Mapping the Patient Journey

Introduction

The patient journey is referred to ongoing sequential process of care events in which a patient is followed from the point of healthcare access into the healthcare system and then continues towards diagnosis and care and finally ending in the care process (Girerd et al., 2018). The process mapping in patient’s journey is also essential to understand the way better care with less hindrance could be offered to the patient that would have enhanced their health (Hibbard et al., 2017). Thus, in this study, case study of the patient named J who is suffering from ovarian cancer will be discussed. In this process, the journey of care of J would be discussed and process mapping of her care will be explained. Moreover, based on the patient journey of J, discussion and analysis of her care will be made to determine activities to be avoided and future recommendations to be followed for similar patients.

Process Mapping

The process mapping is referred to the tool which shows inputs, activities and outputs of a process in clarified and step-by-step manner to determine the way actions in the process are systematically executed to reach the output (McCarthy et al., 2016). In patient care, the process mapping provides picture of the care by identifying sequence involved in the patient journey, people involved in the care, nature of audit performed and others. It also helps to analyse what has gone wrong along with what required to have happened with the help of a flow chart and assist health professionals and nurses in looking after the care through patient's eyes (Reay et al., 2017). Thus, in case of patients J, the process map of her entire care journey for ovarian cancer is to be made to later analyse and discuss the changes in care to be done and activities to be provided. (Refer to Appendix 1)

Description of Patient Journey

The patient journey to be discussed is regarding patient J who is a 40 year old female suffering from ovarian cancer. According to the NMC Code of Practice, the personal details of the patients are to remain confidential so that safety and privacy of the patients are maintained (NMC, 2018). Thus, to maintain confidentiality and privacy, pseudonym J is been used to indicate the patients so that her real identity remains secure. J is married to W for more 10 years and they have a 6-year-old daughter along with a 4-year old son. J works as a manager in a nearby restaurant and W is employed as a junior finance manager in an accountant firm. There is no incidence of any form of cancer in the past in J’s family. J in the last 3 years occasionally faced vomiting and nausea while eating and pelvic pain during sexual intercourse but delayed to avail health check-up. However, the symptoms became worst in the last 2-3 months where J reported to face persistent pain during sexual intercourse in the lower abdomen, abdominal bloating, nausea, inappropriate change in appetite, problem in bowel movement and frequent urge for urination. The persistent symptoms led J to visit a nearby general physician (GP) for health check-up. According to Ebell et al. (2016), people with ovarian cancer feel frequent urge to urinate and experience hindered bowel movement. This is because the presence of cancerous growth in the ovary creates pressure build-up on the surrounding organs such as urinary bladder and the large intestine. As argued by Doubeni et al. (2016), individuals with ovarian cancer due to changes in hormonal production often face vaginal dryness. This leads individuals to face pain and discomfort during sex. Thus, based on the immediate symptoms of J, the general practitioner (GP) initially performed a pelvic examination to determine if J has lumps in the vagina or abdominal region as they are symptoms of ovarian cancer growth. In order to confirm J’s health issue, the GP referred her to the hospital for performing transvaginal ultrasound scan (TVUS) of her ovary. She had to wait for more than three weeks to get next appointment with the GP even after receiving the TVUS report within the next two days of her last consultation with the GP. The GP on analysis of the report identified that she has prominent lumps or tissue growth in the ovary and uterus region. The GP following the scan reports mentioned J to perform CA125 (cancer antigen 125) blood test. This is because blood test in cancer patients helps to determine whether or not there are presence of tumour markers in the blood that are diagnosis for presence of cancer (Kamal et al., 2018). J again has to wait for 3 weeks even after receiving the blood test report in the next 4 days of her last consultation with the GP for getting further appointment for analysis of her blood test report. During this phase, J experienced hindrance with leading her normal life as there was no medication provided to control her pain, urinary frequency and bowel movement even after the TVUS reports indicated lumps on her ovary. After the blood test report, J was initially confirmed by the GP to be suffering from ovarian cancer and referred to the gynecologic oncologist for further verification and treatment regarding the disease.

J was able to get immediate appointment with the gynecologic oncologist and felt satisfied for the speedy reference and availability of the health professional. The gynecologic oncologist reviewed the diagnosis reports of J and identified that cancer has spread from her left ovary to additional area in the fallopian tube and uterus. However, the oncologist further asked J perform the TVUS and blood test again to determine the extent to which her health has deteriorated since the last report. The ovarian cancer which has affected one or both the ovaries and has partially spread to the pelvic region is regarded to be Stage II cancer (Thomson et al., 2016). Thus, it was determined that J had stage II ovarian cancer for which immediate treatment is required. This is because comparing the current and previous reports the oncologist mentioned that the cancer is spreading at an increased rate and there has been a delay in care. J was consulted by the gynecologic oncologist with her reports within one week without creating any delay in care and was mentioned that ovary removal surgery is the only step in ending the progress of cancer. The gynecologic oncologist within the two weeks provided date for surgery along with mentioned the side-effects of the surgery as well as consequences of not performing the surgery for J. It led J to understand the urgency of the surgery and she provide acceptance to the action. The surgery was smoothly performed and the tumours were further taken for biopsy. The biopsy reports confirmed the tumours to be cancerous and thus after the surgery within the next three weeks, chemotherapy for J was initiated. J was provided detailed overview of the importance, side-effects and way chemotherapy is to be provided along with informed decision are been taken to manage her care by the health professionals. The chemotherapy is provided in 6 cycles to J during which combined medication of carboplatin and paclitaxel is provided. This is because they are the drugs that help in destroying any remaining cancerous cells after surgery in ovarian cancer (Chan et al., 2016). The drugs are provided intravenously to J and the oncologist along with the nurses was seen to remain in constant communication with J to determine the progress of her health and manage the side-effects of chemotherapy. The gynecologic oncologist to help J with nausea during and after chemotherapy mentioned her to take light meals in 2-3 hours interval and avoid smelly foods such as onions, tuna and others. J reported to feel less nauseous and vomiting tendency after following the diet pattern. At the end of the chemotherapy, J was asked to monthly visit and check-up for her health with the gynecologic oncologist for the next six months to ensure cancer remains effectively managed and any indication of relapse is detected at the initial stage to control it.

Analysis and Discussion

The analysis of patient journey of J for availing health assessment, diagnosis and treatment of ovarian cancer highlights that the initial issue faced is delay in availing timely health assessment by J. As asserted by Bregenzer et al. (2019), early health intervention and assessment for cancer by detecting the initial symptoms helps in effective management of the disease. This is because it helps the healthcare professionals to act effectively in taking prevention strategies to avoid the spread of cancer to other parts of the body, in turn, avoiding further complication to health. However, in case of J, it as seen that continuous delay in care was made by the GP which could have contributed to further worsening of her condition. Thus, her longer waiting time acted as negative approach towards her care regarding ovarian cancer. It was also evident from the context of the gynecologic oncologist who reported that delay in care has led her to experience increased spread of cancer. As argued by Tørring et al. (2019), delay in care leads the patients to remain unsatisfied with the support and anxious with their health. This is because the patients are worried about their health and feel lack of valued out if the ignored support provided to them by the health professionals. In the case of J, similar condition was faced as extensive delay in consultation with the GP was seen as she nearly have to wait 3 weeks for each check-up and health report analysis. The other thing that went wrong was that the GP avoided mentioning J in performing all diagnostic tests that are ultrasound and blood test at time so that the overall consultation time could be reduced and early referral of J to expert health professional could be executed. In the patient journey of J, which initiates from the access to care, the initial action of availing health assessment from a general practitioner was an effective approach. This is because the general practitioners (GPs) are considered as the first point of contact to be made with for identifying and diagnosing potential symptoms of cancer and rule out other additional diseases (Ladegaard Baun et al., 2019). In case of J, it was seen that the GP performed pelvic examination in relation to the symptoms reported by the individual and immediately referred her to perform ultrasound scan of her ovary. In diagnosis of ovarian cancer, the pelvic examination in the initial diagnosis performed to detect presence of any lumps or aberration in the vaginal or pelvic region (Stewart et al., 2016). Thus, the initial approach of pelvic examination to confirm hindrances in ovary and uterine wall was an effective step. As asserted by Campbell and Gentry-Maharaj (2018), the transvaginal ultrasound (TVUS) through use of sound waves allows screening the area of the uterus, ovary and fallopian tube for detecting any damage or growth of tissue. This is mainly used for is used for diagnosis of ovarian cancer and therefore this approach was effective step in detecting ovarian cancer of J. The advantage of TVUS is that it is painless and provides clarified three-dimensional images of the ovary and other parts of the pelvic region (). Thus, its use at the early stage was appropriate for J in diagnosis of her health complication.

The Cancer Antigen 125 (CA 125) blood test is performed to detect the amount of CA125 protein present in the blood of the individuals. This is because the CA125 proteins are produced on the surface of the cancerous cells in the ovary which are released within the bloodstream (Qin et al., 2018). The diagnosis of ovarian cancer initially involves pelvic examination, ultrasound scan and blood test to initially detect the disease (Yang et al., 2020). In case of J, it as seen that all the three diagnoses was performed by the GP which indicates that initial health assessment for detecting ovarian cancer was effectively performed. However, it cannot be confirmed from these test only whether or not the cell growth in the ovarian region are cancerous and additional knowledge is required. The gynecologic oncologists are individuals who are experts in management and treatment of cancer-related to women's reproductive system (Minig et al., 2016). The referral of J by the GP to the gynecologic oncologist after the initial diagnosis was an effective approach as it helps her to access expert assistance in further management and treatment of the disease. The gynecologic oncologist asking J to repeat the TVUS and blood test to detect the progression of the disease in the meantime was an effective approach. This is because comparing disease progression between time helps to detect to what extent and at what speed the health is been deteriorated assisting professional to understand priority of the health of the patients (Morimoto et al., 2016). Moreover, cancerous growths are found to spread from one region to another whereas the tumour remains specific to the affected part of the organ (Kim et al., 2018). Thus, the progression and spread of lumps from the ovary to the adjacent pelvic areas leads the oncologist to initially confirm J is suffering from ovarian metastasis cancer. As argued by Mallen et al. (2018), before surgery for health intervention of any cancer, stage detection is important. This is because it leads to create idea and knowledge among the health professional caring for the patients to determine person-specific support required to prevent and manage the spread of cancer accordingly. Thus, the detection of ovarian cancer stage for J was an effective approach by the gynecologic oncologist in delivering appropriate care to the individual.

The usual treatment for ovarian cancer is removal of affected ovaries along with the affected parts of the pelvic region such as fallopian tube and uterus. This is because removal of the affected parts leads the cancerous cells to lack ability to spread from the infected regions to the healthy parts of the body (Kim et al., 2018). In case of J, the gynecologic oncologist’s immediate decision to surgically remove affected ovaries and the fallopian tube was an effective approach. This is because it would help to avoid the cancerous cells affect the healthy parts of the body and replicate. As argued by Vercellini et al. (2018), side-effect of partial ovary removal includes early menopause, lower sex drive and others. The patient J was found to be mentioned about the side-effects of ovarian surgery in treatment of her cancer and was found to accept in executing the surgery. According to the NMC Code of Conduct, the patients are to be informed in detail regarding the care support provided to them and allowed to make informed decision in their care (NMC, 2018). This code was seen to be effectively followed as by delivering effective information regarding side-effect and consequences of the ovary removal surgery as well as not performing it, J was able to make informed decision regarding her care without influence. As argued by Corzo et al. (2017), inability to the patients to make informed decision and influence of the health professionals in deciding their care leads to the dissatisfaction of the patients regarding care support. This is because they feel their views and opinions are not valued by the health professionals. However, in J's case, it was seen that effective informed decision was received regarding the surgery which ensures providing satisfaction towards her as J's opinions are respected. The biopsy is essential to test to confirm the presence of cancer among individuals (Giannopoulou et al., 2018). Thus, the execution of biopsy of the removed left ovary and fallopian tube of J was an effective approach to finally confirm and ensure whether or not the cells are cancerous in nature. The reports mentioned that cells are cancerous which led the oncologist determine the further support required for her health to ensure holistic and permanent improvement. As mentioned by Havrilesky et al. (2019), time gap is required between the ovary removal surgery and initiation of chemotherapy for ovarian cancer patients. This is because the time allows the individual to overcome any trauma and heal their wounds and stitches made due to the surgery. In case of J, before delivery of the chemotherapy, it was seen that she was made aware of the importance, side-effects and way it is to be provided. This is an effective approach in the care for J as the action allowed the patient to understand consequences to be faced in the treatment along with the need for care towards her health. It led to help J show effective compliance with the care as she understands the essentiality of the support for her health.

According to Cancer Research UK, the chemotherapy is to be initiated after the ovary removal surgery within 2-4 weeks (NHS, 2018). In case of J, it was seen that after a month the chemotherapy was initiated which ensures the effective time gap as followed in providing appropriate care. The chemotherapy is usually provided in repeated cycles to all the cancer patients irrespective of their condition. This is because it allows the specific cancer cells of the body to be attacked in the most vulnerable times as well as provide capability to the body to replace the damage caused in the therapy to the normal cells (Van Driel et al., 2018). Therefore, providing chemotherapy is six-cycles to J is an appropriate approach to offer her ability to overcome ovarian cancer and health at the same time. In chemotherapy for J, it is seen that carboplatin and paclitaxel are used. The use of combination of medication is approach as they are usually suggested for treatment of ovarian cancer in the UK (NHS, 2018). The carboplatin mainly binds with the DNA of the body which leads to cause damage that avoid the DNA to stop replicating. This stopping of DNA replication leads to prevent the cell from reproducing and develop cancerous growth (Huang et al., 2020). In the study by Shen et al., (2017), paclitaxel controls the growth of the cancerous cells in two ways that are mitotic arrest which occurs with the coincidental serine protein phosphorylation and cytotoxicity. Moreover, the drug causes immediate activation of gene activation and tyrosine kinase pathways to control the expression of cancerous cells. Thus, the two drugs are appropriate to be used for treatment of ovarian cancer of J as they help in destroying the cancerous cells ensuring to avoid any further cancerous growth in the affected parts. The chemotherapy after the surgery is required to destroy any remaining cancerous cells that are unable to be removed during the surgery (Zhai et al., 2018). Thus, this action was effective approach towards J by the health professionals to help her effective fight with cancer. The timely and speedy approach of the gynecologic oncologist throughout the care as seen from the patient’s journey was an effective approach for J to have timely support for her health and prevent further deterioration of her well-being. The principle of the patient-centred care includes integration of the patients in the care decision, offering them physical and emotional comfort, respecting their values and needs and retaining effective communication (Selby et al., 2018). In case of J, it is seen that during her entire journey of care with the oncologist, effective communication between the two is established as well as the oncologist has ensured physical comfort to be assured for the patient. This is evident as gynaecologic oncologist mentioned J the way she can control her meal to avoid vomiting which creates physical distress in her. Moreover, she suggested her to take rest to ensure her emotional comfort and involved her in deciding her nature of care in the entire process. The importance of patient-centred care is that it provides holistic support and ensures greater satisfaction of care for the patients (George et al., 2016). Thus, by implementing patient-centred approach, the benefit of satisfied care delivery is achieved in case of J as she nerve reported any hindrance while availing care from the oncologist. The continuous monitoring of the health of individuals suffering from ovarian cancer is beneficial to avoid relapse of the disease and take active steps in case relapse occurs regarding the health issues (Yang et al., 2016). This action was effectively performed for J by the oncologist by mentioning her to get continuous monitoring of her health after ending chemotherapy for the next six months.

Conclusion and Recommendation

The above discussion informs that J is suffering from ovarian cancer which was initially detected by the general physician by performing pelvic examination along with CA125 blood test and transvaginal ultrasound scan (TVUS) test. During the consultation with GP, it is seen that J has to unnecessarily wait for prolonged time to get appointments and inappropriate breakdown of the diagnosis was seen. However, effective referral to J is made to the gynecologic oncologist which helped her in availing expert assistance and treatment for ovarian cancer. The oncologist is seen to review her health reports and reassess her condition to determine the extent to which the disease has spread. The oncologist mentioned J to performed ovary removal surgery followed by chemotherapy as effective approach. The determined care actions are performed for J by providing her detailed information regarding her treatment and accessing informed decision from her regarding the care. A patient-centred approach was taken to deliver support to J. Moreover, effective health monitoring is established for J by the oncologist to ensure avoiding relapse of the disease and control her health in relation to ovarian cancer. According to the patient journey of J, the initial recommendation is that in future she along with similar patients are suggested to be proactive in making decision while facing delayed care from the general practitioners who are initially consulted for health complications. She is recommended to change the general practitioner (GPs) and avail assistance from other GPs who are able to provide speedy care at the appropriate time. The general practitioners are recommended not to inappropriately break down care which takes increased time in diagnosis of the disease. They are to mention the patients all the diagnostic test to be performed for a single health issue at a time so that all the health reports can be analysed to provide care within less time. Another recommendation is regard to the case study is that all the side-effects of medication and treatment along with consequences of not performing the treatment are to be communicated to the patients with effective proof. This is to help them have effective information in making decision and chose their care. In future practice regarding ovarian cancer treatment, the overall waiting time in receiving initial health support from the GP is to be reduced with changes in policy management within the NHS and in the private health clinic within the UK. The patient-centred approach is to be followed and the NMC Code of Practices is to be considered while delivering care to any nature of patients. This is because it ensures creating satisfaction in care among the individuals for the support provided by the health professionals.

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