psycho-oncology and palliative care: potential contributions
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Psycho-Oncology and 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. - PowerPoint PPT PresentationTRANSCRIPT
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Psycho-Oncologyand Palliative Care:
Potential Contributions
Jimmie C. Holland, M.D.Founding President,
International Psycho-Oncology SocietyAttending Psychiatrist, Psychiatry& Behavioral Sciences
Memorial Sloan-Kettering Cancer Center
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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)
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HISTORICAL BARRIERS – 1
Double Stigma
• Patients not told their diagnosis and psychological responses
could not be explored
• Mental disorders/illness long feared and stigmatized
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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
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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
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Barriers to Psych-Oncology Issues in Palliative Care
• Attitudes of medical staff that assume the “nonphysical” psychological domain as lessimportant
• 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
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• 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
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• 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
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• 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
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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.”
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“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
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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
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• Loss of meaning
• Loss of control (helpless)
• Need for connection to some larger whole, greater than self
J. Kass, 1996
Psychospiritual Crisis of ILLNESS
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• 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
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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
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Contributions to Care - 1• Psychological interventions unique for
palliative careMeaning-centered therapies Frankl Meaning-Based
Breitbart Dignity-Conserving
Chochinov Meaning-Folkman
Holland
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• 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
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Contributions to Care - 2
• Concern for family members
Identifying their concerns Conflict, needs (distress levels are as high as patients)
Evaluation of minor children-guidance in how to talk to them
Grief counseling for family
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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
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Treatment Guidelines for Mental Health Professionals
DSM-IV DiagnosesDementiaDeliriumMood disorder (depression)Adjustment disorder
(reactive anxiety/depression)Anxiety disorderSubstance abusePersonality disorder
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Treatment Guidelines for Social Work
Practical Problemshousing, assistance
Psychosocial Problemsfamily conflictcommunicationculture/language
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Treatment Guidelines for Pastoral Counseling
Death/afterlifeLoss of faith/meaningGriefIsolation from religious communityGuiltHopelessness
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• NCCN Clinical Practice Guidelines for distress have been modified for end-of- life care – they should be tested in a clinical setting
Holland & Chertkov, 2001IOM Improving Palliative-Care
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Contributions to Care – BurnoutMental health of Staff
• Physicians’ acknowledged feelings
(anger, frustration, depression) • Affect
Clinical decisionsBehavior with patientsQuality of careRisk of burnout
Meier et al, 2002
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Common Burnout Symptoms
PSYCHOLOGICALFrustrationIrritabilityTense, sad feelingAngerWithdrawn; “Numb”Detached emotionallyCynical about work
PHYSICALFatigueInsomniaHeadachesBack achesAppetite changeGI disturbance
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UK Study 476 Oncologists
BurnoutEmotional exhaustion 31%Low personal Accomplish 33%Diminished Empathy 23%
Psychiatric Disorder (GHI) 28%
Ramirez et al, BMJ, 1995
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Research Directions - 1
• Pro inflammatory cytokines as cause for fatigue, poor concentration,
depression, anxiety(↑ in pancreatic patients)
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• Cytokine-induced Sickness behavior in animals
• Several cancer-related symptoms
• Fatigue• Pain• Anxiety
• Depression• Cognitive loss• Weakness
Research Directions - 2
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C. Cleeland, et al, Cancer, 2003, Working Group
Research Directions - 3
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Research Directions - 4
• Genetic contributions to chemo-related cognitive deficit
APOE4 allele
• Fatigue (DYPD over expression)
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“….the secret of the care of the patient is in caring for the patient.”
Peabody, JAMA 1926
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8th WORLD CONGRESS8th WORLD CONGRESSPSYCHO-ONCOLOGYPSYCHO-ONCOLOGY
"Multidisciplinary Psychosocial Oncology: Dialogue and Interaction"
18 - 21 October 2006Palazzo del Cinema
Venice, ItalyDetails will continue to be posted on the conference website at
www.ipos2006.it