Psycho-Oncology and Palliative Care: Potential Contributions Jimmie C. Holland, M.D. Founding...
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Transcript of Psycho-Oncology and Palliative Care: Potential Contributions Jimmie C. Holland, M.D. Founding...
Psycho-Oncologyand Palliative Care:
Potential Contributions
Jimmie C. Holland, M.D.Founding President,
International Psycho-Oncology Society
Attending Psychiatrist, Psychiatry& Behavioral Sciences
Memorial Sloan-Kettering Cancer Center
PSYCHO-ONCOLOGY Definition
• Multidisciplinary subspecialty of oncology concerned with the emotional responses of patients at all stages of disease, their families and staff (psychosocial)
• The psychological, social and behavioral variables that influence cancer prevention, risk and survival (cancer control)
HISTORICAL BARRIERS – 1
Double Stigma
• Patients not told their diagnosis and psychological responses
could not be explored
• Mental disorders/illness long feared and stigmatized
HISTORICAL BARRIERS – 2
• Belief that subjective phenomena (pain, feelings) could not be quantitatively
measured
• Patient’s self-report was considered unreliable (only observer ratings reliable)
• Social science methods were not understood by basic scientists
Basic to Psycho-Oncology Research
• Developed and validated quantitative measures of subjective symptoms
• QOL Core and disease specific modules
• Pain • Fatigue
• Distress• Anxiety• Depression• Delirium
Barriers to Psych-Oncology Issues in Palliative Care
• Attitudes of medical staff that assume the “nonphysical” psychological domain as less
important
• Attitudes of patients and family: “Think I’m crazy”: embarrassed, angry by mental health consultation
• Attitudes may discourage integration of mental health member of palliative care team
• Absence of training of palliative care team in recognition, diagnosis and management of distress and absence of an algorithm when to refer to mental health
• Inadequate funding for mental health counselors as compared to medical
• Absence of minimum standards and accountability for psychological, social care and for meeting existential, spiritual needs
Barriers to Psych-Oncology Issues in Palliative Care
• Inadequate numbers of well-trained mental health professionals in psychosocial care
• Too few training programs
• Absence of oversight of staff in management of psychosocial/ psychiatric problems
Barriers to Psych-Oncology Issues in Palliative Care
• Physical symptoms (pain, fatigue)
• Psychological (fears, sadness)• Social (family, future)
• Spiritual – seeking a comforting philosophical, religious, or spiritual beliefs
• Existential – seeking meaning of life in the face of death
Advanced Cancer RequiresCoping With
EXISTENTIAL CRISES IN CANCER
DIAGNOSISOFCANCER
ADVANCINGDISEASE;
DNR; HOSPICE
RECURRENCEOF
DISEASE
COMPLETIONOF
TREATMENT DEATH
INITIALTREATMENT
N.E.D. TERMINALPALLIATIVETREATMENT
Adapted from McCormick & Conley, 1995
“I could die from
this.”
“I have survived --
will it Return?”
“I will likely die” -- depressed;
anxious
“I am dying.”
“We are not ourselves when nature, being oppressed, commands the mind to suffer with the body”
King Lear, Act II, Sc. IV, L 116-119
What to call this constellation of non physical aspects of severe illness?
“Suffering of the mind”
“Existential crisis”
“Human side”
Overlapping psychological and spiritual
domains: psychospiritual crisis
• Loss of meaning
• Loss of control (helpless)
• Need for connection to some larger whole, greater than self
J. Kass, 1996
Psychospiritual Crisis of ILLNESS
• A way of coping and feeling in control despite the uncertainty, treat of death, the
unknown, and loss
• A set of moral values
• Comforting rituals (prayer, mediation)• An existential perspective (meaning of life,
death, connection to greater whole)• Support (emotional and tangible) of those who
share similar beliefs
Spiritual and ReligiousBeliefs Provide
DISTRESS in Cancer
An unpleasant emotional experience of a psychological, social and/or spiritual nature which extends on a continuum from normal feelings of vulnerability, sadness and fears to disabling problems such as depression, anxiety, panic, social isolation and spiritual crisis.
Adapted, NCCN
Contributions to Care - 1
• Psychological interventions unique for palliative care
Meaning-centered therapies
Frankl Meaning-BasedBreitbart
Dignity-ConservingChochinov
Meaning-FolkmanHolland
• Help patient reconcile life goals and plans with constraints of illness and loss
• Use beliefs, values, prior strengths, to find a new and tolerable meaning of life in the face of death
Folkman-based Psychotherapy
Contributions to Care - 2
• Concern for family members
Identifying their concernsConflict, needs (distress levels are as
high as patients)
Evaluation of minor children-guidance in how to talk to them
Grief counseling for family
Contributions to Care - 3
• Education of staff and patients that seeking treatment for psychological problems is not a sign of weakness
• Advocate as a team member to psychosocial and “human” side of care
Treatment Guidelines for Mental Health Professionals
DSM-IV DiagnosesDementiaDeliriumMood disorder (depression)Adjustment disorder
(reactive anxiety/depression)Anxiety disorderSubstance abusePersonality disorder
Treatment Guidelines for Social Work
Practical Problemshousing, assistance
Psychosocial Problemsfamily conflictcommunicationculture/language
Treatment Guidelines for Pastoral Counseling
Death/afterlifeLoss of faith/meaningGriefIsolation from religious communityGuiltHopelessness
• NCCN Clinical Practice Guidelines for distress have been modified for end-of- life care – they should be tested in a clinical setting
Holland & Chertkov, 2001
IOM Improving Palliative-Care
Contributions to Care – Burnout
Mental health of Staff
• Physicians’ acknowledged feelings
(anger, frustration, depression) • Affect
Clinical decisionsBehavior with patientsQuality of careRisk of burnout
Meier et al, 2002
Common Burnout Symptoms
PSYCHOLOGICAL
Frustration
Irritability
Tense, sad feeling
Anger
Withdrawn; “Numb”
Detached emotionally
Cynical about work
PHYSICAL
Fatigue
Insomnia
Headaches
Back aches
Appetite change
GI disturbance
UK Study 476 Oncologists
Burnout
Emotional exhaustion 31%Low personal Accomplish 33%Diminished Empathy 23%
Psychiatric Disorder (GHI) 28%
Ramirez et al, BMJ, 1995
Research Directions - 1
• Pro inflammatory cytokines as cause for fatigue, poor concentration,
depression, anxiety
(↑ in pancreatic patients)
• Cytokine-induced
Sickness behavior in animals
• Several cancer-related symptoms
• Fatigue• Pain• Anxiety
• Depression• Cognitive loss• Weakness
Research Directions - 2
C. Cleeland, et al, Cancer, 2003, Working Group
Research Directions - 3
Research Directions - 4
• Genetic contributions to chemo-related cognitive deficit
APOE4 allele
• Fatigue (DYPD over expression)
“….the secret of the care of the patient is in caring for the patient.”
Peabody, JAMA
1926
IPOS Liaison to National Psycho-Oncology Societies
[email protected] www.apos-society.org
8th WORLD CONGRESS8th WORLD CONGRESSPSYCHO-ONCOLOGYPSYCHO-ONCOLOGY
"Multidisciplinary Psychosocial Oncology: Dialogue and Interaction"
18 - 21 October 2006Palazzo del Cinema
Venice, Italy
Details will continue to be posted on the conference website at
www.ipos2006.it