).
Past studies have revealed that only about 35% of all reviews require medical procedures to be performed hence require the direct input of oncologists (Alfieri et al., 2009 p.46). This means that in the rest of cases, therapeutic radiographers can satisfactorily review the patients and handle all their issues unless the patients have complex medical questions or emerging issues. Even though some specific anatomic sites of disease such as the pelvis, the brain, and the neck pose complexities that may not be handled satisfactorily by radiographers, their role cannot be written off (Alfieri et al., 2009 p.46). In a past study, nurses were able to review such patients well whilst being guided by protocols prepared by oncologists. Being that radiographers are vaster in medical issues and issues surrounding radiotherapy compared to nurses, it would be easier for oncologists to prepare protocols that can be used by radiographers in reviewing patients.
On the negative side, oncologists have not always been comfortable with radiographers prescribing drugs to alleviate adverse effects of radiotherapy or reviewing their patients (Alfieri et al., 2009 p.45). In the past, oncologists have seemed to raise questions about the competence of radiographers to perform these medical procedures. It is obvious that radiographers may find it challenging to handle complex medical issues that patient may present with.
The other negative side of having advanced practice radiography practitioners is the ill definition of their additional roles as advanced practitioners. This may breed anxiety in the practitioner and the patient. In fact, in a past study where nurses lead the reviews of patients on follow-up for breast cancer treatment, patients seemed to raise questions regarding the competencies of nurses as reviewers of their statuses. These same concerns are likely to be raised if radiographers were the ones to review patients. As such, patients questioning the capability of their reviewer may have a negative attitude which might lead them to withhold important information that could have been pertinent to the patients’ care.
My Contribution
As a therapeutic radiography student, I would love to be a practitioner of far more help to the patients. To ensure this, professional development in the form of further studies to reach to the level of advanced practitioner will be of help. Personally, I will be most interested in learning the various aspects of palliation as part of my advanced studies. I appreciate the importance of psychosocial and spiritual support to cancer patients; Berger and colleagues (2007 p.817) attach utmost importance to the management of psychosocial needs of the patient. Even those patients who have not reached a stage of palliation require psychological support in order to go through it. It is thus important for me to be a radiographer that can offer such patients the much-needed support.
Conclusion and Recommendations
Basing of the discussion above, it is important for the system to allow professional development so as to have advanced radiography practitioners. Apart from the obvious advantages that advanced radiography practitioners offer to the facility and the patients, there is a general need for this practitioners. The increase medical technology requires new and competent minds who can use the technology for the good of the patient (Martino and Odle, 2007 p. 157). The increasing prevalence of neoplastic disease and thus the requirement for radiotherapy also calls for the advancement of radiography as a profession so as to carter for all needs of patients.
I also recommend the inclusion of palliative care in the curriculum for radiography education. This will help both diagnostic and therapeutic radiographers at all levels in their careers to help patients that they meet holistically. As seen earlier, many patients land in the hands of a radiographer with unmet psychosocial issues and the radiographer may lack the skill and expertise to help the patients to that effect. Imparting such skill in radiographers at all levels will be of utmost benefit to the patient.
Therapeutic radiographers are an important part of the multidisciplinary patient care team in the management of cancer. In practice, sometimes some of the needs of the patients are not met by the other members of the team and thus the patients vent their fears and frustrations in therapeutic radiographers while undergoing radiotherapy. Equipping therapeutic radiographers with the ability to handle these unmet emotional needs of the patients and addressing a few of the patient’s physical needs can be beneficial for the patients, the facility and the multidisciplinary team (Halkett and Kristjanson, 2007 p.82). As such, advanced practice in radiography is something which can improve the holistic care of patients and thus should be embraced by all health facilities.
Bibliography
Alfieri, F., Le Mottee, M.A., Arifuddin, M., Field, N., Milinkovic, D. and Cox, J., 2009. Radiation therapist-led weekly patient treatment reviews. Radiographer: The Official Journal of the Australian Institute of Radiography, 56(3), pp.44-48.
Berger, A., Shuster, J. L., & Von Roenn, J. H. (2007). Principles and practice of palliative care and supportive oncology. Philadelphia, Lippincott Williams & Wilkins.
Eddy, A. and Duxbury, A., 2015. Advanced practice in radiotherapy and oncology: an interview with Angela Eddy. Journal of Radiotherapy in Practice, 14(3), pp.296-302.
Eddy, A., 2008. Advanced practice for therapy radiographers–a discussion paper. Radiography, 14(1), pp.24-31.
Halkett, G.K. and Kristjanson, L.J., 2007. Patients’ perspectives on the role of radiation therapists. Patient education and counseling, 69(1), pp.76-83.
Lawrence, H., Poggenpoel, M. and Myburgh, C., 2011. Experiences of Being a Therapy Radiographer. Health SA Gosendheid, 16(1), pp.1-7.
Lutz, S.T., Jones, J. and Chow, E., 2014. Role of radiation therapy in palliative care of the patient with cancer. Journal of Clinical Oncology, 32(26), pp.2913-2919.
Martino, S. and Odle, T., 2007. Advanced practice in radiation therapy. Radiation Therapist: The Journal of the Radiation Oncology Sciences, 16(2), pp.155-162.
National Consensus Project for Quality Palliative Care, 2004. Clinical practice guidelines for quality palliative care. The Kansas Nurse, 79(9), p.16.
White, N., 2017. Positioning end-of-life care education within the pre-registration therapeutic radiography curriculum: A survey of current practices amongst UK higher education institutions. Radiography, 30(2017), 1-7.
