Down the Rabbit Hole

Down the Rabbit Hole, collage, 2017 by Julianna Paradisi

Why is it 2018 feels more like “2017, The Sequel, and not an actual New Year?

While I have one or two friends who’ve had an immediate change of luck, many more of us are experiencing 2018 as a poorly constructed, run-on sentence (or rambling blog post) with little progress or clear goals for the future.

Progress requires a release of perceived limitations, and expectations. The process of releasing creates tension similar to a snake shedding its skin, or a butterfly breaking forth from its chrysalis. Things become too tight and uncomfortable before breakthrough occurs.

Nearing the end of January, the growing and stretching feels more intense than in previous years, and I find myself sympathizing with Alice for choosing to follow a rather strange rabbit down a hole, without thought of where it would lead, or how she would return. “Don’t over think it, just do it.”

Choosing to go down the rabbit hole is not a characteristic of most nurses. Nurses like clear goals, something to steer towards, whether it’s gaining a patient’s trust by managing her pain, meeting discharge goals, or simply relieving a fever.

Measurable goals work in nursing. They’re admirable, and create safety.

* * *

Safety. What is safe?

As an oncology nurse navigator, and a cancer survivor, my patients and I grapple with this question daily: How to balance cancer prevention (safety) with an enjoyable and fulfilling life?

If you believe the answer is easily found in NCCN guidelines, and AJCC recommendations, you are most likely not a cancer survivor. Being a cancer survivor is “going down the rabbit hole.”

* * *

Being an artist and writer demands a willingness to go down the rabbit hole; a comfort level with uncertainty.

The challenge of life is learning to live somewhere on the continuum between safety, and recklessness.

Hank Stamper, the burly central character in Ken Kesey’s epic novel, Sometimes a Great Notion, about Oregon’s logging industry, argues towards recklessness:

“Hank would have been hard put to supply a reason himself, though he knew it to be true that Lee’s presence at the Snag tonight was important to him…maybe because the kid needed to see first-hand what kind of world was going on around his head all the time without him ever seeing it, the real world with real hassles, not his fairy book world of his that him and his kind’d made up to scare theirselfs with.”

* * *

Progress begins by asking questions.

What is safe? What is reckless? Should a predictable outcome dictate the beginning of a new enterprise?

An explorer would answer, “No.”

Alice returned from Wonderland, having viewed strange, new perspectives, and with a bunch of great puns. I assume she counted it a good experience, because she went back for a second trip Through the Looking Glass.

Here’s to going down the rabbit hole, and leaving 2017 behind.

 

 

 

 

 

Cancer Survivorship: Breaking The Myth of “Nurses are Bad Patients”

The Queen of Cups I collage by Julianna Paradisi 2017

Are nurses are the worse patients?

Upon completion of treatment for breast cancer, my surgeon remarked, “You got through treatment really well. In the beginning, I didn’t think you would.”

The comment struck me as odd, but I was curious. “Is this because I cried when you diagnosed me?”

“Yes.”

Thoughtfully, I replied, “I cried because I understood the diagnosis. I understood it would change my life.”

In return I received a patient smile.

The first plastic surgeon I chose was forthright in his opinion of me as a patient, however, “You nurses are the worse patients.”

I asked, “Are we your worse patients, or your most educated ones?”

He promptly discharged me from his care.

* * *

I received excellent treatment for breast cancer. My survival and good health are proof. But there were gaps in the emotional support I received.

It’s been nearly two decades since I had breast cancer, and all those years I accepted the label of being “a bad patient;” the one that asked questions, the one needing proof the  medical recommendations were best practice.

Then I became an oncology nurse navigator, with patients who are nurses. They have taught me I was not a bad patient, just a nurse-patient, set apart from non-nurse patients. And there are subsets of nurse-patients I help: those bringing an oncology background to their diagnosis, and those who don’t.

Nurses assume accountability for their care

Nurse-patients with oncology backgrounds manage their cancer diagnosis differently than their colleagues without. I suspect this is because they bring their own toolbox: They work with oncology surgeons, medical oncologists, and radiation oncologists. They personally know and handpick their treatment team. They’re still scared, but the support they seek is more pragmatic: how-to’s for managing treatment, work, home, and family life.

Nurses without an oncology background wonder if we are referred to top-notch practitioners, and receiving state-of-the art options, contributing more stress to our cancer diagnosis. We tend to get second, and sometimes third opinions about treatment recommendations. We are more likely to travel to nearby cities (and sometimes other states) with larger, nationally recognized cancer programs for consultations. We may delay starting treatment to fit in the extra consults. Our family and friends may not understand why we won’t simply “do what the doctor says.”

Here’s my unproven hypothesis explaining why this happens:

The Hot Seat: Nurses are compelled to advocate for themselves

Nurses, in our role of patient advocate, are educated to question doctors. We are accountable for catching, and preventing mistakes.

In my nursing education, this training happened early in the morning before our clinical days, in a potentially brutal ritual dubbed, “The Hot Seat.”

In “The Hot Seat” one by one, nursing students gave report on the patient (s) they were assigned that day: diagnosis, age, treatment plan, and goals for outcome. Our instructor cross-examined each student about everything: medication indications, dosage, side effects, and lab values to monitor. She inquired about imaging, and anticipated needs the patient may have at discharge. The more questions a student answered correctly, the more difficult the questions became. The fewer answers a student mustered, the hotter the seat became.

Nurses know unasked questions lead to harm

In The Hot Seat we learned critical thinking means always ask the next question. It’s the question you forgot to ask that leads to harm.

Nurses know the importance of asking questions. When we seek treatment outside of our specialty areas from doctors we do not know, we manage the stress by asking, “Why?”

My understanding of this means that nurses are some of my favorite patients. I remember what I needed to know to ease my stress during cancer treatment, and I offer it to my nurse-patients. Once they understand how oncology treatment works, they often become so independent in caring for themselves I rarely hear from them.

And I’ve certainly never discharged one from care.

 

 

 

Plateaus, New Goals, & My First Failure of 2018

2017 was a challenging year for me in many ways, some good, some not so much, but it ended positively.

In October, I had opportunity to show ten new paintings where I work, part of an exhibition titled Healers, Artists, and Breast Cancer Survivors. A local TV news station covered it. Around the same time, I was interviewed for a local magazine, also about being an artist, oncology nurse navigator, and breast cancer survivor. I admit, I felt very good about both, because 2017 was a difficult time for pursuing my goals as an artist.

Part of the hospital exhibit was an artist talk. I spoke about how my arts career was launched when I completed cancer treatment, and was told I had a 32% chance of dying in 10 years from disease recurrence. Blah, blah, blah, I decided if I were to die in 10 years there were three things I wanted to do:

  • Become an artist
  • Fall deeply in love with, and be deeply loved by the same person
  • Give people reasons to say nice things about me when I die.

As I spoke these words to the audience, I realized I have achieved the first two of the three, and it’s too soon to know the outcome of the third. I need new life goals.

I spent the past weekend reflecting on what these new life goals should be. I did some deep soul work, and came up with new intentions. They include questions I’m hoping to have the answers to this time next year. I’m not going to write them here. They’re personal.

I started 2018 with a bang. I spent time with some of my closest family, which  was a goal for 2018 (there’s a difference between yearly goals and life intentions). Afterwards, I went to my barre class, and the instructor talked about breaking plateaus. That resonated for me. I’ve reached a plateau in my life goals. 2018 will be the year to break through.

I came home from that class ready to write a post for this blog about how to know if you’re stuck in your life goals, and methods to get unstuck. I was on fire.

The too long knitted sleeve photo by Jparadisirn 2018

I forgot to mention, I began knitting a sweater last week. I’m a pretty good knitter, but the pattern I chose, though it builds on skills I’ve gained by making smaller projects, is the most complex pattern I’ve worked with. It’s knit from the bottom up, beginning with the sleeves, which are joined to the body of the sweater before making the yoke. I’ve been working on the first sleeve for several days. It’s over a foot long.

That’s when I noticed it’s too long to accommodate the rest of the rows needed to make the remaining necessary stitch increases. I re-read the pattern. I had misunderstood the increase rows sequence. Now I have to rip out all of the knitting I’ve done, and start over. Arrgh!

I felt defeated, the wind let out of my sails. It’s the first day of 2018, and already I’ve made a mistake!

Then it came to me: That’s how plateaus are broken. You try something new, and you’re not good at it yet, so you make a mistake, maybe more than one. You have to start over, and keep trying until you get it right. That’s how you get unstuck. That’s how progress is made.

I haven’t ripped out the stitches yet. I decided to write this post first. I feel better because I did. I feel motivated to rip out all those hours of knitting, and start over.

2018 is going to be a transformative year.

 

Art and Nursing: Exhibiting Art Within a Power Point Presentation About Oncology Nurse Navigators

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The above paintings are original works by Julianna Paradisi, and may not be used or reproduced without permission.

This year, I’ve had a few opportunities to try on the art of public speaking, a newish skill for me. The topics revolved around breast cancer, and oncology nurse navigation.

Recently, I was asked to speak to a group of inpatient oncology nurses about the role of nurse navigators for breast cancer patients, and the application to the hospital setting. Integrating the patient experience throughout the continuum of cancer treatment is a prominent part of what nurse navigators do, and inpatient nurses wanting to learn more (and earned CE) about oncology nurse navigation is exciting.  It demonstrates ONNs have an impact on patient care.

For the occasion, I decided to learn a new skill: creating a Power Point presentation. I know, I know, some of you were making Power Point presentations since your first elementary school book report, but you probably can’t write in cursive as well as an older nurse, or use a real typewriter.

Here’s the stipulation: because I am also an artist, I have a thing against using clip art or stock images from the Internet to illustrate my words. If you are familiar with my blog posts for Off the Charts you already know this.

So, not only did I learn to create, and present a Power Point slide show, I used jpegs from a series of paintings I made of mountains, illustrating the presentation from the perspective of my personal practice. For many, the word navigator connotes images of the ocean or GPS, but as a breast cancer survivor turned ONN, I see myself as a sherpa, someone who has climbed the mountain, familiar with its terrain and potential for treachery. I lead patients  up the mountain, summit, and then come back down. The paintings of mountains also suggest the barriers to care ONNs are tasked with removing for patients. The theme was woven into the closing remarks of the presentation.

Most of the paintings depict Mount Hood, the dominating peak and iconic symbol of Portland, Oregon, my home.

I gave the presentation with a sense of creative satisfaction in finding another way to merge art into my nursing practice.

 

 

 

 

Breast Cancer Issues: Physical Activity During Treatment

The following post is the second of a series resulting from preparations for a forthcoming breast cancer conference panel discussion on survivorship.

by jparadisi 2012

by jparadisi 2012

When I was diagnosed with breast cancer I was a pediatric intensive care nurse working twelve-hour shifts, a long-distance runner, practiced weight-training, and a gardener. After the diagnosis, these activities came to an abrupt halt. Surgical procedures meant no running for weeks at a time. Weight training was limited by restrictions. Chemotherapy meant avoiding infectious patients, let alone managing critically ill children with my chemo-brain. Gardening was okay, but only so long as I didn’t get cuts or wounds that could become infected due to a lowered WBC.

Surrendering an active lifestyle in exchange for the other side of the bed was not an easy adjustment, and I held out for as long as possible. During treatment I didn’t have the energy to participate in these activities to the same levels as before. I continued running after my first chemotherapy infusion until one day I completed 1 1/2 miles and then completely bonked. I had to walk back home that 1 1/2 miles with bone deep fatigue. Grudgingly, I gave up running while on chemo.

For some, physical activity is a go-to method of stress relief. For many cancer patients, when this tool is needed most, it is unavailable.  It requires developing new tools for managing stress.

It’s important for nurses and health care providers who are not physically active to understand that a lack of physical activity actually creates stress for patients who are. It’s one reason your adolescent and young adult patients often become sullen. Physical activity is part of their mind-body connection.

The median age of breast cancer diagnosis is 61, so It follows that many hospital-based exercise classes for breast cancer survivors are structured with the intent of increasing physical activity and function for older, sedentary survivors. While beneficial, these classes may not meet the needs of the physically active, regardless of their age. Breast cancer patients who beg to continue swimming, running, bicycling, and even skiing are not uncommon. Here’s some exercise tips for physically active breast cancer patients:

  • Review your level of physical activity with your medical oncologist and surgeon before resuming or starting an exercise program. Surgery remains the cornerstone treatment for breast cancer, and physical restrictions apply post-operatively to promote healing. Mastectomy, reconstruction, and lumpectomies require different periods of recuperation. Some chemotherapy regimens used to fight specific types of breast cancer have potential to affect the heart. Those with metastatic disease may have other restrictions. Forgoing your activity of choice is difficult, but it’s important to remember that taking the time to heal is an investment in overall wellness.
  • Consider alternative forms of exercise. Walking is commonly prescribed during treatment. Meditation labyrinths are a great way to get some exercise and practice mindfulness at the same time. Some hospitals, spiritual centers, and churches have them. Ask about stair climbing-I used a Stair Master (once cleared by my surgeon), and did not have the energy to run outdoors. Running machines are another option: If you get tired, you can stop without having to get back home.
  •  If you are medically cleared to use a gym make sure to bring antibacterial wipes to wipe down the machines before use, if they’re not provided: If you are receiving chemotherapy, you are more prone to infections from opportunistic germs. If you take a yoga class, (another commonly recommended activity for breast cancer patients) bring your own mat, and wear plastic flip-flops to avoid fungal infections from the studio floors.
  • Remember, physical fitness is not what you do in the short-term, it’s an accumulation of activity throughout a lifetime. Going through breast cancer treatment tests your body; it’s working hard. Support its healing through good nutrition and adequate rest.

Dreams: Helping The Patient Who Sees Things That Cannot be Studied

Her body stiffened with strong emotion as she shared a vivid dream she’d had after being diagnosed with a life-threatening disease.

Lung Ta (Windhorse) by jparadisi

Lung Ta (Windhorse) by jparadisi

She me told the dream with tears in her eyes. It brought to mind stories I heard as a child of Saints experiencing visions. Placing my hand on her shoulder was the only supportive gesture I could think of. I didn’t know the dream’s meaning, but I understood its importance.

I had vivid dreams during cancer treatment, a few even while awake during meditation. I recorded them in a journal, paying attention to how they made me feel: peaceful or apprehensive. I was fortunate to have a friend who believes in dreams. She listened to mine, helping me discover their personal messages.

Nursing is based on science. However, I’ve been a nurse long enough to know that science hasn’t found the answer to everything. Some patients, and nurses, see things that can not be studied objectively.

Dreams and visions are narrated with conviction by the alert and oriented, distinguishing them from feverish ramblings, opioid-induced illusions, or the hallucinations of hepatic failure. This personal mysticism commands respect. It does not usually find its way into the patient’s chart.

My patient needed someone to listen to, and validate, her dream. She did not know its meaning. Dream interpretation was not part of my nursing school curriculum (perhaps it should have been), but helping a patient in spiritual distress was.

As I listened, I felt that chilly pull on my gut, alerting me to truth. Maybe not my truth, but certainly my patient’s, who I did not know very well. How could I help her? I resorted to tools I learned from my friend, who helped me interpret my cancer dreams.

First, I asked, “How does the dream make you feel? Does it cause peace or fear?” Although her dream contained dark imagery, overall, it left her feeling hopeful. In dreams, death and dark images do not necessarily symbolize real death, but often represent a significant life change, such as a life-changing diagnoses.

Next, I emphasized that dreams are powerful, personal messages. Only my patient would understand the unique significance of the images she saw.

I asked, “What do the images mean to you?” She was able to describe her personal language of symbolism to me, and in doing so, explained her dream to both of us. I saw relaxation loosen the muscles of her face and body, as she felt the power of the dream take effect.

If you’re interested in learning more about dream interpretation, I suggest reading The Secret Language of Signs, by Denise Linn.

Do you find dreams to be an important part of your patients’ journeys? What do you do when patients present their dreams to you?

Alopecia and the Pirate

Note:  In honor of International Talk Like a Pirate Day, I have republished this post. 

As I write this post, some scientists are searching for ways to prevent male baldness through genetic manipulation. Others are conducting similar research to cure cancer. Is hair really as significant a part of our identity as we are sold to believe?

My hair began falling out the 14th day after the first chemotherapy infusion. In preparation, I bought a wig, styled and colored the same as my real hair. Like a feral animal, it perched on its stand, awaiting an opportunity.

When I saw the first ungodly huge handful of fallen hair I was too stunned to cry. Instead, I mumbled, “F***,” repeatedly, like a demented chicken.

It didn’t fall out all at once. Each morning for a week, I’d step out of the shower holding gobs of hair in my hands to prevent clogging the drain. After blow-drying what was left on my head, I’d take a pair of manicure scissors, like a naughty three-year-old, and try to even it out and disguise the bald patches. When I no longer could, a coworker’s husband shaved my head while she collected the locks, tying them into small bundles with blue satin ribbons.

After a time, I stopped wearing the wig. I preferred to cover my baldness with a red bandana, pirate style. Image

It was summertime, and I was at downtown Portland’s Pioneer Square, when a young man wearing a pirate’s black hat, white blouse with buckskin laces, black britches, and boots approached me. He clutched an authentic-looking sword. This was years before Johnny Depp made pirates sexy. Despite fatigue and chemo brain, I understood:

“Oh, no, this guy sees my bandana. Pirate guy thinks he’s found pirate girl.”

There was no place to run.

He spoke to me. “Ahoy! Me beauty, how art thee this fine afternoon?”

“I art fine, thanks,” I replied. “Why are you dressed like a pirate? Is that sword real?”

“Aye.”

He belonged to a club, of sorts, of people in Portland who dress like pirates and act out sword fights. I puzzled over what he wanted until he reached into his blouse and pulled up a goddess pendant dangling from a leather thong around his neck. He brought the goddess to his lips, kissed it, and then pointed to the carved turquoise goddess I had worn on a silver chain since my diagnosis.

“My fair Muse hails from Hungary, where she symbolized the female spirit of war and led her people to victory. I see you wear the Goddess yourself.”

Doffing his hat, he bowed before swaggering back into the crowd.

He had approached because of the necklace, not the bandana. He hadn’t noticed that I was bald — or had he? Did I just have an encounter with an eccentric or a very kind man dressed as a pirate offering encouragement?

He left me smiling. There is more to each of us than what we look like.

This post was originally published by TheONC.

Nurses & Doctors: Make Appreciation Reciprocal

artist: jparadisi

artist: jparadisi

Few life-threatening or terminal diseases present themselves in otherwise healthy, alert, and charming hosts the way cancer does.

From the get-go, oncologists are not only captain of the ship; they hoist life preservers in the form of treatment to patients drowning in waves of shock after a cancer diagnosis.

In my opinion, oncologists’ hearts closely resemble those of nurses. This is attributed to the fact that although oncologists do not spend the same quantity of time with patients as nurses do, the quality of the time they spend is intense. They often form relationships with patients over years. It’s common for an oncologist to know close members of their patient’s family, also like nurses.

During my last episode of possible (it wasn’t) recurrence, I experienced this truth.

My oncologist and I share a professional relationship. One of the reasons he’s my oncologist is because I know he’s good at what he does. My husband likes him, too. They share an easy communication, which is another reason for my choice. If/when cancer recurs, I know they will cooperate on my care, freeing me to be the patient, not the nurse. This arrangement brings me peace of mind.

Anyway, I had suspicious symptoms, which landed me face down in an MRI. My appointment to receive the MRI results was scheduled at end of a workday for my oncologist.

David accompanied me. Dr. My Choice entered the exam room holding the films, clipping them to the light box.

“I haven’t looked at these yet,” he explained. “I thought we could see them at the same time.”

It hit me in a flash: Dr. My Choice likes us too. He is about to find out if he will tell a nurse he enjoys working with, and her husband, whether or not her cancer has recurred.

Snap! What have I done to him?

Fortunately, the films revealed I am still cancer free. The look of relief on Dr. My Choice’s face nearly equaled David’s.

Oncologists, (doctors) have feelings, too. This knowledge affects the professional relationships of nursing practice in the following ways:

  • When questioning an order, assume the doctor has good intentions toward his or her patient, same as you.
  • Avoid framing questions to a doctor with your personal inferences, such as opinions of whether or not the physician is “good” or “bad.”
  • Consider that doctors suffer from work overload, and burn out, as do nurses.
  • Remember: Being part of a team is catching one another when we fall. No one is on top of his or her game every time.
  • Protect the Rock Star Doctor (every unit has one) by double-checking their orders the same as you do for any other physician. Don’t let them fall to earth because you were not diligent in providing a safety net for their patients.

Education is the tool of our trade. It is our demeanor, which makes us professionals.

Conversations About Dying: Is “Sick Lit” Bad for Teens?

My name is JParadisi, RN and I am a recovering TV medical drama addict.

I am one of those nurses with whom other people refuse to watch TV medical dramas, because I watch them as if I’m playing Jeopardy.

I shout out the answers, instruct the handsome actor-doctor that he must intubate now, and make diagnostic recommendations. It’s a sickness. Anyone unfortunate enough to watch with me chides, “It’s only a TV show!”

Drawing by jparadisi

Drawing by jparadisi

I don’t read books about cancer or illness for entertainment either, but John Green’s young adult novel, The Fault in Our Stars, is a story about living. Told in the first person by Hazel, a 16-year-old living with stage IV thyroid cancer making its home in her lungs since she was thirteen, the novel represents childhood cancer so true to life I will not add further commentary except to urge you to read it.

The book’s poetic title, The Fault of Our Stars, is a bon mot of Shakespeare’s famous line from Julius Caesar:

The fault, dear Brutus, is not in our stars, / But in ourselves, that we are underlings.

While researching this post, I was surprised to find an article criticizing The Fault of Our Stars of being an over-sensationalized addition to the writing genre dubbed teen “Sick Lit.”

 What’s Sick Lit, and why have I, a writer of health-related information, never heard of it?

Sick Lit refers to memoirs, novels, and nonfiction books about dying from, or surviving, disease, either physical or mental. Cancer is a hot topic in this genre — I have no idea why I’ve never heard of it.

The above article’s author complains:

It’s not just the fact that these books feature terminally ill teenagers that makes them so questionable — they’re also aimed at children as young as 12.

My question is: Are books about their peers dying of cancer harmful to teenage readers?

In my opinion, they are not. No matter how adults try to protect children from the harsh realities of life, we cannot.

Many children have parents, siblings, or classmates living with cancer or other terminal illnesses. By deeming books that realistically portray the challenges and social stigmas accompanying childhood cancer, is society protecting children, or avoiding its collective discomfort with the topic?

Do you think children should be exposed to stories of childhood cancer and terminal illness? In what ways do you think it’s harmful? Do you think this topic should be banned for children under certain ages? Why?

Nurses Can Offer Reassurance When Cancer Changes Relationship Roles

Many relationships thrive after cancer, but how?

painting by jparadisi

Self Portrait by jparadisi

I think they transcend.

In a way, a patient is lost to loved ones during cancer treatment. Roles within the relationship change. The big, powerful husband adored by his wife of many years is now too weak to get in or out of their car without assistance, let alone do his longtime chores around the house. The wife and mother who makes Martha Stewart look like an amateur has not only stopped preparing gourmet meals, but can’t tolerate the smell of cooking food either, forcing Dad to pick up deli stuff, or order pizza to feed their hungry children.

Everyone has to adjust when a family member has cancer. The roles have changed.

  • There’s a new chapter in the family medical history. The cancer patient is the unwilling author of a family cancer history. Genetic counseling is an option, but family members may not want to know the results. It depends on their comfort level with the sword of Damocles dangling above them.
  • Partners become caregivers. Suddenly, there are extra duties around the house. Some learn to help with ostomy appliances or continuous infusion pumps. It’s common to teach spouses to flush PICCs. I often assess my patient’s status by the level of distress expressed by the spouse.
  • There is an uninvited guest who never leaves: fear of recurrence. David and I married after my cancer treatment. It’s a cute story; maybe I’ll post it one day. A few years ago, my surveillance labs came back with abnormal liver function results. My doctor ordered an ultrasound. Watching the monitor while the tech swabbed my belly with a wand, I said to David, “Look, Honey, I’m not pregnant!” I laughed, the tech laughed, but I will never forget the look of pain in my husband’s eyes as he uncharacteristically admonished me, “This isn’t funny.” I felt guilty for his fear, for letting someone fall in love with me when the cancer could come back. It turned out, an antibiotic I had taken a few weeks before caused the elevated LFT results. There was no cancer, but our uninvited guest remains.

Nurses cannot make these things disappear for our patients. We can, however, be sensitive to their needs, and reassure that they’re on a well-traveled path. Remind them that the most important thing they can do to help themselves is to talk about the pressures they feel as the cancer patient, or as the partner with increased responsibilities. We can also encourage them to develop strategies against their common enemy as a couple. Finally, we can be prepared to provide information about community resources available to support them.

And hope for the best.

How do you help patients and their families adapt to changing roles during cancer treatment?