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Psychosocial Impact of Breast Cancer Hoping and Coping VideoTranscript

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Professional Oncology Education Psychosocial Impact of Breast Cancer Hoping and Coping Time: 49:03

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Lakshmi Rai Naik, MA, LCSW Assistant Director Department of Social Work The University of Texas MD Anderson Cancer Center

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Psychosocial Impact of Breast Psychosocial Impact of Breast Psychosocial Impact of Breast Psychosocial Impact of Breast

Cancer Cancer Cancer Cancer ---- Hoping and CopingHoping and CopingHoping and CopingHoping and Coping

Psychosocial Impact Psychosocial Impact

of Breast Cancerof Breast Cancer

Hoping and CopingHoping and Coping

Lakshmi Rai Naik, MA, LCSW

Assistant Director

Department of Social Work

Hi, I am Lakshmi Naik, an Assistant Director in the

Department of Social Work at MD Anderson Cancer

Center. Today, I will be speaking about the psychosocial

impact of breast cancer, hoping and coping.

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ObjectivesObjectivesObjectivesObjectives

• To understand the psychosocial impact of breast cancer

• To more effectively meet the emotional and

relationship needs of patients with breast cancer by

integrating psychosocial assessments and interventions

as part of the treatment and follow-up process

• To gain a better understanding about the possible

resources among the various professionals and staff

• To increase awareness among medical teams of

the process for assessment, tools used and how

to direct referrals

The objectives of this presentation are: to first understand

the psychosocial impact of breast cancer; to more

effectively meet the emotional and relationship needs of

patients with breast cancer by integrating psychosocial

assessments and interventions as part of the treatment and

follow-up process; to gain a better understanding about

the possible resources among various professionals and

staff; and to increase awareness amongst medical teams

of the process for assessment, some of the tools we use,

and how to direct referrals.

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Cancer Cancer Cancer Cancer ---- Hoping and CopingHoping and CopingHoping and CopingHoping and CopingMD Anderson Cancer Center Goals and MD Anderson Cancer Center Goals and MD Anderson Cancer Center Goals and MD Anderson Cancer Center Goals and Strategies for Future Achievement Strategies for Future Achievement Strategies for Future Achievement Strategies for Future Achievement 2005200520052005----2010201020102010

• Strategy 1.4: “We will continue to enhance the patient

experience by providing counseling, compassion, and

hope in a supportive environment”

• Vision: “Every patient’s emotional needs are assessed

and identified providing referrals to the appropriate

psychosocial service throughout the entire spectrum of

care at MD Anderson Cancer Center”

According to the MD Anderson Strategic Vision,

Strategy 1.4 states, “We will continue to enhance the

patient experience by providing counseling, compassion

and hope in a supportive environment” by meeting “every

patient’s emotional needs that will be assessed and

identified, providing referrals to the appropriate

psychosocial services throughout the entire spectrum of

care at MD Anderson Cancer Center.”

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“I will remember that I do not treat a fever chart,

a cancerous growth, but a sick human being, whose

illness may affect the person’s family and economic

stability. My responsibility includes these related

problems, if I am to care adequately for the sick.”

A modern Hippocratic Oath, written by Louis Lasagna, M.D., 1964

Dr. Louis Lasagna in 1964 stated, “I will remember that I

do not treat a fever chart, a cancerous growth, but a sick

human being, whose illness may affect the patient’s

family and economic stability. My responsibility

includes these related problems, if I am to care

adequately for the sick.”

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TreatingTreatingTreatingTreating the Whole Patientthe Whole Patientthe Whole Patientthe Whole Patient

Emotional

Function

Physical

Health

Spirituality

PsychosocialRefers to the social, psychological,

emotional, spiritual, quality of life and

functional aspects of person’s life

And so our goal is to look at the cancer patient in relation

with the patient’s environment; treating the whole

patient’s physical health, spiritual health, emotional

health, psychological functioning in the cultural and

social context of his life.

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“Psychosocial health services are psychological and

social services and interventions that enable patients,

their families, and health care providers to optimize

biomedical health care and to manage the

psychological/behavioral and social aspects of illness

and its consequences so as to promote better health.”

IOM Brief Report 2008. Cancer care for the whole patient: Meeting psychosocial health needs.

Definition of Psychosocial Health ServicesDefinition of Psychosocial Health ServicesDefinition of Psychosocial Health ServicesDefinition of Psychosocial Health Services

So, what do we mean and how do we define psychosocial

health services? The Institute of Medicine of the United

States brought out a report in 2008 titled: Cancer Care for

the Whole Patient: Meeting Psychosocial Health Needs,

where they say, “Psychosocial health services are

psychological and social services and interventions that

enable patients, their families and healthcare providers to

optimize biomedical health care and to manage the

psychological, behavioral and social aspects of illness

and consequences so as to promote better health.”

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The Challenge and Opportunity The Challenge and Opportunity The Challenge and Opportunity The Challenge and Opportunity

• To understand that psychosocial barriers and

emotional health of patients and their family

members are as crucial as their medical

treatment in the cancer journey

So, what is the challenge and opportunity? Our

challenge, basic, is to understand that psychosocial

barriers and emotional health of patients and their family

members are as crucial as their medical treatment in the

cancer journey. And so, one cannot happen without the

other.

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Meeting the ChallengeMeeting the ChallengeMeeting the ChallengeMeeting the Challenge

• Provide a culture of compassion in which patients’ emotional

concerns related to cancer treatment are acknowledged and

supported by MD Anderson faculty and staff in alignment with

various initiatives like: The Psychosocial Council Initiative, The

Relationship Centered Care Model, The Customer Service

Initiative, The Culture of Caring Initiative, The Cancer

Survivorship Initiative

• Increase knowledge about the various professional

psychosocial resources available to support patients and

their family members within MD Anderson

• Provide timely referrals to psychosocial professionals

so that patients and family members may access appropriate

support quickly

How do we meet this challenge? We meet this challenge

by providing a culture of compassion in which every

patient’s emotional concerns related to treatment are

acknowledged and supported by everyone in the

institution. We have started several initiatives to assist

with this: The Psychosocial Council, The Relationship

Centered Care Model, The Customer Service Initiative,

The Culture of Caring, and The Cancer Survivorship

Initiative. To also increase the knowledge about various

professional psychosocial resources within the institution;

a lot of times there are a lot services that happen within

an institution, but professionals, the physicians, the

nurses, the medical teams, are not always aware of these

supportive services and how patients can be connected to

them. Providing timely referrals to these psychosocial

professionals, so an oncologist is looking at a patient,

looking at the disease status, looking at the chemotherapy

to be started, the patient is in great pain, the patient has a

lot of fatigue, has nausea, has vomiting. A lot of these

problems may be addressed right away, but the patient’s

other problems, which may include emotional pain, the

fear, the anxiety, the panic, the family caregiver issues,

the financial, the social, and the cultural context, are not

always specifically addressed.

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Framework for Care Framework for Care Framework for Care Framework for Care

• Communication

• Education

• Research

• Identify

• Link

• Support

• Coordinate

• Follow up

• Staffing

• Response

• Delivery

And so, the framework of our care for addressing the psychosocial aspects of a patient’s care are, basically, to identify, to assess: what are the distress points and levels of concerns for these patients? How do we link these patients with services? How do we support them? How do we coordinate this? And how do we follow? Most essential elements, communication, education, and research. And more importantly, we must be able to match these with adequate staffing, immediate response, and effective delivery.

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Process Framework Process Framework Process Framework Process Framework

Efficacy defined by

the balance between:

Need Response

Service Delivery

Expectation Experience

• Need

• Service

• Expectation

High Quality Care

• Response

• Delivery

• Experience

This process framework must be so well synchronized to bring out the most effective outcomes. This efficacy of balance between need and response; between service and delivery; expectation and experience, is what will define the quality of our care to our cancer patients.

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Continuum of CareContinuum of CareContinuum of CareContinuum of Care

Psychosocial care of cancer patients should be an integral

part of their medical care and available at all stages of their

diagnosis, treatment and survivorship and must occur in a seamless continuous manner.

• New patient diagnosed

• Treatment

• Remission

• Recurrence

• Progressive

• Advanced disease

The continuum of care is very long with cancer patients and their treatment. From the point a patient is diagnosed to the patient’s treatments, or when a patient goes into remission, comes back with remission sometimes, the disease gets progressive or if the patient is in the end stages of disease. At each stage, the psychosocial aspect of the patient’s care must be a part of their medical care for us to have the most effective outcomes.

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Walk the TalkWalk the TalkWalk the TalkWalk the Talk

We need to walk the talk and we know that each and

every stage has fear, anxiety, anger. There are financial

issues. There are social issues. There are relationship

issues. There are caregiver fatigue issues, caregiver

burden issues. There is physical pain. There is emotional

pain. And not one stage is immune to this fear and

anxiety. At each point, we have different levels of

distress.

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So Why ? So Why ? So Why ? So Why ?

• Frequent crisis intervention

• Lower compliance

• Treatment delays

• Poorer outcomes

• Increased staff time

• Higher costs

• Less able to use resources

• Poorer quality of life

Psychosocial Barriers Lead to:

So, why are we so interested in looking at the

psychosocial impact of cancer on breast cancer patients?

Because we know that barriers lead to frequent crises.

There is panic in the system. There is panic in the

patient’s family. There is panic with the patient’s psyche.

There is lower compliance. The patient does not want to

go for treatment because he is afraid of going through an

MRI procedure. He says, “I would rather die than go

through an MRI”. There are treatment dealings because

there has not been sufficient communication. Or the

patient has not understood, or the patient does not have

the means to get to that test or treatment. This leads to

poorer outcomes, increased staff time, higher costs to the

system. The patients are less able to use resources and

there is poorer quality of life.

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Cancer Cancer Cancer Cancer •••• Psychosocial Functioning Psychosocial Functioning Psychosocial Functioning Psychosocial Functioning •••• Quality of LifeQuality of LifeQuality of LifeQuality of Life

Cancer patients with serious depression are more likely:

•To be non-compliant with cancer therapy, more likely to

have cancer treatments delayed or reduced

•To eat and sleep less and have poor self-care

•To be less vigilant about disease symptoms and less

able to use proactively those resources that might bring

health improvements

And so, for us, it is so important to know that cancer patients with different levels of emotional distress will show symptoms and behavior problems that impact their quality of life and their psychosocial function. They eat less, they sleep less, they are noncompliant and they are less vigilant about their disease systems.

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. (,� '7�3',6 وأd�$% �L��k &J أ/24Y�' �rوه2

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DepressionDepressionDepressionDepression

• Patients with compromised immune systems due

to depression have been shown to have higher

incidence rates of cancerFord S et al. Br J Cancer 1994 70(4):767, Holland JC and Rowland J, Handbook of Psycho-

oncology, New York, Oxford University Press, 1989, Brewin C et al. Psych. Med. 1998 28(1): 219

• U.S. National Cancer Institute estimates that 25%

of cancer patients experience major depression

• “Depression and anxiety are highly under-diagnosed

in cancer patients”

Patients with compromised immune systems due to depression have been shown to have higher incidence rates of cancer. And this we know from a study by Jimmie Holland and Rowland in 1989. U.S. National Cancer Institute estimates that 25% of cancer patients experience major depression. Now this is a pretty common statistic and we do know that depression and anxiety are highly underdiagnosed in cancer patients.

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ر ا�?�-�V��O .



Impact on Breast CanceImpact on Breast CanceImpact on Breast CanceImpact on Breast Cancerrrr

• In a study by Spiegle et al., 86 patients with metastatic breast cancer were randomized to receive either routine oncologic care, alone, or routine oncologic care plus one year of weekly supportive group therapy and self hypnosis

• Survival from the time of randomization was significantly higher in the intervention group (36.6 months compared to 18.9 months)

• A number of studies also draw attention to the high levels of distress beyond the period of initial diagnosis

Ganz PA et al. Cancer 1992 69(7):1729

In a study by Spiegle et al., on 86 patients with metastatic breast cancer who were randomized to receive either routine oncology care, by itself, or routine oncology care with attendance to support groups on a weekly basis for 12 months. The survival time of randomization was significantly higher in the intervention group by almost 100%. That is phenomenal. A number of studies also draw attention to the high levels of distress beyond the period of initial diagnosis.

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ة �� ,�*EL؛{�4ا 12أ � ا�!,�ة -� ا�5,,J S3� ء�VEة ا� ' o/آ�*H5رب ا��V% E��O &> . -� ا��B 100اB, أ�O S3?�,� -� '$�*� ا��

د '6 ا� را�Lت أ+^� ا�/�d�E إ�S و�*د ��oآ�� . وهeا {�ء 'eه&�5 -��ة ا��IH,. ا�و��O S�k ،ة Hت ��, '6 ا��+*��' .

10



• Goldberg et al. found high levels of anxiety and depression

in approximately 25% of breast cancer patients at 12 months

following initial diagnosis

• There is evidence that this level can persist for up to two years

or more after diagnosis. Levels of depression and anxiety can

also be higher in those patients with advanced disease, with

pain being an important contributory factor

• Pain and depression impact each other closely and

management of one without the other will not be most effectiveSpecial Section: Cancer, 568 Current Science, Vol. 81, No. 5, 10 September 2001

Impact on Breast CanceImpact on Breast CanceImpact on Breast CanceImpact on Breast Cancerrrr (continued)(continued)(continued)(continued)

Goldberg JA et al. EurJ Surg Oncol. 1992 18(4):327

Ganz PA et al. Cancer 1992 69(7):1729 ; Maunsell E et al. Cancer 1992 70(1):120

And we know that, again, at least 25% of patients feel these symptoms even 12 months after initial diagnosis. And we know that this can extend up to 2 years or even more depending on the traumatic stress disorder that this diagnosis and treatment has imposed on the cancer patients. Again, pain and depression impact each other closely and management of one without the other will not be most effective.

،Gو/!6 /�5ف ذ� ، ,/��ا�eي -� ا��B '6 ا��SY 25ه��ك '�ة 5 '�ور O S�k اض��ا G3�O �5ونH+12 و��ا .,IHا�� 5O �4ا} .

5� �� ى ا��pYاب E% 6 أو أآ��,'�� Sإ� ��% J ة��آ�� /235 أن G3% ا�� ا��%g �6 ا�= ' ا��ذ�G ا��IH,. وا�h5ج � ى '��4EE�+� SY ا�

�� آ& '6 ا��2 وا�آ��vب �5O ��4^5O S3^و. ��ناZ+ ،ة أ<�ى�'� ه�� دون ا�<�kأ N' &'�5��O ,��5- S=Jأ \V!�% 6و� ،\,� . HO?& و



Breast Cancer Incidence Breast Cancer Incidence Breast Cancer Incidence Breast Cancer Incidence

• As of 2008, there are about 2.5 million women in

the United States who have survived breast cancer

• Breast cancer incidence in women in the United

States is 1 in 8 (about 13%)

• About 40,170 women in the United States were

expected to die in 2009 from breast cancer, though

death rates have been decreasing since 1990. These

decreases are thought to be the result of treatment

advances, earlier detection through screening, and

increased awareness

As of 2008, there are about 2.5 million women in the United States who have survived breast cancer. And 1 in 8, about 13%, have breast cancer in the United States. About 40,000 women in the United States were expected to die in 2009 from breast cancer, although the death rates have decreased considerably since 1990. These decreases are thought to be the result of treatment advances, earlier detection through screening and increased awareness.

'3,*ن ا'�أة -� ا�*�+�ت 2.5، آ�ن ه��ك '� +�Vب '6 2008وS�k ��م ة 'O 6,6 آ& ه��كو. /$��L 6' oن ا�� يkأي '� /��ء 8ا'�أة وا ،

. -� ا��O O�=' ، Bن ا�� ي -� ا�*�+�ت ا��! ة �V+13ب '6 2009أ�` ا'�أة -� ا�*�+�ت ا��! ة -� ��م 40وآ�ن '�*5J� و-�ة

UE�O ،ي ��ض '5 �ت ا�*-�ة وذ��L Gن ا��I/ا��(2 '6 ا S3��Yت ر��O آ�/O1990 . o=*رة آE,�ة '�e ��م I/ا� G3% أن V�5+و

�^& ا<��Eرات ا��!�ي O �?Eف ا��Hج، وا�آ�h5م -� ا� V�3� $,�/ .وز+�دة ا�*��

11



Emotional PainEmotional PainEmotional PainEmotional Pain

• The intensity and duration of a patient’s “emotional”discomfort or pain can be sometimes “more crippling”

than the disease itself

• Patients/families have multiple stressors at different stages of their disease, the intensity of which can

change dramatically at different points in the journey

• Emotional comfort is a vital piece of the treatment and “significantly enhances a patient’s overall care”

And again, when we talk about awareness, we want to say awareness amongst the patients, the families, the medical staff, the physicians, the nurses, the social workers, the case managers, the business center people, patient advocates. All of these people being able to work as equal partners in the single goal of providing the most optimum quality of life for our patients. The intensity and duration of a patient’s emotional discomfort of pain can be sometimes more crippling than the disease itself. I have had patients who have felt this pain, this emotional pain that does not allow them to think clearly; does not allow them to want to even go through this treatment anymore even though we have a highly optimistic view of a cure of treatment for their disease. And patients will sometimes say, “Forget it; I do not want to go through this.” And that comes from a sense of deep emotional pain, which has crippled them and we need to do something about it as soon as possible. Patients and families have multiple stressors at different stages of their disease. The intensity can change dramatically at different points in the journey depending on what triggers this patient’s state of mind, and fear or anxiety. There are patients that are terrified by MRI images, patients that are terrified by just seeing the prick of a needle or looking at bandages or smells even. So, emotional comfort is a vital, vital piece of the treatment and significantly enhances a patient’s overall care and also the family’s overall care.

ثو'�ة أ<�ى، !�/ �' �5�� 6�G�eO ا�*�� / ، SYى ا�� ا�*�� وا�2J�p ا��Ep وا��Eء وا��Yت وا�<=�B,,6 ا��,,6 و' +�ي SYق ا��*Vk 6� 6,5-ا . ا�!��ت وا��5'6,3 -� '�اآ7 ا��ل وا��

م J S3� آ�ء�Hا��5& آ S3� 6+در�J �5,�� ء�Zأن +?*ن ه U$+و ه* %*-,� /*�, k,�ة '��Y�� S3/�ا��واة '6 kف وا . أ�& %!V,\ ه

ة ا��VH ا�*� ا/, ا�� +�5/,�4 ا��+l '6 ا��2 وH� 6?�+�4 أن �و% �j%أآ�� '6 ا��ض ذا d 5V% .O �' V�� ،2��ا Gذ� &��O �5وا} SY�'

�?,� Y*O*ح؛ ��O 24� ��+ � يeا/� ا� 24 � +�,� � أ�2إ/j ذ�G ا��2 ا�*� 24%�r/ 6' 2)ا�� S3� جh5ا� �- �' J �^ا�� - E)ا�� S�kة ا� + H

�^& ا�h5ج ا�eي +�O� j/*V3ا��ؤل O ء��H�� جh524Y�' . ل*V+ �' �/�,kوأSYا��" :Gذ� �- �' J �^ا�� - U)؛ � أرG,3� �. " Sإ� Gذ� N��+و

v,} &5�� أن /,3� U$+243، وE?+ \,�� /ا � %$�d ذ�G -� ا�5H*ر 2�qO و�6?�' oJب و�Jو. أ _i^ت ا��EE�' 6' + +*ا�j ا��SY وأ�Lه2 ا�5

3� ��3ض�Iا�� &kى ا��ا ' S3� �� %�4 . ا�} �,i�% و+�?6 أن ى /�Vط ر3k ا��ض' S3� ة�,Eرة آ*=O ا��3�I� ، Gوذ� UE�3� �5E%

3\ � +jا�?�'6 وراء %G3% g,�q ا�!�� ا�eه�, �l+��3، أو ا�I*ف، أو Vا� . 6,/��O �+*=6 إ��اء ا��' U��O �5ونH+ SYا�� l5E- Sإ� �r��,��، أو +�I-*ن '6 '$�د رؤ+ 6L ا�Osة، أو ا�iا��

�Bا��وا S�k أو ، pOر�ا، -و. اe� نT وري، و�7ء�Y �'أ ,��ا��اk ا� ' V�4 أن %75ز آ�,�ا ا��+ ا��5' ا��/q} 6'ج، وh5وري '6 ا��Y

. l+��3، وآG�e ا��+ ا��L�� '�5ة�

12


Cancer Cancer Cancer Cancer ---- Hoping and CopingHoping and CopingHoping and CopingHoping and CopingHoping and Coping Hoping and Coping Hoping and Coping Hoping and Coping ---- A Dynamic Paradigm A Dynamic Paradigm A Dynamic Paradigm A Dynamic Paradigm Cure Cure Cure Cure •••• Respect Respect Respect Respect •••• Compassion Compassion Compassion Compassion •••• TimeTimeTimeTime

• Medical treatment/physical care

• Emotional comfort

• Communication both with patient and providers, accurate

and timely information, education about

care plan, resources and long term implications

• Comprehensive plan of care

• Emotional support and alleviation of fears and anxiety

• Transition and continuity of care

• Coordination of care and integration of services

within an institutional setting

So, while we are hoping and coping, what are we doing? What is the paradigm for helping patients hope and cope while they are on this journey? Their emotional comfort, the communication to the patient between the providers. So we have a physician who has seen a patient; he has done his notes on the chart, he has talked to the patient briefly, given some details, but the patient has not completely absorbed this. Patient is still very upset, but afraid to talk to the physician. He has gone home and now he has become suicidal. What do we do in situations like this? What is the barrier that came up here? How do we make sure that we have provided the patient with the best possible information, in the best possible way, in a compassionate understanding way, where the patient is able to cope with that information? And if not at that time, what other kind of support system am I building for him to stand up strong? To be able to provide a comprehensive plan of care, sometimes we give them plans of care in bits and pieces. The next step is you go and you get a bone marrow aspiration. So, he goes to bone marrow aspiration. The next step is you come in and get a CT scan. These are bits and pieces of information that don’t not bode well, or help the patient to understand the complete plan. If a patient knows what the complete plan is, it is much easier for the patient to emotionally prepare himself for the next step; transition and continuity of care and the coordination of care and integration of services within an institutional setting.

ا�'& و%$�وز ا��!� ، '� ا�eي س-� ا�*oJ ا�eي /V*م -,�iO jووا�ن، ة ا��S3� SY و/V*م jO؟ ��' �- ' Iه,2 ا��r*' ا��' �'

��ء ر3k ا�h5ج؟ ا��اk ا�*� ا/, ، �(�س ا�'& و%$�وز ا��!� أ l+ا�� N' &bتوا��*ا�' Iا� �' V' 6,O .- 6 '�+^�؛+�� U,E� ��'�'q

ن 'j%�rkh -� ا�$ ول، و%?N' 23 ا��+�J�O l^�ب، وأ�l5O Sp ودو�-��+l '� زال . ا��b,&، و�?6 ا��+U�*��+ 2� l ذ�HO G?& آ�'&

U,Epا� Sث إ� ��7$�، و�?�SHI+ j ا��!' . o!Ebوأ ،j�7�' Sد إ��'� ذ�G ا�B�5\ ا�eي و��ذا /�5& -� '*اJ` آde4؟ -. � +j ',*ل ا/�!�ر+

5& ��qآ '6 أ/�� وه��؟ �4f ه�� '�ذا /J ��3bا�إأو S &^-أ l+�� ، �?�' V+�� &^-qO ، ��4 رk ، �,k,� وا��35*'�ت ا��?�' V+�pO

+��?6 ا��+l '6 %$�وز ا��!� 'h> 6ل G3% ا��35*'�ت؟ وإذا �2 +?6 �- ��?�' Gاذ�eه ��- ،oJ*ة ه� ا� ا�/*اع ا�<�ى '6 '�r*'�ت ا��/

� أJا�� 4' jة؟ و�*VO �� ?� +��N,p أن +=��?� ،�/�,k6 '6 وأ?��/ �?� +��3� 3'�} p> 2+ V%، �/ l+ا�� v,H- �v,} +ا�� _pIO .

��V ا��r5م و� _�). /�Iع ا�2r5(ا�pI*ة ا��, ه� أن %eه��s Uاء {��ءO2 وr5ع ا��I�� _�ه� %�4,3ا�pI*ة ا�� و. ��s j�*�+ ،j,3اء {

�5pV' �+*=% اء��s ق . ا�!^*ر�� ر +�� و'�J 6� رة�E� *ا هeوه%IO �HE,�، أو %�� ا��+S3� l -24 ا�pI ا�� ا��35*'�ت '6

4& � ا ,-Tذا أqO .kآ��43L�ا�?�'3 ، -�,?*ن '6 ا pI��O ��3� l+ا�� _5 اد و� ا/,� �pI3*ة ا��, ؛ ا��p> 6,O &V*ات ا��Lا� j,3� +�

�LZت دا<& '!,_ ا��' Iا��+ و%?�'& ا� \,�� . وا��Lار+��4 و%

13



Coping with Coping with Coping with Coping with

• Pain, swelling, body changes

• Feeling overwhelmed

• Anxious

• Fearful

• Relationships

• Life changes

• Getting back to “normal”

How do people really cope ?

�I just can’t take this constant stress anymore not knowing

what is going to happen.

�I am going to shoot that doctor. He told me I was going to die!

�I am going to beat this. I am NOT going to die.

So the coordination outside of the institution is different

than the coordination within the institution. Has the

physician called the PA? Has the physician called the

social worker? Has the PA talked with the pharmacist?

Has the nurse spoken with the nutritionist? This is

coordination of care where everybody is looking at every

aspect of the patient’s care. The pain, the feeling

overwhelmed, anxiety, fear, life changes and getting back

to normal. How do people really cope? “I just cannot

take this constant stress anymore not knowing what is

going to happen”. There is this constant sense of dread,

so how do I stop this dread for my patient? “I am going

to shoot that doctor, he told me I was going to die”. Now

what brings about a response like this? When a physician

has with all good intentions provided the patient with the

most correct information as a scientist, and still faces a

response that can be as violent and aggressive as this.

The reason is that we did not quite understand or gauge

the patient’s emotional state at that point. And to be able

to break that piece of news, or present that piece of news

in a different manner, is the skill we need to pick up. “I

am going to beat this; I am not going to die”. So, we

have a lot of patients who want to fight, who want to beat

it, who are hopeful that they are going to live forever.

� O�6 6[ داC$P� إذا�� X$ �� &i�رج ا��P .� KG[ا� :W3ا :C�؟ و� ا�]GK؟ �� ه: �23ث وه: اW3: ا�]G� K�WP.��V ا��

ه: x-�23 ا��h� �Y أWP��V ا� j?��؟ و�� ا�]Gh� K ا�W��؟ K�[ � �6O ا��؛ F�� l6� oh ا.��اد �� آ�� %ا6>�ه?ا ا�?ي

Z��$� ��ا� ��ت j3�اوا��%ف وا��$O وا��<%ر ��C وا.��، . ا��>G[ة ا��ا�2 Sة وا�<%دة إ��ا�2 . S$آX �<�: ا�6�س �� ا��2��

� ��660 23�: ا�� / ذ�� ا�jH| ا��56 ا�� "93�وز ا��62؟ -�� w<%ر �� ه�G، و" .�� ا�%xJ ا�?ي � أ$� �[ �� ا�?ي &�2ث

&J4%م "�H؟ �� ا�?ي ��660 �$[ ��M�ف ذ�� ا��<%ر ��ه�G ��ى ��$S و�w ا��%ت �6�� أ�GP؛ �� أKG[ذ�� ا� S$ ".�m# ق ا�6�ر

KG[ا� ]� ا�?ي ��ود xJ%ا؟ �� ا�?Cوراء رد �<: آ KGا�� ن، �vوا�[ �%ا�[ رد m� ،��>ت آ��%$>� /� ]�� }U4� �$��آ �� /�2� Z��ا�

�C�6� أو J�&6� �$2�� وا��KG وراء ذ�� ه% �م. �<: 65� أو �وا�� آC?ا�$F��3$� ا� �� Z��$� ��2 �ج إ�C� �$>3 S�رة �V�93 3$� و�2/ . ا�%��ا��5$ �� [� �CY�$S ه?ا؛ و�/ أ�%ت. "ا.GP�ر، أو �W �4& ."

W�ر ه6� ��6� و�ا�A0� �/ ا��SY ا��ا>G/ �� 2�ر�� ا��ض، وا� ،]$/$V�5 .�� ا�<n �~�� ا��

14



• How do I tell my daughter I’m sick?

• Where can I talk to other cancer patients

about treatment?

• Are the changes in my sex drive normal?

• What if I can’t afford the expenses?

• What things should I tell my family?

How do we manage this expectation? How do we take them along on the continuum from the best to the worst, and from the worst to the best? Patients have questions all the time. “How do I tell my daughter I am sick?” “Where can I talk to other cancer patients about treatment?” “Are the changes in my sex drive normal?” Now how many patients would talk to you about this on a daily basis unless you really ask them? And sometimes, even if you ask them, they are not going to tell you. So, what kind of skills do we need to get an understanding for some of these issues and are these issues important? Absolutely, because that impacts the patient’s quality of life. “What if I cannot afford these expenses?” “What things should I tell my family?”

�� أن /e>qهS3� 2 �*ل �� ا��N' &'�5 ذ�G ا��*NJ؟ آ,` +�?�آ,` +�? 24+ � SY-^&؟ ا��ا Sأ إ�*L�أ، و'6 ا*L�ا S-^& إ��ا��3�3 '6 ا

3vLأ ��B؟. "دا�Y��O ��Oا �E>qL `,آ" " Sث إ� �� ا��!�أ+6 +�?ه& ا��i,�ات ا�� %! ث -� " "'�SY ا��ن ا�<�+qHO 6ن ا�h5ج؟

آ2 '�+^� +�?6 أن +�! ث إ�,G -� هde ا�'� " (��E ا�$��, �E,5, ؟ر *� S�k ،ن�,k�ا l5O �-؟ وNJا�*ا �- &Bا�� o/أ o�آ& +*م، إ� إذا آ

أ/*اع ا��4رات ا�� /!��b*3� �4*ل إ�S ه� �� -. �EI+ 63- ،24��qLوك5% -24 أ-^& �G3% l5E ا��B&، وه& ��Z% �4/� ،NEp��O �4 ؟' S3�

l+ة ا��,k ,�*/" .{,�ء " "'�ذا �* �2 أ%�?6 '6 %!�& ا��?��,`؟�ا �'%�L�4,3 أ� N3أن أ� �iE� " ؟�ا�� +



• How do I make sure I won’t be kept alive by a machine?

• Am I supposed to feel sad all that time?

• Why do my husband and I fight so much now?

• What if someone is abusing me?

• What does hospice mean?

• What if I lose my job?

“How can I tell my family?” “I do not want my wife going crazy and jumping off the roof because I have this diagnosis because that is not going to help.” “How can I manage this?” “How do I make sure I will not be kept alive by a machine?” “Am I supposed to feel sad all the time?” “Why do my husband and I fight so much?” “Our relationships have changed and some things have gotten worse.” What if someone is abusing? “What does hospice mean?” “I do not have anything like hospice in my country or in the city where I live.” “Is that another hospital?” “Is that another service?” “What if I lose my job?”

�7 '6 ا��p أن � أر+ أن +6$ ��*ن زو�� و" "آ,` أ<�E أ�L%�؟"V% ي /�UE�O-�5 ذ�G ا��ض، $+ 6� G�e". "؟Gذ� N' &'�5%آ,` " "آ,` أ

ا�!,�ة O*اpL ~� ؟,J S3� �B�VO6 +�2 إ� j/أ ه& '6 " "�� أن أ%qآ�� *ال ا�*oJ؟+7k SVOض أن أ��" ؟��ذا أ%��H أ/� وزو�� آ�,�ا" "ا��

�� و�bرت l5O ا�'*ر أL*أ"�Jh� ت�,i% V� ". kء أ�Lذا �* أ�'3 ي أو " "'� '5�S دار ر��+ ا�!��ت ا��q<�ة"'�5'��3؟ EO �*+ �

O�+ ور ر��+ ا�!��ت ا��q<�ة�� &��S ~<�أه� ". "� {�ء '��H��'؟ " ' ؟"I؟" "أه� /*ع ~<� '6 ا��,fت و V- *� ذا�' "

15



Hoping to Hoping to Hoping to Hoping to

• Feel better

• Focus on possibilities

• Lead a healthier meaningful life

• Strengthen body and mind

• Take charge

• Build connections with survivors, counselors

• Set new goals

• Adjust to a new normal

“What are my alternatives to manage this disease” and “what am I hoping all the time?” The patient is saying, “I hope to feel better” because most patients come with a hope that they will be cured. And again it is up to the professional to be able to navigate through this and manage that expectation in a very tactful manner, where we are looking at cancer as a more chronic illness, where there is no cure, so to speak, for diseases like diabetes, And so cancer, in much the same way, may be a long-term phenomenon with no actual cure, but maybe remission, maybe stabilization of disease. And maybe we can say that this disease will never come back for the next 10 to 15 to 20 years or over the lifetime. But again, it is about managing expectations where patients are able to move along the continuum of care with much more comfort. To focus on the possibilities of what can happen in a positive direction. Lead a healthier, more meaningful life, even in the face of a terminal nature of any type of disease, if it is terminal. Strengthen body and mind. Take charge. Help the patient if the patient wants to take charge, be in control. And so, always being told do this, do not do that, eat this, must have this, can wear a patient down and make him feel like he has lost control. Build connections with survivors, counselors, they want to set new goals, you want to help them set new goals. “Okay, so I was a marathon runner yesterday and I cannot do that anymore, but what is my next alternative. Maybe I can start painting. Maybe I can start cooking lessons.” There are so many different alternatives one can look at and there is such a thing as creative problem- solving, which most patients themselves are able to come up with the solutions as long as they know they have the

اB& ا��*"Eا��ضا'� ا� Gذ� N' &'�5�3� �'�'ي "و" -�ة أe6 �� '� ا�?�+

jVVk؟ أن ~'& -� أن أoJ*ى ا� ' S3� " l+ل ا��*V+" 5*رHا� �- &'~6�!�O "ء��Hن ~'6,3 -� ا�*%q+ SY2 ا��r5' ن� Gو'�ة أ<�ى، . وذ�

T- Gن ا�'� +��N إ�S ا��I. -� ا��?6 '6 ا��,�ز ذ�G وا��N' &'�5 ذ� �r�/ �,k ، +�i3� L��k V+�pO NJ*ا�إا�� S �Y�' dر�E��O ن��

��ء �j، آ�� } � ،��'7'� E��O ه* ا�!�ل &��Oاض '�& ا��?�ي، و�' +�?6 أ+^� ��3ن أن +�f &?Hه�ة �*+3 ا��& � {��ء ,5O k Sإ�

,V,Vk� �� ا��اض، ور�V��+ ��O ا��ض'�I% ��O�4، ور .&O ��?�+� �Jد' ، 20أو 15أو 10'�ة أ<�ى �� ة *دا�V*ل إن ا��ض �6 +5L

ى ا�!,�ة' S3� ��Oأو ر .`J*�+ �'�و�?6 ا ، ,�'�ة أ<�ى، �S3 آ,�*ن '6 ا��3�3L �E� &V ا��+ ?��+ �,k SY�5ت ا��J*% N' &'�5ا��

�k�,%وه2 أآ�� ار .pO ث �+V ا��آ,S3� 7 ا��kت '� +�?6 أن +! ,O�$+ي /*ع . إ� ,B�4��,� k,�ة أ�b، و'��ة، f �- S�k& ا�Ep,5 ا�

ن وا�eه6. '6 ا�'�اض، S�k و�* آ�ن -� ا��اk& ا�<,�ةEا� +*V% . ا��+l إذا آ�ن را(E� -� %*�� ز'�م ا��Zو�,. %*�� ا��Zو�, ��L ��ء و. وز'�م ا��,�pةOو�ا j,�*% S3� 'او ا'� �l+��3؛ �T- ،j,3ن ا��

*!/ : ،G5& ذ��% � ،Gولا-5& ذ��هeا، +$G,3� U ذ�q} 6' ،G/�4 إ/�4ك % j/q�5 وآH+ j35و� l+ا�� Jة�p,ا�� V- . '�Jتإ�Jh� 6' 6,��'N ا�

ة، وأ/o %*د + أه اف �+ ا��ض وا��Hر+E)�+ 24- ،6*ن -� %! ة+ أه اف �+ !% S3� 24% ��'" .o� آV� ،��k ق�EL �- �'��O

Gذ� �- �' J �^ا�� N,p�Lو� أ ،�/*� +& ا�<� . '�راEو�?6، '� ا� ء -� ا��2L. أ'�'�Eا� ��?�+ ��Oدروس -� . ر �V3% �- ء Eا� ��?�+�4pأ+^� -." ا� G�e�4، وآ�!O 6?�+ ا�� 3�Iا�� &Bا E6 ا�' + 4��ك ا�5

(U3 ا��SY '6 +�?6 إ+$�د 3k*ل '�E?�ة ��H�3آ&، k,� +��?6 أ ون ا��/ ة وا�� ة، دا'ا��*b& إ�3k S*ل '�$,L 24/qO 23� S3� ا*

+ � �5,E� NYو N' `,?'& -� ا��وا.

16

support and the resource, And hoping to adjust to a new normal.



Hoping to Hoping to Hoping to Hoping to

How do people really cope ?

�I will do what it takes to get well but I will also plan

for the worst.

�I am going to try and live a normal life even though

so much has changed.

�This cancer has given me a new perspective on life.

Now, pre-cancer and post-cancer are two different

phases. And to know that this is a life-changing event in

the life of any patient. And how do people really cope?

“I will do what it takes to get well, but I will also plan for

the worst.” Some patients will say that. Whereas some

will say, “I am going to try and live a normal life even

though so much has changed.” And some others will say,

“This cancer has given me a new perspective on life.”

These are all ways people cope. Some cope by being

angry, some cope by being depressed, and some cope by

saying, “I am going to take the next step and move

forward.” And so, we have got to be able to gauge,

where is this patient in that journey of coping and

hoping?

6�F�� $F�� >3 ،� GJ: اUM�� #�ن و��F$� �� <� ا��#�ن $F�� 5$ وإذا �� $�6� أ�C� -�F :A�3� �j�ا �2�ة أي . / 3��/ ��Z�� .ا� :�>� X0� Z>� %ل�وز ا��62؟ &�93 S$6�س �� ا��2��

SY��ا��]| "ا� hY4& �60و&<� ��0 أ�23/، و� �� 4?ل آ: �&F4&n�ول أن أ: "وا�Z>G ا�Pv &�%ل" .G�23� �~&%أ �>G# ة�F

�C� �j3 ا�?ي �A0ا��>� �/ ا� S$�� 626 : "و&�%ل ��Pون ".A�3: 3$� و&�C� 49$� :V� ا�6�س ". �ة�2$S اا��#�ن �l6%را ��ا

�Wف �KHj، وو. � 9�وز ا��62� Z>Gا� KW� Z>Gا� �Pvا �: إ�S ا��]%ة ا� �� وأ��J �H�: "آ R�ب، و��Pون ��%��Cا��4&. "

�K9 أن �0%ن J�در�/ $J S�س �%hY ا��Z �� رF$� 93�وز ،و�?�� ا��62 و>�س ا.�:؟



Impact on Family and Caregivers Impact on Family and Caregivers Impact on Family and Caregivers Impact on Family and Caregivers

• Shock of diagnosis

• Increased caregiving demands

• Relationships

• Role strain

• Internalized feelings

• Reluctance to discuss physical change

• Fear of losing partner

• Resources

• Coping

Says a survivor: “The support of my family has truly helped me to better cope with the challenges I’ve faced after my cancer diagnosis.”

Another very, very important aspect, which we

sometimes tend to forget, because we are more focused

on the disease itself and curing that disease, but the

patient’s family and caregivers are an extremely

important part of this person. The shock of the diagnosis

that the patient feels is felt equally or sometimes even

more by the family and caregivers. These increasing

caregiving demands on a wife who never used to work,

was at home taking care of her children and bringing

children back from school, and making good hot meals

for the family now goes to work. Now has to start a

whole different lifestyle of working and coping with the

disease of her spouse. Relationships change. The roles

have changed and so relationships change. There are

internalized feelings, “I am angry, but I do not want to

tell my sister or my brother about what I am feeling

because that will further stress them out.” Reluctance to

discuss physical change and often spouses of cancer

��lا ،�C�� Sإ� ��F69{ أ� � �/ �/ ا�9%ا�K ا��C�� ا ��ا، وا�$S ا��ض ذا3[، و$S �<��9 ذ�� ا��ض، وه% أن � �آ�� ا. �Gآ

��?� �G�6�� j$� ��C� 0$%ن ��ءا�� ]� ��أ&�ة ا��Z و�� ا��_��. ا� �� ]�$�<� �C� ا��Z ��ى � � �<� �C� ��W ا�� _

�Aأآ ��5[ ور�� ]$G�ت . أ��اد أ&�3[ و�� ا�� [ ��ر �� oF ،:�>ا� S$ :GJ /� � �� ا�� G�6 ��و�� 3<� ��YMا

�3S أو�ده� و3 �C � �� x��/ ا��ر&� وh6W3 ا�%�G�ت �CG$9آ��Gء �� | F�ة و�<�6 ذ�� ا. ا��6P ا��C� C3�&.�، ��3ج اvن �$<�:

�5$ ا� j� �� . / ا�<�: وا� <��: �h ا��ض ا�?ي أU�ب ا��وج آ$�� داP$�، . ا�< J�ت �� j3�ت ا.دوار؛ وآ?. ا�< J�ت�� A�" ��أ

F ي�� w أو � ��w �GPو��60 �/ أ ،KY�<S /� أز�� C$�� ا� j ".ا�jH| ا��56 J�6� �� دد� ��، وآA�ا �� 5j: ا��Gات ا��

�[P ن أو أي ��ض�#��ن، ��ا��# SY�� أزواج ��Uإ _��3 ،�P� وذ�� S$�م ا� �KG �� ز��دة ا�jH| ا��56 S$ �CU�2� ا�l��ذا &�4<: "ا��%ف �/ ��ان ��w ا�2�ة وآ�� %ل أ�F ا�6��/، . ا��وج

�� %ارد " ".F ��w��3 � ��660 ا�<n ��ون زو�� أو. �<� ذ��] إن ��ة " "،ا��ة ا�� %ا��ة، وآX ��660 ا� <��: �h ا.��

�C Cوا� � $S ا� ��2�ت ا� :H0: أ�� K$j $S ا� ��F �63�أ&��3 &�

17

patients have gone undiagnosed, with cancer or some

other serious illnesses, because they did not want to

impose further stress on the spouse. The fear of losing a

partner and, “What am I going to do next. I cannot live

without my spouse or without my partner.” “What kind

of resources are there and how will I cope with this whole

thing.” Says a survivor, “The support of my family has

truly helped me to better cope with the challenges I have

faced after my cancer diagnosis.”

� ��#�ن��Uإ _��3 �>�."



It’s unpredictable

It’s a roller coaster

It is unpredictable. It is a roller coaster. There is no

point in time where a physician can truly say, “Hey, you

are going to live forever,” or, “You are going to live for

20 years,” because none of us is a God. However, we all

do know that there are ups and downs in every phase of

life, and with cancer, it is even more unpredictable. And

all we can do is strengthen these patients along their

roller coaster journey and make sure we are able to pick

them up when they fall off the coaster.

G6 � . أGw[ ��آ%ب &5�6 ا�� ه� ا��وارةإ�[ . �[ iإ�[ أ�� 0/ ا� �Fا�U :0� �� xJأن ��%ل �� و KG# 0/ .ي��" n>، ��60 ا��6�F

<n "أو " �~��&20 ��،" Kj<$� ا�� ا �6�Fن أ. . �>�� $>�و�660� �G�6 ��ض أن ��h ��اF: ا�2�ة 3�� 2��ت U<%د وهG%ط، و��

hJ% وآ: �� 660� �<$[ ه% ��ة . ا��#�ن، �mن ا.�� أآ�A �<�ا �/ ا� S$$S 3$� ا��5�6 ا��وارة، وأن �0%ن J�در�/ �C $Fء ر�أ-6 �� SY��ا�

�C6� &�]%ا �ذه� إذا �� . إ

18



“I’ve been touched by the smallest gestures - a

squeeze of the hand, a gentle touch, a reassuring

word. In some ways these quiet acts of humanity

have felt more healing than the high-dose radiation

and chemotherapy that hold the hope of a cure.”

Kenneth B. Schwartz

“I’ve been touched by the smallest gestures, a squeeze of

the hand, a gentle touch, or a reassuring word. In some

ways, these quiet acts of humanity have felt more healing

than the high-dose radiation and chemotherapy that hold

the hope of a cure.” Kenneth Schwartz said this.

��، أو آ$�� ]��6R أو jY]� �� ؛�5$ �ت�� 43-�ت �/ أJ: ا" �F �� . � أآ�A إ��اء �/ ��Wا� ��Mت ا��W و�/ �<Z ا�6%ا�F، آ��x 3$� ا��4: �/ وراCV� ا��5�ء � �ت اwM<�ع ا�<�� وا�< ج ا�0��وي ا��. "

e3ار%w o6آ ]��J �� ه?ا .



A Comprehensive ApproachA Comprehensive ApproachA Comprehensive ApproachA Comprehensive Approach

• Psychosocial assessments

• Psychosocial counseling and cognitive behavioral interventions

• Transition planning

• Education and referral

• Advocacy

• Program development, monitoring and follow-up

So, at the end of the day, what we want to look at, is a

comprehensive approach institution-wide, wherever this

institution may be, wherever this cancer care is being

provided, to make sure that we have a comprehensive

approach towards cancer care, in that, other than the

medical assessments and the treatments, that we are on a

parallel front, dealing with the psychosocial aspect of a

patient’s care. Which means psychosocial assessments,

counseling and cognitive behavioral interventions,

transition planning, education and referral, advocacy,

program development, monitoring and follow-up.

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�، . وا�< ��ت ا�]G� ا�� 3 وو�<�6 ذ�� ا� ��ت ا��56� ا��3]| ا� �6: �/ وا��%رة وا��Mاءات ا� �P$� ا��<�� ا��$%آ�،

�� واFM��، و P]%ات ا��% وhY ا��Gا�z و/ ا��2%ق ا��ع وا� .ا��U وا�� <�و

19



Tools for Psychosocial AssessmentTools for Psychosocial AssessmentTools for Psychosocial AssessmentTools for Psychosocial Assessment

• Screening should be routinely established

• Depression in the terminally ill should be

treated as vigorously as for those patients with

a better prognosis

• All staff should have basic skills to determine if there

is any suicidal risk so patients may be managed

Identification of barriers and stressors, which impact

patient and family coping and/or compliance with

treatment must be done in a systematic manner.

So what are some of the tools for psychosocial

assessment? At MD Anderson, we have several ways to

identify barriers and stressors that impact a patient at

family coping or compliance. We may have a patient

who is highly compliant, but there may be a family

member who has a mood disorder or a family member

who is completely stressed out, burnt out and fatigued,

and may not be willing to comply with the treatment plan

or even be supportive of the patient or the medical team.

A lot of our discharges get held up because patient’s

family members do not think that it is the right time for

discharge or are not ready for the patient to be taken

home, because they are afraid of how to care for the

patient. Screening should be routinely established.

Depression in the terminally ill should be treated as

vigorously as for those patients with a better prognosis.

So we are looking at screening at all levels, from the

point of diagnosis to the end of treatment, at the point of

progressive disease and advanced disease. And all staff

must have the basic skills to determine if there is any

suicidal risk so patients may be managed and be able to

refer these patients very quickly to the department of

professionals within the institutions that handle these

issues.

�؟ ��6� و�0/ �� ه� �<Z ا.دوات ا�� ا� �� ا��56 ا�� -i3 � �� إم دي أ��ر&%ن �ة #�ق � ��2 ا�<%اOV و��GG�ت ا�jH%ط ا�

$S ا��Z �� ا� <��: �h ا.&�ة أو ا�� ام ��< ج . SY�� 6��$� ��%ن ��ا، و�0/ ر�� آ�ن ه6�ك أ�F أ��اد ا.&�ة �<�� / اY]�اب $� ،�C9� أو �J�[�56 ا� �� ،��w |jY x23 hJا��، أو ��د �� ا.&�ة وا�� Z��$� ة�� S ��3 ا��F ام ��]� ا�< ج أو� و�J � �0%ن را>G� �� ا��

�G[ا� O��5اج. أو ا��Pإ :�i��S5 وآA�ا �� .ن ؛ا��SY �/ ا�� ون أن ا�%6� xJ��PM K&ا�[، أو �<�م >� � Z��أ��اد أ&�ة ا� ��# /� �C�%�� ا�l�ا& <�اده� �U]2�ب ا��Z إ�S ا��6ل،

] �� G�رات . رPإ��اء ا K9�23يو� �6رة رو3%W� . �9��>� K9و��ا�?ي �<��z �[ [�5ا�آ R�ب ��ى ا��SY ا�?�/ � ��S ��ؤه� ��2��س

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�� $F�� 0%ن ا��ض� ��6 �� hh أ��اد ا�]��J . و� و�K9 أن � 2�ر��ف ا��%ل ا� �S6 ا� <��: �<C� ��C�رات أ&�&� �� اآ� S F ��

وإF�� ه�iء ا��SY &��<� إ�S ا�� ا�?ي �<�: �[ � �WW%ن �� $3 ��&i�� ت��ا�2 .

20



Psychosocial assessment varies by :

• Provider

• Screening tools

• Emotional state of patient at different

point of assessment

• Reporting

Depression ratings were influenced by crying,

depressed mood and medical factors rather than

more reliable indicators such as anhedonia, suicidal

thinking and hopelessness.

So again, psychosocial assessment varies by provider, the

type of screening tools they use, emotional states of

patients at different points of assessment, and the

reporting structure.

� �C� K�F ��3 ا�� ة أ�Pى، � 5�وت ا� �� ا��56 ا�� $X أ�%اع أدوات ا� �2ي ا�� و�� SY��$� ��وا�2��ت ا�%��ا

��ط ا� �� وه0: إ�اد ا� ��ر�� .



Practical Concerns

• Housing

• Insurance

• Work/school

• Transportation

• Child care

• Caregiver

• Home care

• Prescription coverage

Family Concerns

• Dealing with partner

• Dealing with children

• Spiritual/religious concerns

Emotional Concerns

• Worry

• Fears

• Depression

• Nervousness

• Loss of interest

Physical Concerns

• Pain

• Fatigue

• Sleep

• Getting around

• Bathing/dressing

• Sexual

• Other _____________

NCCN Distress Thermometer NCCN Distress Thermometer NCCN Distress Thermometer NCCN Distress Thermometer

The National Cancer Comprehensive Network of the

United States came up with a very, very valuable

assessment tool for patient distress. This simple tool

looks at four dimensions of patient care. Those

dimensions are the practical concerns, the family

concerns, emotional concerns, and the physical concerns

encompassing the entire patient, which then gives us an

idea for the patient’s distress level on a scale of 1-10.

And, if the patient tells me that he is feeling suicidal, or

he is feeling sad, or he is concerned about his sexual

functioning on a scale of 1-10, his distress level is 6.

Then that tells me something about where I need to start

with this patient and where I need to go with this patient.

$�� $��#�ن ��%��ت ا�� 2ة أداة J�� x��U ا��0G ا�%#6� ا�SY��ى ا�� OH�� ر%>� �� ا�� j$� .و �[�Gول 3$� ا.داة ا��6 3

SY��ا� ��ا��%ا>: وو3$� ا.�<�د ه� ا��%ا>: ا�<�$� . أر�<� أ�<�د ��0: وا.&�� Z�� |23 � �� ا��Gا>: ا�%�ا��%ا>: ا�%��ا�� وا�

/� � �م، وا� OHى ا�% �� /4�C� أن 3<]6� ��0ة w]6� �� ا�?ي �<� /� z�3ر� S$ Z��1ا� Sوإذا . 10إ� �� >�� ]�J�ل �� ا��Z إ

2�ر��، أو ��<� ��2ن، أو أ�[ �C�%م ��4ن أداV[ ا��69، ��%ل ا ]�� OHى ا�% وه0?ا . �1-10/ � �اوح ، $S �3ر�z ��60%ن ��

�� ذ�� إ�S ا��%�w�� ]6� ا�?ي ��660 أن أ��أ hY :�>ا� ،Z��ذ�� ا� h�]>� �Hأي ��ى ��0/ أن أ� Sوإ� .

21



Patients at Increased Risk for Distress Patients at Increased Risk for Distress Patients at Increased Risk for Distress Patients at Increased Risk for Distress

• History of psychiatric disorder/substance abuse

• History of depression/suicide

• Cognitive impairment

• Communication barriers

• Severe comorbid illnesses

• Family/caregiver conflicts

• Inadequate social support

History of psychiatric illness, history of depression,

suicide, cognitive impairment, communication barriers,

severe comorbid illnesses, like diabetes or hypertension

or bipolar disorder or AIDS, all of these will put the

patient at increased risk for distress and more so the

inadequate social support of a patient’s circumstances can

impact the patient’s distress level very highly.

2�ر أو ا�<�9 إن و�%د &%ا� ل ا��56 أو ا�آ R�ب أو ا� � O�Mدراآ� ا OVا%ا��Y ا��، �A: داء ا� لا� %اU:، أو �� أو

ا��0ي أو ار53�ع ا�jH| أو ا�Y]�اب -6��V ا��]K أو ا��Mز، آ: ذ�� ،k�<و OH�� Z��ا� ��U#� إ�أن �� / �� ]�4w /ن و�m� ا?�

S$ �-i3 0/ أن�� Z��وف ا��l� ��0ا� �< �� ا��ة ا�� %ى ا�HW� ]�� O%رة آG�ة ��ا�� .



Patients at Increased Risk for Distress (continued) Patients at Increased Risk for Distress (continued) Patients at Increased Risk for Distress (continued) Patients at Increased Risk for Distress (continued)

• Living alone

• Financial problems

• Limited access to medical care

• Young or dependent children

• Spiritual/religious concerns

• Social problems

Again, patients living alone, how many times and how

often have we had patients being dropped at our doorstep

who have no family, no friends, nobody wants them back

home, or they are so tired taking care of the patient that

they think it is the hospital’s duty to take care of this

patient. Patients with financial problems, limited access

to medical care, they are living in remote locations and

areas and want to be closer to the hospital, they have

young and dependent children, spiritual religious

concerns as well as social problems. And how do we help

these patients? These are the patients at increased risk for

distress, but which are these patients? Who are these

patients and how can you tell?

�� .S ا�?�/ �<�%ن �%�Fه�ا��Yه6�� 9دا، �Cw آ� ��ة �C� SY��S5، � أ&�ة، � أJ�U�ء، �$�%ن $S أ �ب ا�� Fأ �C6� K<��

C9ا� �C6� �$� ��ا��6ل، أو ر� Sإ� �C3د�ا��Z ه?ا � �� ر�� إ] ��S5 ر ا��SY ا�?�/ �<��%ن �/ . و�6l%ن أن �/ وا�K ا��

��2ود�� ا��رة $S ا�W2%ل $S ا�� ا�]G�، و�/ ا��آ: ا��، �Cو�� ،S5� ��ل �Jب ا��V� و��ون ا� hJو�%ا O#�6� �� ن%�و�<

وF�، وآ?�� آ: وw%ا>: د�6� ر وأ�w�ص �<$%��Cأ#5�ل jU�ر �� 2% زا�V . ا� S$ �Y��م ا�<%ن ��iCء ا��SY؟ ه�iء Xآ

��]� اUM�� HO، و�0/ �/ ه� ه�iء ا��SY؟ �/ ه� ه�iء ا��SY وآX ��60 ا� <�ف $�C؟

22



Periods of Increased VulnerabilityPeriods of Increased VulnerabilityPeriods of Increased VulnerabilityPeriods of Increased Vulnerability

• Finding a suspicious symptom

• During workup

• Finding out the diagnosis

• Awaiting treatment

• Change in treatment modality

• End of treatment

• Discharge from hospital following treatment

Again, when a patient finds a suspicious symptom after

treatment and feels that, “Oh, gosh, my disease is coming

back, I am not going to through this again and I am not

going back.” Or patients during work-up get into panic

bouts where they feel, “Well you know I am feeling

really sick, my hair is falling off and I think probably this

is not a good sign. I might as well go home instead of

spending so much money on this treatment and save up

all my bucks for my family.” Finding out about the

diagnosis: this is a pivotal moment in the life of any

cancer patient is finding out about the diagnosis. Almost

feels like a death warrant to many. Then awaiting

treatment, anxiety of awaiting treatment, [you know]

“What kind of treatment? How long will this treatment go

on?” “What kind of side effects are going to happen?”

“How can I cope with this?” Change in treatment

modalities, okay, so we finished Herceptin, now we are

going to do Taxol and then we are going to go and do

radiation, or we are going to do surgery. “When is this

treatment ever going to end and what does the end of

treatment mean? “Is that the end of chemotherapy and the

start of radiation or the beginning of immunotherapy?”

“What does treatment itself mean?” “What is the

difference between acute treatment and palliative

treatment?” Discharge from hospital following

treatment? Patients do not understand the differences

between transition -- between transition points, being in

the hospital, being discharged from the hospital, going to

a nursing home or to a hospice.

C� Z��ا� X� 0� ��6%ر أ�اض �A�ة �$�0%ك �<� ا�< ج أآ�ر، <�ا �$��ور "و�6 ��[ ذ�� ا��<%ر �� xو�� ،�� إ��C، ا��ض �<�ود

�%��ت ." �?�� ة أ�Pى، و�/ أ%د ��ة أ�Pى �C�� أو ا��SY ا�?�/ 63�ء، وw<�ي "�/ ا�h$C أ-6�ء إ��اءات ا�< ج M�� :>5�� >wأ ��إ �< �� J|، وأ�/ أن �$3 ��G# . �� Sإ� Kو��660 أن أذه

أو�� ?�� <Z ا.�%ال أن �/ إ�5�ق آ: 3$� ا.�%ال $S ذ�� ا�< ج، و�3�&.." _�� 9 ا�� >� : �l2� _�� 9 ا�� >� �>3

�ام ��G�6 . �2%ر�� F�ة أي ��Z ��#�نM�� 0F ��A�� C�Z>G$� . �>� ر ا�< ج�l � l�ر ا�< ج، -� ا�� KF�W�ا� O$[ذ��، وا�� آ� �jق ذ�� ا�< ج؟] "3<$�%ن�& xJ%ع ا�< ج؟ آ� �/ ا�%� ه�� " "��

j3� " آX ��660 ا� <��: �h ذ��؟" "اv-�ر ا�9��G� ا�� %�F hJو-C�؟ /، و&�G6أ اvن �� إ]�ء G&/ ه�� 6C �#�ق ا�< ج، 6�F�، �� ا

�، أو إ��اء ��ا3�F�آ�%ل، و�<� ذ�� &6�>wMا�< ج ا h� ��J �H� . C�ء ا�< ج؟ "�6 �C ا�< ج و��ذا �<�6 ا& S �C�� A�� >��ه: "�

� أو ��ا�� ا�< ج ا��6��؟�>wMوي و��ا�� ا��ا�< ج ا�0" " S6>� �� {ا�" �� ا��5ق �/ ا�< ج ا�2�د وا�< ج ا��$]X؟" "ا�< ج ��5[؟ /�S5� �<� ا�< ج؟ � ��رك ا��SY ا��5ق �/ ��ط ا� �6:، ا�%�%د ا��

�S5، ا�?ه�ب إ�S دار Z��3 أو إ�S دار �S5، ا�PMاج �/ ا�� ا�� . ر�� $2��ت ا�� P4ة

23



Periods of Increased Vulnerability Periods of Increased Vulnerability Periods of Increased Vulnerability Periods of Increased Vulnerability (continued)(continued)(continued)(continued)

• Stresses of survivorship

• Medical follow-up and surveillance

• Treatment failure

• Recurrence/progression

• Advanced cancer

• End of life

Periods of increased vulnerability, again, could include

stressors of survivorship for patients who survived their

cancer, who have now been treated, their disease is in

remission, but they still need to go back to a normal life.

They still need to pick up the pieces where they left off.

They need to have medical follow-up and surveillance.

They need to understand that, if there is recurrence or

progression, they need to come back, and who do they

need to come back to? Again, how are they going to deal

with advanced cancer issues, end of life issues?

�ات ا�X>H ا�� :��ا�V، ��9دا، ا�<%ا�: ا��F�� |jH$� �GG$� و3$J S� ا�2�ة �<� �9�3[ �/ ا��#�ن، ا��Z ا�?ي �3 Z��ء ا��

/� ��F �� ا��ض }GUوأ ،]� hا�� ، و�60[ � ��ال �� F�� إ�S ا��>G[ة ا��ا�2 Sا�<%دة إ� . oF /� ع أ��ه��9� �F �� C�� إ�S ا&

��<� وإ�wاف #G/ و�2 ��%ن. 5J%3%ا� Sإ� . ]�وه� �� F�� إ��C� S أ �jG6�و 53�J�[، وآ?�� <�� ا��C9 أ�C ا�<%دة �� F�� <�ودة ا��ض $

��آ: ا��#�ن � h� :��> ا� � �<%دون إ�C�؟ و��9دا، آ�C60�� X ا� ا�� ، و��آ: �Jب �C�� ا�<��؟



Patient Needs Assessment or Patient Needs Assessment or Patient Needs Assessment or Patient Needs Assessment or ePNAePNAePNAePNA

A patient needs assessment screen

to review the various dimensions of

a patient’s care i.e. psychosocial,

nutrition, spirituality, etc.

At MD Anderson, we have what is called a Patient Needs

Assessment, which, a patient-- when the patient comes

into the hospital or as an outpatient, the patient fills out a

self-assessment about their own needs that are on a form,

which are sectioned, or categorized into different

sections. And so, when a patient decides that he is

feeling a stress level from 1 to 10, of 6 or 5 or 4, he will

indicate that on this form. When he does that, that

referral is kicked out to social work to assess for

psychosocial distress. If a patient says that they are not

eating well, they need some nutrition consult, then the

section on nutrition is checked off and the referral is

kicked off to nutrition. If the patient has problems with

mobility and needs physical therapy, or the patient has

problems with bowel management, all of these sections

deal with these problems separately and referrals are

kicked out to the different disciplines to assess the

patients further and meet their needs quickly.

��ت ا��6>� ،Z� ��P: �� -��6� �� إم دي أ��ر&%ن Fا �� S�� S5 أو ��34 إ�S ا�<�دة ا��ر��، ��%م ��:ء ��%ذج �$ ا��Z ا��5$ ��3[ ا��U، �� إ�S أ�J�م أو �X6W إ�S أ�J�م ��F� �3ا�?ا .

%ى �/ ا�jH| ا��56 �و�/ -�، �� /� ��>� ]� �رج mذا �Jر ا��Z أ� /�1 S10إ� A� :6 ذ�� ا�6�%ذج4أو 5أو Sإ� ��و��6� ��%م . ، ��

�� ى ا�HO ا��56 �3?��، � �� [ إ�S ا.WP��V ا��Fإ � � ا�?ي �� [�� 4�[ � �4آ: ��ا، �K9 أن و. ا�� Z��ح ا��U إذا

$S ا�� ا��ص �� hY%3 ]$��رة >?اV�، و�6�ء �93ى ا& j?�� و�2��?j3 �V�WPأ Sل إ��آ: �� و. �� /� ��>� Z��ن ا��إذا آ

��آ: �� ا��2آ�� /� ��>� Z��ن ا��أو آ ،�>G# ج Sج إ�� و�2 6�ول 3$� ا��آ: �W%رة ا� �F �� 02آ� ا.�<�ء، �mن آ: 3$� ا.�J�م &�h� ،�$W56 إF�� ا��Z إ�S ا� �WW�ت ا�� M �5$اء �� /

� �� $S و�[ ا��ا� ]3�� Fا �G$3و Z��$ .

24



Strategic Intervention Strategic Intervention Strategic Intervention Strategic Intervention

Psychosocial Need Service

Understanding of illness, treatments,

and services

Strategies to improve patient-provider

communication

Coping with emotions surrounding illness

and treatment

Peer support groups,

counseling/psychotherapy, pharmacological

management of symptoms

Managing illness and health Comprehensive self-management/

self-care programs

Behavioral change to minimize

disease impact

Behavioral/health promotion interventions

such as smoking cessation help, patient

education

Managing disruptions in work, school

and family life

Family and caregiver education, assistance

with activities of daily living (ADLs)

Financial assistance Financial planning, insurance counseling,

eligibility assessment for social security

disability income

So there are different psychosocial needs and different

strategies for each psychosocial need. Whether it is the

understanding of the illness, treatments and services.

And this is not just for patients, but also for the patients

and their families. Coping with emotions, managing

illness, how to manage this illness both at the hospital

and at home. There are a lot of behavioral changes in

patients. Some of them become quite obsessive

sometimes. The families become overanxious

sometimes. And that can have a very dynamic effect on

both sides, including the providers. We do have patients

sometimes who will not listen to any advice or instruction

because they are not emotionally comfortable. And how

do I get this patient there?

�Hك أ��5، وه6$ �� ت ��5� ا�Fك ا��5 إه6$ �ا39�ت ��&�� ج ��5 ا�Fت . �0: ا�ا��ض وا�< � �C5� O$> 3 x�&%اء أآ�

��: أ�H� أ&�ه� [و� �� W ا.�� $S ا��SY، و�60. وا��ت� .�<%ا#X وإدارة ا��ض أي آ5� إدارة ا��ض �� آ: �/ ا� <��: �h ا

�S5 وا��6ل . �23ث ا�A0� �/ ا� j�ات ا��$%آ� ��ى ا��SY. ا�� W3�ب ��$O ��5طوا.&� � . �J��&%&%� }GW� Z>G� �� Z> ا.F�ن

و��0/ أن �i-� ذ�� $S آ ا�]��/ 43-�ا �$j�، �� . �� أF�ن أ�Pى �<%ن $6�� . ا��ت %ذ�� SY�� ن�F.ا Z>� ��

�<�ون ��ا�F ا�%��ا�� ؛إ�S أ�� W�2 أو 3<$��ت� � �C�. . Xوآ �� أوU: ا��Z إ�S 3$� ا��ا�F؟ أن



Patients with Breast Cancer Patients with Breast Cancer Patients with Breast Cancer Patients with Breast Cancer

• Crisis intervention

• Adjustment to diagnosis and treatment

• Coping with life changes

• Stress/anxiety

• Fear, panic, anger, guilt, denial

• Issues related to:– Body image

– Sense of identity

– Sexuality

– Disability

– Grief and loss

– Advance care planning

– Death and dying

So, patients with breast cancer again have the same

problems. We are constantly dealing with crisis

intervention: a patient who is in a panic bout, has major

issues adjusting to the diagnosis, cannot cope with the

idea of maybe a surgery, radiation treatment, the side

effects of fatigue, body image, grief and loss, the fear of

death and dying. And so we try to provide services with

counseling, the transitions of care, and patient protection

or patient safety.

�5� <��: . C�6�F�� ،��H�ت ��#�ن ا��Aي �<��/ �/ ا��آ: � /2�و�5 �� ة �h إ��اء P�3$� �2��ت ا.ز��W�: � Z��3 ،h$ه ��%� ]�� 6

h� �#�> ��_، و� ��60[ ا� ��آ: آG�ة �� ا� 0h� X ا�� /� ��و�<� ،�Fج أو ا��0ة إ��اء ��ا >Mا ،��>w د، أو�C�� G�أو اv-�ر ا�9�

و�/ . ا��%ت وأا��%ف �/ ا��%ت، أو ا.&S وا�H�ع، أو U%رة ا��9، �2�ول ��3 ا��ت / #��O ا� �- ��Fو ��%رة، و�63 ت ا��

Z��أو & �� ا� Z��ا� .

25



TRANSITIONS OF CARE

- Assisted living

- Nursing home

- Hospice

- Custodial/provider care

- Home provider

- Extended care facility

- Nursing home

- Assisted living

- Hospice

- Aged and disabled

services

Psychosocial Support Resources Psychosocial Support Resources Psychosocial Support Resources Psychosocial Support Resources

PATIENT PROTECTION

- Guardianship

- Abuse - children and

adults

- Domestic abuse

- Exploitation/neglect

- Clinical ethics

There are different types of counseling and there are

different specialists for the different types of counseling.

And so we must be very aware of who is the right

professional or staff that can do the most effective piece

of counseling for the different issues: adjustment to

diagnosis, crisis intervention, communicating with the

team, making treatment decisions, helping the family and

caregiver to be more supportive, empowering them,

discussing end of life issues. And discussing end of life

issues, there is the point where the physician says, “Okay,

we are at the point where the disease is so advanced,

terminal nature of disease, the prognosis is less than a

few months,” that is discussing end of life in terms of

providing the prognosis. However, there is much more to

that. There is more to discussing the end of life in terms

of, “Okay, so we are at a point here and let us look at

what our goals are from this point onwards. Is this

quality of life? Do we want more treatment? What would

be the impact of that? Where would you like to be at this

point? How would like this to be planned?” The different

mental health resources within the institution and outside.

%� �WW%ن �� $5%ن .�%اع ه6�ك أ� �Hك أ��رة، وه6%�اع �� $�5 �/ ا��5$ $6� أن �0%ن $S و� 3�م �%6� . ا��%رة ا�� K9� ا?�

4�[ أن �%�� ا��%رة w /� ا�?ي �J�[أو ا� K&�6�ا� �U�W Pا� �Aا.آ ��>�:V��ا� X$ �� : �� $P� ��_، ا��Mاءات ا� ا� 0h� X ا�

�، ا� %اh� :U ا�O��5، ا�3�ذ ا��ارات ا�< ��، ��ة F��ت ا.ز� ��J�6و� �C ��$S ز��دة ��C3 و��%�3 ��ا.&� و�� ا��

و��$� �G�6�V: ا�� <$�� C6�� ا�<��، .ا��V: ا�� <$�� ب �C�� ا�<��]� أ� �$F�� " :}GU� ��G[$� /0K أن ��Wح Sإ� �6$U، �� و�6�F

ا�� GC� ا��ض � �� $j��، و�� ا��اF: ا�C6�V� �6[، وا��/ hJ% �� J ��4ب �C�� ا�<�� / "،أH� /� :J<� أ�Cwه% ا��J�6� أي oFhJ% ��_ ا�� 6C�ك أ�%ر . و�0/، -�� أw�ء أآ�A آA�ا �/ ذ��. ا�

C� ��W%ص �C�� ا�<��؛ �J�6� /0�� ى�P6"أ$U، �� و�6�F Sإ� �k?ه �jG6ا��6]� و�� 23�C� �/ اvن $ � 6� ا� 05� �� ا.ه�اف ا�

�ا�W� . ة؟�ا�2 �%� �� 05 2 �ج إ�S �� / ا�< ج؟ و�A: ا��ه: آX وأ�/ H53: أن 03%ن �6 3$� ا��6]�؟ ووآX &0%ن 43-� ذ��؟ � داP: ا��i&�� ا��%ارد ا�� 2W$� �5$ ا�K<�3 "�56 �� ا� �]| �?��؟

�Cر��Pو.



Psychosocial Support Resources Psychosocial Support Resources Psychosocial Support Resources Psychosocial Support Resources

FINANCIAL ASSISTANCE

-Insurance

-Employment issues

-Health insurance

-Governmental/state assistance

-Short/long term disability

-Cancer help organizations

DOCUMENTS

-Visa letters

-Letters to attorneys, criminal

justice system, patients and

family members to employers

or schools, FMLA, military

leave, jury duty excuse

TRANSPORTATION

-Volunteer airlines: Angel Flight Corporate Air Angel,

Air Lifeline Mercy Flight,

Freedom Flight

-Air Ambulance

-Gas, bus, cab vouchers

-Parking

-American Red Cross

-American Cancer Society

HOUSING

-Contracted programs

-Hotels, motels

-Guest programs

-Charity organizations

PHARMACY/SUPPLIES

-Explore resources/indigent

drug reimbursement

-Provide information

EDUCATION/INFORMATION/

REFERRAL

Now, there are also other concrete resources, which are

equally important and that address the practical concerns

of a patient’s day-to-day treatment journey, and that is:

housing, transportation, financial assistance, pharmacy,

education, documents. These are not small issues.

� �3: �� ا.ه��، و3 6�ول ا��%ا>: ا�<�$� ه6�ك �%ارد أ�Pى �$�%&�:A� ،Z��$� ��%ا�< ج ا� �$F�� :/0�6: و ا�� ا��ة ا��وا�

�و ا.دو��و% .3$� ا.�%ر ��jU :V�ةو� 3< �G . ا�� 6اتو ا�

26



• Social Work

• Place…of Wellness

• Psychiatry

• Chaplaincy

• Anderson Network

• Fatigue Clinic

• Neuropsychology

• Cancer Prevention

• Patient Advocacy

• The Learning Center

• Supportive Care

• Palliative Care &

Rehabilitation Services

• Pain Management

• Ethics Services

• Tobacco Treatment

• Sleep Clinic

Psychosocial Support Services at MD AndersonPsychosocial Support Services at MD AndersonPsychosocial Support Services at MD AndersonPsychosocial Support Services at MD Anderson

A patient came in for cancer treatment, was told what the

estimated bill would be, this patient was self-pay. Patient

paid up a certain amount as a deposit and then was told

that he can go in for a couple of consults. The patient

went for consults, went and checked on his bill. The

amount that he had deposited was almost now down to

half. The patient was shocked and the reason being that

the patient had not been adequately informed or provided

the information about what happens at each stage. The

patient said, “Hey, I have been here only for two consults

and one test or two tests and the bill is so much.” Well,

all the rates were then provided to the patient and he

finally understood where his money had gone, and how

quickly the money can go, and what we need to do to

make sure that he is still able to continue his treatment.

So, now at MD Anderson Cancer Center we have several

departments that help with psychosocial support services

and each area has its area of expert professionals who

work with patients to resolve psychosocial concerns and

issues.

�Jن، و�ج �$��# ��$ � Z��3%رة ا��رة، اأ�3 ا��ا�5 ��J S$ h$# oFص�[ ا��0$�5 �/ � د�h ا��j$G� Z� . آ�ن ذ�� ا��Z ��د ا�

��رات ��،�<6� آ��<� � أ��ى . وأ�GP �4ن $[ إ��اء �د �/ ا�&Z��3%ر3[ ا��25_ �� Kف وذه�W��رات، وا �� ا��xH5 . ا�&

XW6ا� S5<: إ�� C�Uم ا��Z، وا��KG أ�[ �� ]$h . ا��<� ا� � أود�$F�� :�2ث �� آ� �4ن ��J�ل . ��6� :0�K& أو �� ود ��<$%��ت �

Z��ا�" : �� ،�l2� ،/6-أو ا �Fر وا�G P/ وار3�� أ�� ه6� &%ى ا&�C� ��G� 3%رة�و". وا�5�- /� ��C� �� C5� ،ر�ا.&< h�� Z��$� x��J

Swا.�� أ�/ ذهxG أ�%ا�[، وآX ��0/ �~�%ال أن 3 �، و�� ا�?ي �� 4آ� �/ ا& ��ار �Jر3[ $S �%اU$� ا�< ج$� ]$>� �6� �jG6� .� �� 6�� ،ا?

�� آ� إم دي أ��ر&%ن �$��#�ن �ة أ�J�م �$��ة �� P ��3�ت ا�� h� ن ا�?�/ �<�$%ن%WW� �، وآ: �9�ل �[ �GPاؤk ا�� ا��56� ا��

�� $F S: ا��%ا>: وا��آ: ا��56� ا�� SY��ا� .



• Individual and group counseling: Screen and identify high risk

patients and families, crisis intervention, adjustment to diagnosis

and treatment

• Transitions of care: Pre-hospice, nursing home, assisted living

assessment, education and counseling

• Protection issues: Guardianship, abuse (child and adult), domestic

violence, exploitation/neglect

• Resources for housing, transportation and practical quality

of life concerns

• Custodial/provider services information, mental health resources,

family service centers, etc.

• Advance care planning

Department of Social WorkDepartment of Social WorkDepartment of Social WorkDepartment of Social Work

Psychosocial Counseling Services

The Department of Social Work provides individual and group counseling that identify and counsel high-risk patients and families, provide crisis intervention, and help with adjustment to diagnosis and treatment. They help with transitions of care. So if a patient is going into hospice, just to tell the patient, “Oh you know I am going to get you connected to hospice,” means nothing. But to be able to explain to the patient what hospice can do, how will it help the patient in the long run, what does it actually mean, and making the patient feel completely comfortable about this new transition to care, because, if you do not do that, the patient is going to come right back through our emergency center and not have the quality of life that they could have got otherwise. Protection issues like guardianship,

S3� رات -�د+ و��, ��5�3ف�H�Lت ا��, ا�' I2 ا��J م V+ 2+ V%رة �24، و*H2 ا��+ V%ا��5, و ��I�3� 6,Y�5ا�� L�وا SYا��

�ز' ، وا�� ة �S3 ا��?,` 'N ا��IH,. إ��اءات % <��k �- ,3ت ا-Tذا آ�ن ا��+l . آ�� +�� -� ا��p> 6,O &V*ات ��3+ . وا�h5ج

j� ل*V% ن� S�5' h- ،ة�>qدار ر��+ �3!��ت ا�� Sإ� &V�,L" S3� o/أ S3� &��qL �� ار ر��+ �3!��ت EO وS3� G5Y ا%=�ل�23 أ/

�+l '� ا�eي +�?6 � ور ر��+ �Hح ��3%و�?U$+ 6 أن ". ا��q<�ة�4 '�� ة ا��+S3� l ا�� ى � +�j، وآ,` +�?V% ة�>qا�!��ت ا�� de4� '�% kا�O �5H+ l+و�5& ا�� ، V,V!ا� �- ��ا�p*+&، و'�ذا 5%

ة -� ا��+ + ��د ؛ا��3V ا�$J l+ا�� $��- ،G�eO 2V% 2� إن G/��*�, ا�!,�ة ا�� آ�ن +�?6 ، و�S3� �+ 6 ا��*ر إ�S '�آ7 ا�p*ارئO N��

�4O Sr!+ ا. أن +�b*ا� &�' +��!��O V35ا�� &Bءة ا��5'3 و��Lإ+�5/� ا�?�,� 'SY�' 6 ا��ن '6 . ا�5�` ا��7 وا�hi�Lلو

+3�5*ن �S3 ا�hi�Lل أو إ�Lءة ا��5'3 ، و� +5�� ذ�G و�*د أ{�Iص l+ءة '�5'3 ا��H)5& -� ا��O ،7ل� &O3V�' +ا�� ' V' ن�ن *

Jء و(�ر�E��O*2ه kو `J*ا�� N' &'�524 ا��'*ارد . ن -,�4 و� +�?

27

abuse, domestic violence, exploitation. A lot of cancer patients do have issues with being exploited or abused, not because there are actually abusers in the home, but because the caregivers are completely burdened and overwhelmed and are not able to cope with the situation themselves. Resources for housing, transportation and practical quality of life concerns, custodial and provider services information. This is very, very important because patients, -- this is the first time they have been hit with something like this. They have no idea of where to start, where to go and what to do. And advanced care planning in terms of, “Okay, so this might take another six months to a year, or two years or five years. Let’s look at what we want to do; what are the different things that could happen and how do we want to proceed in a planned manner?”

�*�, ا�!,�ة، و'35*'�ت O V35ا(& ا�3�5, ا��*Hت، وا��V�/ا��?6، وا� '�تIا� �' V'و ، ,B�b*ت ا��' I6 ا�� . �,k ، +�i3� 24' �'�ا اeه j/أ

\E�+ 2� 3� SY3 ا��ور��' O�$�O &EJ 6' . ة�?- S/ه2 أد �و�,� � ؤون'6 أ+6 E+35*ن� م ��3+ . ، وإ�S أ+e+ 6هE*ن، و'�ذا +Vا�� _,pIوا��

&�' *!/ S3�" أ{�4 أ<�ى، أو ��'�، أو �L �'�ق ا�i��+ J ،��k�� j3. ��',6، أو <�� 3� ا�� ه� ا�'*ر '� : �� '� ا�eي +�?�Iا��

��r ؟+�?6 أن ' V+�pO �4��,k وآ,` +�?6 ا��=�ف ،NV% "



PlacePlacePlacePlace...of Wellness...of Wellness...of Wellness...of Wellness

• Integrative medicine consultation

• Acupuncture

• Massage

• Individual and group counseling

• Support groups

• Expressive therapies (art, music)

• Movement therapies (yoga, tai chi, pilates)

• Nutrition groups and consultation

• Relaxation techniques

• Complementary

We have The Place of Wellness that helps patients with integrative medicine consultation. They have acupuncture. They have massage. They have individual and group counseling, support groups, expressive therapies like art and music. There is yoga, tai chi, nutrition groups, relaxation exercises and complementary medicine consults that give patients another alternative to the cancer treatments, or complements the cancer treatments that they are undergoing currently.

��+ ا�eي +�� ا��h> 6' SYل ا�H�Lرات �E, " ا��5-, '�آ7 "� م ا�H�Lرات -�د+ . ا�� ,Gو. -� jO ا�*<�Os�O 7او+�*. %?�'3, V+ *وه

SV,L*ن وا��*��آ�� . و��, و'$�*��ت د�2 و��hت E5%,�+ '�& ا� م ا�,*(� وV+ا��H% رات ��ي�H�Lء وا�>��Lو%��ر+6 ا +ei% و'$�*��ت ،

اB& أ<�ى ��h5ت ا��ن، أو '?�3 ��4، O SYا�� % ,3,�?% ,E��,��k +ا��ر &Bا E6 ا�,O 6' .

28



PsychiatryPsychiatryPsychiatryPsychiatry

• Counseling for individuals, caregivers, couples

and children

• Medication management for psychiatric disorders

• Treatment for sexual dysfunction and substance

dependence

• Physician referral required

Also Psychiatry helps with medication management for psychiatric disorders while providing counseling for individuals, caregivers, couples and children. They also help with the treatment of sexual dysfunction and substance dependence.

,��r,2 أدو+ ا��pYا�Oت ا�% �- ��آ�� +�� أ+^� 2�J ا�Up ا� +2 ا��H*رة ��-�ادV% U/�� Sل إ�� '� ا��+ وا�زواج وا��V'آ�� . و

أ+^� -� �hج <3& ا�داء ا�$�� وإد'�ن ا��*اد��+ .



• Spiritual support to all patients, family members and staff

• Spiritual support for all faith traditions

• Visits from a particular religion upon request

ChaplaincyChaplaincyChaplaincyChaplaincy

Chaplaincy is a wonderful department at MD Anderson that helps with spiritual support to all our patients and family members. And this support is provided for people from all faith traditions.

�,k ن*Lر ا��Jم ا��,7ة -� إم دي أ/kأ ,�� '�ت ا�?I2 ا��J و+5 +2 ا� �2 ا��وSY��3� �k وأ�Lه2V% S3� ��+ .

29



Anderson NetworkAnderson NetworkAnderson NetworkAnderson Network

• Connects patients with patients

• Two hospitality centers

• Patient/caregiver telephone line

• Pediatric caregiver telephone support network

• Annual patient/caregiver conference

• Weekly educational presentations (PIKNIC)

• Adult patient camp and day trips (camp carefree and day away)

• Community outreach programs

• Online support: Cancer Survivor Message Board, WarmNet, Ask the Expert

We have what is called The Anderson Network that is a network of patients who have been diagnosed with cancer, treated with cancer, and are part of the MD Anderson family. So this Anderson Network connects one patient to the other. A patient with breast cancer with metastatic disease, Stage 1, might be connected to another patient who has a similar diagnosis, disease has been treated or undergoing treatment, and help the other patient to find some support with emotional, psychological, and cultural issues. There are hospitality centers all around the hospital. There are patient/caregiver telephone lines. They have adult patient camps, community outreach groups and online support groups through The Anderson Network.

�� '� +E} j,3� \3p? أ/ رL*ن، وه� {E? '6 ا��SY ا�eي + و��O O�bs�O ا*=I} ة إم دي و%�5-*ا ��ن�Lا �7ءا '6 أ*!Ebوأ j�'

{E? أ/ رL*ن �S3 رO_ ا��5O SY^24 %�5& ،و'6 �2. أ/ رL*نl5EO . Sو��3 اk�3 -� ا��,V��O ^+�� 6?�+ �,kن ا�� ي ا�

��/ .,IH��O أ<�ى ^+��O ا�%=�لj وا��ض j�' o-�5%أو و � ,J ة ا��+^ ا %7ال �<�ى -� ا��5*ر �l5O S3 ا� �2 ا�h5ج، ��

,-�Vوا�� ,��و%*� '�اآY 7,�- . وا��/ ة -� ا�'*ر ا�*� ا/, وا�S�Hأ/!�ء ا�� N,�� - .و%SY��3� ,� '� ا��+ /*� <p*ط ه�%V' .

'I,��ت �SY��3 ا�i��E,6 و'$�*��ت %*�, '$��5, %آ�� * . رL*نو'$�*� �3 �2 ا��h> 6' �}�Eل {E? أ/



CancerCancerCancerCancer----related Fatigue Clinicrelated Fatigue Clinicrelated Fatigue Clinicrelated Fatigue Clinic

• Comprehensive evaluation of fatigue

• Patients with or without evidence of cancer


We also have a Cancer-related Fatigue Clinic. And we know, we all know that fatigue impacts the quality of life of a patient just like pain, and can, in fact, drive a patient into serious depression. Comprehensive evaluation of fatigue, and again, for patients with or without evidence of cancer, this can be done at our Fatigue Center.

�� ,�دة �h5ج ا�4�sد ا��%��O _Eنأآ�� + �!6 /235، وآ3�� . ن �-�� k ,�*/ S3,�ة ا��+j3�' l '�& ا��2، وZ+ �4د�s235، أن ا+ �- j�?�+

+ و+�?6 إ��اء %V,,2 . ا�*اNJ أن +Zدي l+��O إ�S ا� <*ل -� اآ��vب { O�bsا S3� &B24 د�+ {�'& ��4د، �L SY��3*اء '6 و� ت �

�� و��Oن أ+ 2 %*� ، -� '�آ7 ا�4�sد �� .

30


Cancer Cancer Cancer Cancer ---- Hoping and CopingHoping and CopingHoping and CopingHoping and CopingChild, Adolescent, and Young AdultChild, Adolescent, and Young AdultChild, Adolescent, and Young AdultChild, Adolescent, and Young AdultPsychosocial Outreach ProgramPsychosocial Outreach ProgramPsychosocial Outreach ProgramPsychosocial Outreach Program

• Child and adolescent life

• Pediatric psychology and

neuropsychology

• Pediatric education

• Career and vocational counseling

• Kim’s Place

We also have a Child, Adolescent, and Young Adult Psychosocial Outreach Program for children, adolescents, siblings, parents of children. We have a wonderful place called Kim’s Place where children can go and play games and connect with each other.

�� ,�� أ+^� g'�/�O ��3*�, ا�+ � �EH3ب ��3اهV,6 و��ل وو+*��ل و�� j%�' م <V+6 و�,V��3اه�ل وأه24,3�� . {�Vء ا��+ � آ�� +*�

S� + NB�5ب '!& '?�ن را��ا Lر�� dل ار%,�د�� 6?�+ �,k 2,آ^5O 24^5O N' &b�وا��*ا .



Patient AdvocacyPatient AdvocacyPatient AdvocacyPatient Advocacy

• Complaints

• Unresolved issues

• Questions about MD Anderson

• Resources and services

Patient Advocacy helps with patient complaints regarding, maybe wait times. Maybe they do not like the way someone has spoken to them, or they are not happy with the billing concerns or issues. Patient advocacy will assist patients and navigate them through the right channels to address their questions and concerns.

م 2�J ا� -�ع �Vk 6*ق ا��SY ا�� ة �SY��3 -� {?�واه2، V+وh�' ،ر�r�/7'6 ا�O \35�+ ��,- . �4O ث أو �/24E$5% 2� j ا�V+�p ا�� %!

ه2 إ�,24، أو �/24 (,� راUE�O 6,Y و�*د {*ا(& أو '�Hآ& kأ<�ى أ�*ا%,��O \35�% .- م 2�J ا�V+و SY��3� ة �ع �Vk 6*ق ا��SY ا��

��رات أو ا�H*ا(& ا�� Lات ا�=!,! ��5$ ا�*�Vا� Sو+*�244 إ� J +24 %?*ن� .

31



Learning CenterLearning CenterLearning CenterLearning Center

Latest information on:

• Cancer care

• Support

• Prevention

• General health and wellness

We have a wonderful Learning Center that has immense information and updated information on cancer care with every type of cancer, the support, prevention programs, and general health and wellness information.

� �6 ر��+ �� '�آ7 %235 راNB +!�*ي �S3 '35*'�ت ه�3B و'!+ � �*+'�SY ا��ن �?& /*ع '6 أ/*اع ا��ن، و'35*'�ت �6 ا��/ ة،

. ��5' وا��-�ه و�Oا'g ا�*�J+ وا�=! ا



Supportive Care CenterSupportive Care CenterSupportive Care CenterSupportive Care Center

Assessing and managing cancer related:

• Physical and emotional symptoms

• Preventing or minimizing losses of

physical functioning

Our Supportive Care Center assesses and manages physical and emotional symptoms, preventing, minimizing losses of physical functioning, and this is very, very crucial to our patients who have mobility issues.

/, وا�*� ا/, و+��5'& '�45، Eاض ا��ة ا و+V,2 '�آ7 ا��+ ا��/ ان -� ا�*B�f` ا�$��/, ، وه* أ'� '24 +! '6وو+!*ل دون V- وث k

h?H' 6' ي +�5/*نeا� �/�Y�� E��O +�i3ا�!�آ ت� �- .

32



Pain ManagementPain ManagementPain ManagementPain Management

• Comprehensive pain assessment

• Multidisciplinary pain treatment for inpatients

and outpatients

• Treatment for acute and chronic pain related

to cancer

Pain Management, again, we have a superb Pain Management Service that does comprehensive pain assessment and treats acute and chronic pain related to cancer.

��+ ' را5B ��5$ ا��2 %$�ي %V,,�� ، '�ة أ<�ى، '��5$ ا��2، �>pE%ا�� . ��Oن{�'h ��2 وg��5% ا��م ا�!�دة وا��7'



Ethics Consultation ServiceEthics Consultation ServiceEthics Consultation ServiceEthics Consultation Service

• Patients and caregivers who face difficult decisions

related to medical treatment or other aspects of care

• Ethics consultation advisory only

• Available 24 hours/7 days a week

• Strictly confidential

• Free of charge

Our Ethics Consult Service is available 24 hours, 7 days a week. This is strictly confidential. And patients and caregivers who face difficult decisions related to medical treatment have the privilege of asking for an ethics consult with their providers to be able to make a reasonable decision.

ى او%�*' S3� ��+ � ,Jh>�رات ا�H�Lا� ' ��L �*ال 24-� < '� ا��+ ا�SY��3� 6?�+ �,k� 6+e و. وه� i��O ا��+ . ا�EL*عV�

pج ا�h5��O \35�% E5b ارات�J رة +*ا�4*ن�H�Lا U3� 7ة,�O Nا�� E '�ت ��3?6 '6 ا%�Iذ �Jار Iا� �' V' N' ,Jh>لأ*V5' .

33



Neuropsychology and Chemo Brain Neuropsychology and Chemo Brain Neuropsychology and Chemo Brain Neuropsychology and Chemo Brain

Neuropsychologists provide:

• Assessment of cognitive and neurobehavioral

symptoms

• Intervention strategies for cognitive and

neurobehavioral changes due to cancer, cancer

therapy or co-existing problems (MIND Clinic)

We have Neuropsychology and ChemoBrain Clinics that help with assessment of cognitive and neurobehavioral symptoms, which come up with intervention strategies for these patients with chemobrain.

��3 ة آ�� %� �B�,�,?غ ا��' �� ,�دات /��, �=E, و�,�دات ا�+ � �* N' �4r% ا��3*آ, ا�� ,E=5(�اض ا��5-, وا��2 ا,,V% �-

' 'N ا��SY ا�eي +�5/*ن '6 إI3, ا��> ��Lا%,$,�ت ا��sاءات ا�� . ا�?,�,��B ا� '�غ



Cancer Prevention Cancer Prevention Cancer Prevention Cancer Prevention

• Comprehensive and site-specific

cancer screening

• Risk assessment and risk reduction

• Smoking cessation and programs

• Genetic testing

Also our Cancer Prevention Center that does cancer

screening, risk assessment, has smoking cessation

programs and genetic testing.

G�رات يو��9Pن ا�ا��# /� ��J%�2ي��آ� ا� ��$��#�ن و�3� � G�رات ا�و [ ��ا�J�� z ع / ا� �P/�$��#�، و��Pا��را-% .

34



Tobacco Treatment Tobacco Treatment Tobacco Treatment Tobacco Treatment

• Voluntary program

• Counseling and tobacco-treatment medication to

eligible MD Anderson patients

• In-person behavioral counseling

• Over-the-counter nicotine replacement

• Therapies

• Tobacco-treatment prescription medication

Our tobacco treatment is an extremely effective program

that helps with patients who want to stop smoking. And

this again, they provide behavioral counseling on an

individual basis and also provide over-the-counter

nicotine replacement therapy.

�ة ا��9� ذ �P/و�<� ��69� �$< ج �/ ا�� j�� ءة�آ5Mن �� ا%G<�� /�?ا� SY��عا� J /P� ��رات . / ا� و��م أ�H� ا&

/ ��Wف �j� آ�� م �� $60%3 .&$%آ� $S أ&�س ��دي�G# �5Uو.



Sleep Clinic Sleep Clinic Sleep Clinic Sleep Clinic

For patients with the following symptoms:

• Sleep apnea and snoring

• Restless leg syndrome

• Insomnia or excessive daytime sleepiness

• Behavioral sleep disorder

We have a wonderful Sleep Clinic that helps with the

sleep apnea, restless leg syndrome, insomnia and

behavioral sleep disorders; a lot of counseling, and

management of their sleep cycles.

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35



• Assess and manage chronic cancer-related symptoms

• Help patients attain the best possible quality of life


Palliative Palliative Palliative Palliative CareCareCareCare and Rehabilitation and Rehabilitation and Rehabilitation and Rehabilitation

Our Palliative Care and Rehabilitation Center assesses

and manages chronic cancer-related symptoms. This

could be while they are undergoing active cancer

treatment, or when they come to the end of their

treatment, when they are at the end stages of their

treatment or in the advanced stages of their disease. This

service helps patients obtain the best possible quality of

life by coordinating their symptom management between

pain and fatigue, emotional, psychological, physical and

spiritual. Again, physician referral is required and this

service also helps patients understand the difference

between symptom management in acute care treatment,

and symptom management at the end of treatment where

it is mainly palliative and end of life therapy. So, we

come to the end of this presentation with the psychosocial

support for patients with breast cancer and I do hope that

this presentation was useful to you. Thank you for your

time and attention.

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C�ء ا�< ج��6� �0%ن ا��SY �� ا��اF: ، أو�$��#�ن، أو �6 او�3�� ه?k ا�� . ا�C6�V� �$< ج، أو �� ا��اF: ا�� / ا��ض

O�6 � F�ة ��60 / #��O ا�%� :Hأ� S$$S ا�W2%ل SY��ا�9%ا�K ا�%��ا��، وا��56� �� <��9 ا.�اض �/ ا.�� واC�M�د وا�

�Fوا��و ��G. وا� �آ� ،KG[ا� /� ��Fا.�� إ K$[ و��ة أ�Pى، �$�C� S ا�O��5 �/ �<��9 ا.�اض SY��ا� �H3$� ا�� أ� ��3�C�� ا�< ج، �6�� ا�� ا�< �� ا�2�دة، و�/ �<��9 ا.�اض

�5W� �5[$� ا�< ج ��C��C�� دورة ا�< ج Fo �0%ن �� 6. أ&�&� �6Y� ا� �� ا�?ي 63�ول ا�� ا��56 ��C� Sإ� �6$Uو �J 0%ن�و�C?ا � ا��م ��H�ت &�#�ن ا��Aي، وأر�% أن �0%ن ذ�� ا�<�ض �� ا��

�د $5� �0��Vة �J �� 0w�0ا . ا�Jو S$ G�ه�0� �0 � .و$S ا

psychosocial impact of breast آ ا ا ة ا ةˇ ا ،˙ˇ ˝ ˛آ ˝أ ، ًهأ ...…ارو˜ا...

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