Caring for Nursing Home Residents with Cancer
Are nursing homes equipped to handle residents with cancer? These patients need special attention, but many facilities fall short in providing the right care. Missed symptoms or poor coordination can quickly lead to suffering. In this week’s episode, nursing home abuse lawyer Rob Schenk welcomes guest Charlotte Goor to discuss the unique needs of cancer patients in long-term care settings.
Goor:
It’s oh, why is this resident now not eating as much and their nutrition is affected? And especially if they’re cognitively impaired and they are not able to express that it actually is because they have these painful sores in their mouth and throat that are affecting them. And if a patient lives at home, as with their family I think the family member perhaps would be more attentive to those subtle changes.
Intro
Schenk:
Hey, out there everybody. Welcome back to the Nursing Home Abuse Podcast. My name is Rob. I’ll be your host for this episode. We are talking about the challenges today of caring for nursing home residents that are also going through cancer treatment, but we’re not having that conversation alone. We have the fantastic Charlotte Goor on with us to walk us through that process.
We have Charlotte Goor with us today. Charlotte is a triple board certified nurse and medical surgical oncology and breast cancer care. With nearly a decade of experience, she has worked with diverse patient populations in both hospital and clinical settings in 2020. In 2024. In 2024, she joined the breast cancer clinic at City of Hope and launched her legal nurse consulting business.
Charlotte is passionate about patient advocacy and education, striving to improve outcomes through compassionate evidence-based care, and we’re so happy to have Charlotte here. Charlotte, welcome to the show.
Goor:
Thank you. It’s nice to be here. Thank you for the invitation.
What unique challenges do nursing home residents with cancer face compared to those receiving treatment at home or in a hospital?
Schenk:
Sure. So I, in all the years I’ve been doing this, I don’t think I’ve had an episode dedicated to the challenges of caring for long-term care residents or nursing home residents that have cancer.
So thank you for agreeing to talk to us today. And I guess the first question is the softball, which is. What are some of the more broad challenges that you have when dealing with that population, the nursing home population at the same time as dealing with their cancer? Treating their cancer?
Goor:
Yeah. That’s a great question. I guess before I dive in I perhaps just make it clear to your audience and to yourself that while I have nearly a decade of experience working with cancer patients, I don’t actually have any experience with nursing home residents. Okay. My nursing career does not span nursing homes, but as you probably know, over 50% of cancer patients that get a diagnosis are over the age of 65.
So since the majority of residents in nursing homes are elderly I think what we can speak about, at least I can, and hopefully you can help me in terms more of the nursing home residents, is challenges with the elderly population and cancer care.
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Schenk:
Sure.
Goor:
Which I’ve certainly seen a lot of. So in terms of challenges for nursing home residents that have cancer I guess I can think of a list here and then we can break it down.
But I would say limited access to specialized care, especially in terms of transportation is something that I see a lot. Also complex comorbidities with the elderly population. Age related changes in pharmacokinetics. Another thing would be undertreatment or delayed diagnosis and some specific issues with psychosocial emotional needs and also with staffing constraints.
So I know that was a long list, so we can start breaking this down if you’d like. Sure. In terms of limited access to specialized care, one of the issues that I’ve seen a lot in my practice working both in a hospital and now more, my focus is working at the clinic at City of Hope, is I see a lot of issues with transportation.
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For example, patients that we have coming from a rehab facility, ltac, LTAC or nursing home, oftentimes we have to arrange for EMS transport for them to take them back and forth to their appointments. And this can be challenging especially, if they are frail or if it’s a gurney patient and sometimes they miss their appointments or they’re running late to the appointments or running late.
Taking them back now with. Cancer care. I dunno if people are really aware, but there are just so many appointments that a patient has. So it could be, coming to see their medical oncologist, their surgical oncologist, or radiation oncologist if needed. Endocrinologist, dietician. There’s just. So many facets to it.
And then they have to come maybe for their chemotherapy appointment. They also have a lot of imaging appointments that they have to do, whether because we’re trying to monitor to see if the treatment that we’re giving them is effective or perhaps there’s a new adverse effect that we need to check on.
So Echocardiograms PET scans, cts, you name it. Another example I mentioned is radiation. When a patient has radiation, the schedule for it will often be that they come, let’s say, every day for radiation, five days a week for five weeks. So you can imagine. The challenge with that, trying to get them back and forth, five times a week for five weeks.
So perhaps you can also help me in that discussion here. Maybe knowing a little bit more about nursing homes. I see a lot of challenges with EMS transport. What have you seen.
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Schenk:
I guess that makes sense. I guess it’s a payer issue that maybe Medicare has an issue like billing out for transportation.
But I can’t, I would, in a million years, I would not ever have imagined that The challenge with this, as you’ve mentioned, is transportation. But I would imagine that it has to be, what is that?
Goor:
I think you’re right. A lot of it is related to insurance issues, which even with patients right, who are residing at home, that can be an issue as well, depending on their insurance.
And another thing too, sorry if I can move along that I, you. Okay. The issues with complex comorbidities. So with the elderly population oftentimes they have multiple chronic conditions, and this can complicate cancer treatment and pain management. So chemotherapy, as we all know, is toxic.
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Toxic to the body. And if a patient has a dysfunction, let’s say, in their kidneys or their liver, then. This makes it more challenging for us to deliver chemotherapy, and we would have to do a dose reduction or consider an alternative regimen. Another example would be in, in our elderly population, oftentimes they have underlying cardiac issues.
So many of our treatments are what we call cardiotoxic. So for example, a chemotherapy we administer called doxorubicin is cardiotoxic. And that means it actually has a. A lifetime dose limit on it of how much we can administer because of the damage to the heart. So these are just some. Issues again that we have to consider when we’re treating cancer with our elderly population.
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How do nursing homes typically handle cancer diagnoses for their residents?
Schenk:
Are you typically in communication where you’re at with the long-term care, with the nursing homes in terms of do you have access to their care plans? Do you have access to their medication administration records and things like that? Or is it just like you’re just, you’re looking at this as a subset of the treatment that you’re, that they’re getting overall? Does that make sense?
Goor:
It does. I left my bedside about a year ago, but I was there for almost 10 years. And when the patients came to us from a nursing home, and we were at the hospital then yes, you’re correct. They would come with their medication list and the care plan from the nursing facility and we would sometimes have challenges with that.
And then, we would of course call and try to clarify that with the staff there. But at the clinic we actually. Don’t really have access to that. So we just have the medication list that we have in our chart from there, coming from them coming to see us. So it, yeah, I, I think I see where you’re going with this.
There are some communication gaps that we have to deal with. And this ties in right to the issue also of polypharmacy because a lot of the medications that we administer can interact with some of the medications that they’re on at the facility. And we wanna make sure that it’s either not increasing the toxicity right, of a medication that they’re taking or reducing the effectiveness.
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Are there common misconceptions about treating cancer in elderly nursing home residents?
Schenk:
Just a general question is the individual with cancer, that is in the elderly population, 65 and above, are they typically seeking aggressive treatment? Are they seeing chemotherapy with these folks? And if not what’s the alternative to chemotherapy for them?
Goor:
So I actually do see that quite a bit.
More often I would say with our patients who are coming from home. At the clinic especially, we don’t see as many patients coming in from the facilities or at the hospital. I certainly saw it much more. I guess in terms of, so of aggressive treatment this kind of ties into maybe some of the misconceptions, right?
With treatment, because. It’s not always with curative intent. So treatment, whether it’s radiation or surgery or if it’s chemotherapy, it can also be palliative in the sense of either just increasing their lifespan or their quality of life. And in oncology we also have this concept of tolerability, which is essentially addressing.
We want the treatment to not be more harmful than the disease itself. So if they can tolerate the treatment that we’re giving them, then you know, again, with conversation with the family and the patient, then that’s the option we would choose. So I guess going back to your question. Yeah, I would say I do see a kind of standard treatment being given to even the elderly population, again, with dose reductions and taking into consideration their underlying conditions as long as it’s something that they can tolerate and that they are feeling is increasing their quality of life.
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Are there specific challenges in managing cancer pain and symptoms in elderly residents?
Schenk:
What are some of the challenges with, in terms, you mentioned palliative care and managing comfort, like what’s the, what are some of the challenges with. Managing cancer pain in this population.
Goor:
So with this elderly population they oftentimes have an atypical pain presentation. So older adults may underreport pain or describe it vaguely, and, if they have cognitive impairments also that makes self-reporting unreliable and can also require more.
Observation and assessment by the staff that’s working at the nursing home. So that would be one challenge that we have with pain management. And then I mentioned polypharmacy earlier the polypharmacy. So again, with the elderly population taking multiple medications, we wanna make sure we don’t increase the risk of adverse drug reactions, especially if we’re giving them any kind of opioid ’cause opioid sensitivity.
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Can be heightened, which requires more cautious titration. If they have chronic conditions like a renal disease or heart failure, diabetes, any liver disease that can again, affect the metabolism of the pain medications that we’re giving them. But I think oftentimes a challenge that we have, not just in the metabolism of the medication, would be really.
That sort of pain is reported either by the patient themselves who may also attribute a symptom to, oh, this is just a natural process of aging or some other ache that I’m having and may not necessarily attribute it to the cancer. And also for either the family member or the staff at the nursing home was taking care of them.
Who may not attribute that certain pain to something that is a cancer related process, if that makes sense.
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Schenk:
Yeah, of course. Walk us through like you mentioned, sometimes someone seeking cancer treatment is at the hospital multiple times a week. What’s happening?
Like what is it for an hour or 30 minutes, six hours? What’s going on typically during that treatment process?
Goor:
You know that, that’s a great question and it really varies. At the hospital, where I was working for years, if patients were admitted to the hospital, it would either be because, perhaps there is some adverse reaction related to the cancer, the treatment.
Stop me if this is too much medical jargon, if maybe they’re neutropenic. I don’t know if you’re familiar with that. I know their immune system is down and now perhaps they’re getting a secondary infection. Or there are all sorts of adverse effects that can happen tumor lysis syndrome, which is something that happens when we administer chemotherapy.
And essentially all these electrolytes are coming out of the cells, the cancer cells that we’ve destroyed, and that can cause adverse effects. Effects. So that would be a reason why they’d be at the hospital.
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Schenk:
I see.
Goor:
Or if they’re actually receiving a chemo regimen that is hours and hours long and takes multiple days.
So that would be a reason for admission to the hospital. Now at the clinic, at the outpatient setting, there’s also variation. So sometimes the chemotherapy that we’re giving, some of them are. A couple hours long. Sometimes they’re there six, seven hours. It just really depends on the cancer and that particular treatment that they’re on.
If they’re coming for radiation, usually it’s a pretty short visit. It’s just, every day for multiple days. Or if they’re just coming to see the provider, get some imaging. Again, it may just be a few hours that they’re there, getting labs done and having some appointments. So I know those. Not a very specific answer, but it just really depends, I would say.
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Schenk:
No, it paints a picture too, that makes a lot of sense. But again I guess all that is being shared theoretically with the attending physician at the nursing home.
Goor:
Yeah.
Schenk:
Before we go, what are some of the other challenges that you think that they’re, they exist for treating cancer patients that are also nursing home residents.
Goor:
So one of the things that for me is a primary concern, and I’ve seen this, when patients have come to us from the hospital and also now working in the outpatient clinic, are the staffing constraints in nursing homes and also the lack of specific training to treat cancer patients.
So in terms of staffing constraints, as we all know, issues with understaffing that. Happens unfortunately everywhere in healthcare and especially in nursing homes. So the patients who are, have cancer and are getting treatment and have all these adverse effects, unfortunately they don’t have.
I guess the attention that they can get from the staff because of the staffing constraints, but also the staff there is really not trained to monitor and assess for the side effects that as an oncology trained nurse I would be monitoring for with a cancer patient. That would be, signs and symptoms of bleeding, of infection.
GI complications that can happen a lot of times from chemotherapy and immunotherapy, like new diarrhea, constipation, mucositis, which would be the sores that can develop in the mouth. And, in terms of nursing home residents if that’s not something you’re really looking out for. Perhaps you would not be aware.
It’s oh, why is this resident now not eating as much and their nutrition is affected? And especially if they’re cognitively impaired and they are not able to express that it actually is because they have these painful sores in their mouth and throat that are affecting them and. The medications we have for it are easy to administer, but it does require prompt and immediate assessment for that or any, I don’t know, for example, skin issues that can happen from radiation treatment.
So it is just a lot of things that I think you really have to be more specifically trained to notice and assess for when patients are going through cancer and treatment and that would be a challenge. And if a patient. Lives at home, as with their family. I think the family member perhaps would be more attentive to those subtle changes.
Schenk:
Very well said. Charlotte, thank you so much for coming on the show today and sharing your knowledge with us.
Goor:
Thank you so much. It was a pleasure.
Schenk:
Folks, I hope you found this episode educational. If you have an idea for a topic that you would like for me to talk about, let me know. If you have an idea for a guest that you would like for me to talk to, let me know that as well.
Please enter to win the mug. Tell me what your favorite fast food hamburger is and the question of the week on TikTok, new episodes of the Nursing Home Abuse Podcast out every single Monday. And with that folks. We’ll see you next time.
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