Download What is lung cancer?

LUNG CANCER
Lung Cancer
What is lung cancer?
Lung cancer is a malignant tumor of the lungs. Originates in the tissues of the lungs.
Lung cancer is the leading cause of cancer deaths.
Who does it affect?
Lung cancer mainly affects smokers; males more than females. African Americans are
40% more likely to have lung cancer.
Why?
The main cause of lung cancer is smoking and exposure to environmental carcinogens.
What types of lung cancer are there?
The lungs are made up of several kinds of cells that perform different functions. The type
of lung cancer depends on which type of cell the cancer has infected, there are at least
12 different types.
Pathophysiology of Lung Cancer
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Lung cancer arises from a single transformed
epithelial cell in the tracheobronchial airways.
A carcinogen (i.e. cigarette smoke,
environmental agents) binds to a cell’s DNA
and damages it.
The damaging of the cell results in cellular
changes, abnormal cell growth and
eventually a malignant cell.
Pathophysiology of Lung Cancer
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As the damaged DNA is passed
on to the daughter cells, the DNA
undergoes further changes and
becomes unstable.
Due to the accumulation of
genetic changes, the pulmonary
epithelium undergoes malignant
transformation from normal
epithelium to eventually invasive
carcinoma.
Pathophysiology of Lung Cancer
How Smoking Affects the Lungs
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Normal Respiratory Epithelium change
when put under stress – smoking
Dysplasia
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First abnormality observed is dysplasia
 Smokers cough develops
Metaplasia
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Secondly, metaplasia occurs
 All steps still reversible
Anaplasia
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Lastly anaplasia occurs and is irreversible
when lung cancer develops
2 Main Types of Lung Cancer
Small Cell
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15-20%
Starts in the cells of the bronchi, bronchioles, aveoli, or supporting tissues of the lung
Grows quickly and metastasizes in other parts of the body (generally the liver and brain)
Most aggressive of the two main types and has the worst prognosis
Cells look like oats when viewed under a microscope. It will sometimes be called oat cell
carcinoma or cancer.
2 Types:
 Limited
 Extensive
Non-small Cell
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75-80%
Grows more slowly
3 Types:
 Squamous cell carcinoma
 Large cell carcinoma
 Adenocarcinoma: including bronchioalveolar carcinoma
Stage
Limited
Tumor is small and confined to the
chest including mediastinum and
supraclavicular lymph nodes. There
is no pleural effusion (fluid around
the lung).
Extensive
Tumor is wide-spread and cannot be
confined to the chest
Recurrent
If small cell lung cancer recurs, the
prognosis is very poor regardless of
stage or treatment
Signs and Symptoms
Diagnostic Tests
Treatment
Survival
Rate
New or changing cough
Hemoptysis
Recurrent lung infections
Hoarseness
S.O.B.
Increased sputum
Weight loss
Swelling of face or arms
Fatigue
Difficult to DX.
Only 1/3 of patients with small
cell are identified early on
Blood tests: chemistry profile;
examination of sputum or fluid
from chest for presence of
malignant cells
Imaging: chest x-ray; CT scan,
MRI; spiral CT scanning has
been developed to identify early
stage lung cancer in at risk
populations
Biopsy: of mediastimum, lymph
nodes, chest lining
Microscopy: once cells are
collected, pathologists can use
this to accurately diagnose small
cell lung cancer
Combination
chemotherapy:
multiple drugs are much
more effective than
single-agent
Radiation therapy:
given at the same time as
chemotherapy, this may
improve survival rate
Surgery:
A small % of patients
with very early stage
disease may benefit
2 year: 20%
Same as above
If tumor has metastasized:
Severe headaches
Double vision
Weight loss
Pain in bones chest, abdomen
or neck
The above exams plus those to
evaluate presence of metastases
Scans: CT of abdomen; MRI or
CT of brain; PET scans of
mediastinum; bone scan
Endoscopy/biopsy: fiber-optic
bronchoscopy with brushings or
biopsy; biopsy of bone, lymph
nodes or liver
Combination
chemotherapy:
Different combinations
may be more effective
than others
Radiation therapy: this
may help relieve
symptoms or with
metastatic disease (brain,
bone) but it is not
necessary to the chest
2 year: 5%
Any of the above plus others
The above
Palliative therapy:
Pain relief and
orthopedic aids
Investigational drugs/
clinical trials
2-3 months
Non-Small Cell Lung Cancer
Stages
Staging for non-small cell lung cancers, called the TNM
system, takes into account…
T: nature of primary tumor ie. lung
N: lymph node involvement
M: evidence of metastases
Stage I
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Confined to one lung
Has not spread to the
adjacent lymph nodes or
outside the chest.
Stage II
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Located in one lung
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May involve lymph nodes on
the same side of the chest
Does not include lymph
nodes in the mediastinum or
outside the chest.
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Stage IIIA:
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Cancer is a single tumor or
mass that is not invading
any adjacent organ
Involves one or more lymph
nodes away from the tumor
but not outside the chest.
Stage IIIB
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Cancer has spread to more
than one area in the chest
Not outside the chest.
Stage IV
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Cancer has metastasized to
different sites in the body
May include the liver, brain
or other organs.
Recurrent/Relapsed:
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Cancer has progressed or
returned
Following initial treatment
Types of Lung Resections
For non-small cell lung cancer
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Lobectomy
Single lobe of lung is removed
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Bilobectomy
2 lobes of the lung are removed
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Sleeve Resection
Cancerous lobe(s) is removed and a segment of the main bronchus is resected
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Pneumonectomy
Removal of entire lung
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Segmentectomy
A segment of the lung is removed
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Wedge Resection
Removal of a small, pie shaped area of the segment
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Chest Wall Resection
removal of cancerous lung tissue for cancers that have invaded the chest wall.
Signs and Symptoms
Symptoms that suggest lung cancer include:
 Dyspnea (shortness of breath)
 Hemoptysis (coughing up blood) most often rules out a pneumonia
 Chronic cough or change in regular coughing pattern
 Wheezing
 Chest pain or pain in the abdomen
 Cachexia (weight loss b/c the tumor deprives the body of essential
nutrients causing normal tissues to starve), fatigue and loss of
appetite
 Dysphonia (hoarse voice)
 Clubbing of the fingernails (uncommon)
 Difficulty swallowing (ataxia)
Monday Morning in the Emergency
Department
Patty Nelson, a 56 year old woman presents with a 12-week history of
cough with hemoptysis, progressive SOB, dyspnea, and a 20 lb weight
loss. Patty appears disheveled and smells of cigarettes. Her husband Jeff
says that she has had trouble breathing for at least 3 months.
Relieving her severe respiratory distress is our primary concern.
Her vitals are as follows:
T – 37.4, P – 114, R – 32, BP – 134/88, O2 – 87% on RA
An IV was initiated with NS @ 125ml/hr. Patty was given Ventolin 2.5
mg via nebulizer and Atrovent 400mcg via nebulizer to bronchodilate. O2 is
administered via nasal cannula @ 4L/min. She was also given Decadron
10mg IV to decrease swelling and inflammation in her chest. Once her
SOB and dyspnea were controlled Patty stated she had chest pain and
rated her pain as 2/10.
Once Patty was able to properly intake oxygen a further assessment was
conducted...
ER Continued….
Patty is a retired cashier at Sears and her husband Jeff of 33 years, is
a retired City worker. They have three grown children who live out of town.
Patty informs us that she has visited her family physician several times in
the past six months for what was first suspected to be a recurring common
cold, and was later treated as a pneumonia. The suspected pneumonia
was unresponsive to treatment with antibiotics.
The physician is suspicious of her presenting signs and symptoms
and orders a CXR, CT scan of the chest and abdomen, and blood work.
Patty’s physical assessment reveals:
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Normal heart sounds
Wheezing in the lungs with decreased air entry to lower lobes
Respirations are rapid, labored, and shallow with mild accessory muscle use
CMS is adequate with PPP, and delayed capillary refill
Soft abdomen with bowel sounds x4, passing flatus, last BM this am
As suspected the CXR revealed a mass in the lung located in the
lower left lobe. The CT scan provided a view of the thorax showing swelling
in the mediastinal lymph nodes. The physician diagnosed Patty with lung
cancer. To determine the type of lung cancer present the physician ordered
the following tests to provide a more accurate diagnosis:
Fiberoptic Bronchoscopy for
Biopsy:
 Provides a detailed study of
the tracheobronchial tree and
allows for biopsies of
suspicious areas
 A biopsy is necessary to
make a definitive diagnosis of
cancer cells: tissues are
removed from the body and
checked under a microscope,
if they are cancerous they
may be studied further to see
how fast they are growing
Tissue
sample
taken to
diagnose or
rule out
disease
Mediastinoscopy
 Used to obtain biopsy samples from lymph nodes in the
mediastinum
MRI
 To rule out brain metastases
Chemistries:
 For renal, bone, and liver abnormalities
CXR
 shows pulmonary density, a solitary peripheral nodules,
atelectasis, and infection
CT Scan of chest and abdomen:
 to assess disease extent
 identifies small nodules not visualized on the CXR and also to
examines areas of the thoracic cage not clearly visible on CXR
Sputum for cytology
 Sent for culture in the lab
Mediastinoscopy is a procedure in which a lighted instrument
(mediastinoscope) is inserted through a neck incision to visually
examine the structures in the top of the chest cavity and take tissue
samples. This procedure can be used to biopsy lymph nodes
surrounding the airway to help diagnose or see how far a particular
disease has spread.
Sputum Cytology
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Sputum sample obtained by coughing deeply
and expelling the material that comes from
the lungs into a sterile medium.
A positive culture may identify diseaseproducing organisms that may help rule out
respiratory conditions
Rarely used to diagnose lung cancer; it is
used as a screening tool
CXR and CT Results
Patty’s
Diagnosis
Small Cell Lung Cancer
Extensive Stage
(left lobe and mediastinal lymph
nodes)
Diagnosis
Small Cell Lung Cancer (SCLC)
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Small cell carcinoma is called
oat cell cancer
Is a fast growing type of lung
cancer
Very early metastasis
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10% patient are alive at 2 years
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Each Pt’s Tx Is Unique
Treating lung cancer depends on:
 The cancer's specific cell type
 How far it has spread in the body
 The patient's performance status.
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Measures pts general wellbeing and overall strength.
Used to determine whether they can receive
chemotherapy, whether dose adjustment is
necessary, and as a measure for the required
intensity of palliative care.
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Patty’s cancer team will consist of:
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Doctors:
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Hematologists
Oncologists
Pathologists
Radiation Oncologists
Radiologists
Surgeons
Nurses
Physicists
Radiation Therapists
Social Workers
Occupational Therapists
Psychiatrists
Respiratory Therapists
Treatment
Patty is not a good surgical candidate b/c her cancer is in
the extensive stage.
Chemotherapy will be the first choice of tx
A PICC line is inserted so that Patty can begin
chemotherapy. She is started on 6 cycles of Etoposide
and Cisplatin.
 Patty is given 10mg IV Decadron and 75mg IV Maxeran
30 min prior to chemotherapy.
 After chemo, Patty is prescribed Maxeran q2h prn for
two doses, then 75mg q3h prn for three doses.
The Meds so Far…
Atrovent (Ipratropium)  bronchodilator, anticholinergic
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Maintenance of airway and control of bronchospasm
 Inhibits contraction of bronchial smooth muscle
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Assess respiratory status
Ventolin (Albuterol)  bronchodilator, adrenergic
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Prevents reversible airway obstruction and controls acute bronchospasm
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Relaxes smooth muscle of the airway
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May cause nervousness, restlessness, tremor, chest pain
 Assess lung sounds, pulse, BP,
Decadron (Dexamethasone)  corticosteroid
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Used for a wide variety of chronic diseases
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May cause HYPT, ecchymoses, euphoria
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Assess respiratory status, lung sounds,
Maxeran (Metoclopramide)  antiemetic
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Prevention of chemotherapy induced emesis
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Blocks dopamine receptors, causing CNS depress
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May cause drowsiness, extrapyramidal reactions, restlessness
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Assess N&V, bowel sounds, abd distention
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If distonic reactions occur administer 50mg IM diphenhydramine
Morphine  opioid analgesic
 Binds to opiate receptors in CNS to decrease pain
 May cause confusion, sedation, hypotension, constipation,
respiratory depression
 Assess type, location, and intensity of pain
Narcan is the antidote for respiratory depression: Dilute 0.4mg
ampule in 10ml NS and administer 0.5ml IV push every 2 minutes
Hyrdomorphone (Dilaudid)  opioid analgesic
 May cause confusion, sedation, constipation, hypotension
 Assess type, location, and intensity of pain
 Narcan is the antidote
Oxycodone (Oxy IR)  opioid analgesic
 Same as above
PCA Pumps:
 Allow the patient to administer their own pain medication when
needed
 Think “pain prevention” rather than sporadic pain control
 PCAs allow the patient to receive adequate pain control with less
medication
 Check q1h x 2h, q2h x 12h, q4h x 5 days, then q8h
Chemotherapy
The use of cytotoxic drugs to treat cancer
 Systemic: drugs circulate and kill
cancer cells
Combination chemotherapy is
administering more than one drug at a
time
 More effective
 Reduce side effects
 Prevent resistance
A chemotherapy cycle:
 Period of treatment followed by a
resting period with no treatment
 Length and timing of the cycle
depends on the combination of
drugs used
 After drug administration there is
3-4 week rest period to allow body
to recover
 Usually given for 4-6 cycles
What is Chemotherapy
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Use of chemicals to alter tumor growth
patterns and cell reproduction and treat
metastases
Can be used as an adjunct to surgery or
radiation therapy.
Non-selective therefore both cancer and
normal cells are affected.
Targets RNA and/ or DNA in cells to prevent
mitosis and/or induce apoptosis (self-death).
Act on cells that are dividing and cells in
interphase.
Chemo Side Effects
Early side effects cause changes to rapidly dividing cells such as:
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Hair loss
Erythema and other skin changes
Bone marrow causing reduced WBC, RBC, platelets, HgB
Mouth sores
N&V, diarrhea
Changes in reproductive organs i.e. menopause
Phlebitis
Headaches
Anorexia
Burning on urination, blood in urine
Numbness to extremities, generalized weakness
Hearing problems i.e. tinnitus
Late side effects can cause problems after treatment and can last for long periods of
time
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Fatigue
Bone marrow suppression
Organ injury: heart, kidney, lung
Infertility
Renal failure
Renal Failure
CrCL (ml/sec)
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REDUCE BY
ANCILLARY SUPPORTIVE
TREATMENTS
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0.2-0.8
Etoposide by 25%,
cisplatin by 50%
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Oral or IV hydration is encouraged
Antiemetic Regimen
DRUG ADMINISTRATION
GUIDELINES
CISPLATIN
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< 0.2
Etoposide by 50%
and OMIT cisplatin
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Check serum creatinine prior to
cisplatin
May be given together with 50mL of
mannitol 20% and 100mL 0.9% NaCl
Infuse IV rate of 1mg/minute
Monitor input and output
Extravasation potential: irritant
ETOPOSIDE
Baseline blood pressure and every 15-30 minutes during infusion
 Infuse IV over 60 minutes
 EXTRAVASATION POTENTIAL: IRRITANT
DURATION OF CHEMOTHERAPY VISIT
Approximately 3 hours
RECOMMENDED CLINICAL MONITORING
 CBC before treatment
 Oral examination for stomatitis
 Baseline and routine renal function tests
 Baseline and periodic liver function test
 Monitor hearing and neurologic toxicities
DRUG COSTS (PER 1.7 m2 BSA)
Approximate chemotherapy cost $102.00 per cycle
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Treatment Results
Patty has been discharged and visits her
family physician for a follow up appointment.
She has a complete response to chemotherapy
on CXR and CT scan of the thorax and
abdomen as evidence by a reduction in the size
of the tumor. Her cancer seems to be under
control at the present time.
Symptoms of Metastases
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Headache
Weakness, numbness, or paralysis
Dizziness
Partial loss of Vision
Bone or joint pain
Abdominal pain upon probing
Unexplained weight loss
Loss of appetite
Unexplained fever
Jaundice
SOB, caused by fluid in the chest
Cardiac symptoms, including irregular pulse and difficutly breathing
Swelling of the face, arms, and neck, possibly, with visible vein
distention on the skin of the chest caused by superior vena cava
syndrome (pressure of a tumor on the large chest (SVC)
6 Months Later…
Patty returns to the ER with c/o persistent
headaches, severe SOB, dyspnea, and hemoptysis.
She is also experiencing pain in her muscles and joints.
On assessment the physician notices mild yellowing of
the skin and sclera and some swelling in her neck and
left arm.
Patty is referred for X ray and CT scan of her head,
chest, and abdomen.
X ray shows that the original mass in her lungs has
grown and CT scan reveals multiple brain and liver
metastases.
CT of Brain
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Right sided brain
metastasis
Palliative Care
Goal: Relieve suffering and improve quality of living and dying
when disease can not be cured.
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It is important for people to live out their days with meaning and as
little distress as possible.
It may complement and enhance disease modifying therapy or it
may become the total focus of care.
Embraces life and regards death as a normal process.
Neither speeds up death nor delays it.
Provides relief from pain and other distressing symptoms.
Integrates the psychological and spiritual aspects of care.
Offers a support system to help patients live as well as possible until
death.
Offers a support system to help families cope with their loved one's
death and to help them cope afterward with their own bereavement.
Palliative Cont….
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What is Palliative Radiation Therapy and
Chemotherapy?
When cure is not possible, both radiation
therapy and chemotherapy can help to relieve
the symptoms and to improve the quality of life.
These treatments are used to shrink a tumor, or
to slow down it's spread, so that while you may
be living with an incurable cancer, you can still
continue to live well.
Patty is admitted due to the severity of
the metastases. Due to the recurrent
nature of her cancer she has a poor
prognosis, she is treated palliatively with
decadron and radiation therapy to help
relieve her cough, dyspnea, chest pain,
hemoptysis, and joint and muscle pain.
Radiation
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The treatment of cancer
using high energy x-rays,
gamma rays, and
electrons.
Radiation targets rapidly
dividing cells
Side Effects:
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Fatigue
Hair loss to treated area
Erythema
Radiation Therapy
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Interrupts cellular growth
More than ½ of patients with cancer will receive
a form of radiation at some point
It is most often used when a tumor cannot be
removed surgically or when local metastases is
present
Sometimes used prophylactically to prevent
leukemic infiltration to the brain or spinal cord
Used palliatively to relieve symptoms of
metastases
2 Types of Ionizing Radiation
Electromagnetic Rays:
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Radiation breaks the strands of the DNA helix which leads to
cellular death
Particle Rays:
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Lead to tissue disruption
Cells that divide frequently are more sensitive to radiation
therapy ( ie. Bone marrow, lymphatic tissue, epithelium
of GI tract etc.)
Tumors that are well oxygenated have more successful
rates with radiation treatment
Chemotherapy creates a more sensitive tumor
Radiation Delivery Methods
There are 2 forms of Radiation Therapy;
External Radiation:
Rays are delivered from outside of the
body, and are calculated by the size and
depth of the tumor
Internal Radiation:
Radioisotope device is implanted by many
routes (needles, seeds, beads or catheters
into body cavities)
Radiation improves Patty’s quality of
life by relieving some of the complications
associated with her cancer. Patty is
experiencing constant pain during this
stage of her illness. The following tool is
used to assess the severity of her pain
and which medications will best relieve her
pain.
Factors Contributing to Decreased
Intake of Nutrients
Effects of Cancer Treatment
Reduced Oral Intake
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Anorexia
N&V
Altered Perceptions of Taste and
Smell
Local Effects of Tumor
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Odynophagia, Dysphagia
Malabsorption
Early Satiety
Psychosocial Factors
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Depression, Anxiety
Food Aversion
Surgery
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Altered mastication and swallowing
Postgastrectomy syndromes
Pancreatic Insufficiency
Anastomotic stricture
Chemotherapy
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N&V
Altered Perceptions of taste and smell
Stomatitis, mucositis
Diarrhea
Radiation
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Odynophagia, Dysphagia
Xerostomia, mucositis
Strictures and Fistulas
Cachexia
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A syndrome that includes anorexia, early satiety,
weight loss, anemia, asthenia, taste alterations,
and altered metabolism.
Most severe for of malnutrition associated with
cancer.
Causes 80% of deaths associated with cancer.
Pt experiences weight loss despite normal food
and fluid intake.
Pts with cancer have a high BMR, due to energy
demands of the tumor.
Pt’s may end up on TPN.
Purpose
To provide nutrition for
a) pts who can not eat or drink
b) pts who can not absorb what they eat or drink
c) pts who can not intake enough calories to gain weight, gain
energy, or heal tissues
It may be given to people who are unable to absorb nutrients
through the intestinal tract because of vomiting that won't stop,
severe diarrhea, or intestinal disease.
It may also be given to those undergoing high-dose
chemotherapy or radiation and bone marrow transplantation.
A form of nutrition that is delivered into a vein.
TPN does not use the digestive system.
TPN Solutions
Amino Acid Solution 4.25%
Dextrose 10% or 25%
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10% can be delivered via peripheral or central route,
and 25 % is delivered via central route only
Lipids 10% or 20%
Different additives such as
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Trace Elements
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Vitamins
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Zinc, Magnesium
A,D,K
Electrolytes
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Sodium, Potassium
Pt Care Plan
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Routine TPN blood work
CBG’s QID
Strict I & O
TPR QID and once during the night (notify MRP if T is >38.5)
BP Q shift
Give Vit K 10 mg IM weekly
Treatment
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Pt. wt. as per protocol
Central midline drsg changes
IV line changes
Perpipheral IV site changes (Q 96 hours or as per protocol)
TPN Cont…
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A fluid balance record, diabetic record and
graphic records are kept for TPN pts as well as
A TPN record in their chart which includes the
following
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Date & Time of Hanging Sol’ns
Type of Sol’n and Volume
Rate ordered
Initials
Date and Time Sol’n Finished
Date and Time of Line changes (amino, lipid)
Date and Time of all other IV line changes
IV site drsg change ( RN Note)
As Patty’s condition continues to
deteriorate, Patty’s family realizes that the
end is near.
 The nurse must now take on added
responsibilities with family care as they
become the primary patient (in some
ways).
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Care for the Family
When all treatment options have been
exhausted, the nurse must continue to
care for the family.
 The nurse can ensure that the family has
begun to plan ahead in organizing the
patients’ personal affairs.
 The nurse can remind the family to
remember to care for themselves:
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Adequate rest and nutrition.
Signs of Death & Dying
Pt becomes less social, sleeps for long periods of time, and is difficult to rouse:
Nursing Intervention
 Allow quality rest time
 Reassure patient that it is alright to sleep
 Plan to spend time with the patient when they are most awake
 Speak in a calm, natural way; never assume that the patient can not
hear
Pt shows a decrease in eating habits:
Nursing Intervention
 Offer small servings of light food and fluids, ice chips, popsicles
 Remind patient to swallow, as they may forget
 Promote comfort by keeping the mouth and lips moist
Signs of Death & Dying
The patient may Become confused/disoriented
Nursing Intervetion
 Speak calmly and clearly, explain what you are doing as you provide
care
 Remind the patient of time, place, and who is in the room
 Keep a soft light on
The patient may become restless
Nursing Intervention
 Offer music, light massage, medication, or other comfort measures
They may lose control of bladder and bowels
Nursing Intervention
 Keep the person clean and comfortable
Have Changes in breathing:
 Irregular rate, may stop for 5-30 seconds followed by a deep breath;
periods of rapid, shallow, panting breathing; wet sounding breathing
Nursing Intervention
 Raise the head of the bed, or place patient on their side
Signs of Death & Dying
Patient may:
Have an irregular pulse or heartbeat
Decreased circulation:
 Skin may feel cool or moist, become pale, swollen, or blue, but the patient will
not be feeling cold
Be unresponsive to voice and touch (withdrawal); sleeping with eyes open
This is the preparation for release, the beginning of letting go:
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Hearing remains to the end, speak in a calm, natural way
Identify yourself when you speak
Hold the persons’ hand

Give permission to let go
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
When Death Has Occurred
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


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The person will be entirely unresponsive
Breathing will stop
Pulse stops
Eyes will be open or
closed, with a stare in a
fixed direction
Jaw will relax
Loss of bladder or
bowel control may occur
Notify Physician if not already
Care After Death
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Apply Gloves
Remove all tubing ie. Indwelling catheters
Reinsert dentures if applicable
Position patient according to agency policy
Elevate head of bed or place small pillow under their head
Close eyes
Wash any soiled body parts
Place an absorbent pad under the buttocks
Change dressing with a clean one
Put Patient in a clean gown
Brush and comb hair
Cover body with sheet exposing only the head (only if family wants to see
them)
Place into body bag and label body
Call a porter
Care of the Dead Body
The following forms must be completed
1.
2.
3.
4.
Medical certificate of death ( must be filled out by a nurse and
signed by a physician)or (coroner)
Warrant to bury the body of a deceased person (filled out by the
nurse and signed by the coroner)
Consent for autopsy ( for all deaths can be completed by a nurse
or physician)
Release of liability and responsibility, removal of bodily remains (c
by nurse, signed by family)
Patty’s body and personal effects have
been taken care of and the family are
about to go home.
 Patty’s husband, Jeff, turns to you as he is
leaving and asks, “How will I cope? Patty
did everything for me. I can’t even read.”
