Most oncology nurse navigators and patient navigators meet their patients at diagnosis, the very beginning of what could be a long and hard journey for our patients with cancer. While we hope that all of our patients reach survivorship, the main goal of care is to ensure that the patient is meeting the milestones they’ve set for themselves and maintaining quality of life. From diagnosis, to treatment, to managing symptoms, we are by each patient’s side every step of the way. If survivorship is attainable, it’s important to remember that this goal starts at diagnosis.
Establishing Care Goals
When discussing a new patient’s treatment plan, we need to facilitate conversations around the patient’s goals outside of medical treatment. Medical professionals often set milestones based on treatment, but we as navigators need to assist our patients in meeting milestones that reflect a good quality of life and personal goals, such as planning a trip, seeing the birth of their grandchild, or being able to go for a long walk outside every morning.
After we’ve determined the patient’s initial goals, we need to keep these in mind and ensure they evolve along with the patient’s cancer journey. It’s possible a patient’s goals will change throughout treatment and it’s possible that they won’t share those goals with us, but by watching, listening, and learning about our patients along the way, we can pick up on clues they may be leaving about what is truly important to them. This information will help us determine if treatment paths and survivorship will reflect their quality-of-life goals.
Different Phases of Survivorship
When a patient does reach survivorship and we continue to navigate them through this new phase of their journey, we need to tailor our approach to each patient and each phase of survivorship. The different phases of survivorship include:
- Acute survivorship - the period from diagnosis through active treatment.
- Extended survivorship - the period just after primary treatment ends and is referred to as the transition from active treatment.
- Permanent or long-term survivorship - the last phase that extends through the balance of life.
Navigating Patients Beyond Treatment and Through Survivorship
Our patients will always be our patients, and when they reach survivorship there are many ways we can continue to support them and ensure they will be capable of living the quality of life for which they set intentions.
While you may be seeing your patients less, there will still be time to connect with them, where you can have meaningful conversations and take steps to continue to support them. Here are some ways you can support your patients after they reach survivorship:
- Recommend complementary therapies to help with any long-term symptom management, such as yoga or acupuncture
- Discuss their mental health and provide psychosocial support
- Talk through any other barriers they may be facing, like financial toxicity, for which you could help provide resources
- Empower patients to self-monitor and report any symptoms that are abnormal
- Check in on their goals and quality of life to see if there is anything you can be assisting with medically
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