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PsychoOncology and Palliative Care: Potential Contributions

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Title: PsychoOncology and Palliative Care: Potential Contributions


1
Psycho-Oncologyand Palliative Care Potential
Contributions
  • Jimmie C. Holland, M.D.
  • Founding President,
  • International Psycho-Oncology Society
  • Attending Psychiatrist, Psychiatry Behavioral
    Sciences
  • Memorial Sloan-Kettering Cancer Center

2
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)

3
HISTORICAL BARRIERS 1
  • Double Stigma
  • Patients not told their diagnosis and
    psychological responses could not be explored
  • Mental disorders/illness long feared and
    stigmatized

4
HISTORICAL BARRIERS 2
  • Belief that subjective phenomena (pain,
    feelings) could not be quantitatively measured
  • Patients self-report was considered unreliable
    (only observer ratings reliable)
  • Social science methods were not understood by
    basic scientists

5
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

6
Barriers to Psych-Oncology Issues in Palliative
Care
  • Attitudes of medical staff that assume the
    nonphysical psychological domain as less
  • important
  • Attitudes of patients and family Think Im
    crazy embarrassed, angry by mental health
    consultation
  • Attitudes may discourage integration of mental
    health member of palliative care team

7
Barriers to Psych-Oncology Issues in Palliative
Care
  • 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

8
Barriers to Psych-Oncology Issues in Palliative
Care
  • Inadequate numbers of well-trained mental
    health professionals in psychosocial care
  • Too few training programs
  • Absence of oversight of staff in management of
    psychosocial/ psychiatric problems

9
Advanced Cancer RequiresCoping With
  • 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

10
EXISTENTIAL CRISES IN CANCER
I could die from this.
I have survived -- will it Return?
I will likely die -- depressed anxious
I am dying.
Adapted from McCormick Conley, 1995
11
  • 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

12
  • 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

13
Psychospiritual Crisis of ILLNESS
  • Loss of meaning
  • Loss of control (helpless)
  • Need for connection to some larger whole,
    greater than self
  • J. Kass, 1996

14
Spiritual and ReligiousBeliefs Provide
  • 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

15
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

16
Contributions to Care - 1
  • Psychological interventions unique for
    palliative care
  • Meaning-centered therapies
  • ? Frankl Meaning-Based
  • Breitbart
  • ? Dignity-Conserving
  • Chochinov
  • ? Meaning-Folkman
  • Holland

17
Folkman-based Psychotherapy
  • 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

18
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

19
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

20
Treatment Guidelines for Mental Health
Professionals
DSM-IV Diagnoses Dementia Delirium Mood
disorder (depression) Adjustment disorder
(reactive anxiety/depression) Anxiety
disorder Substance abuse Personality disorder
21
Treatment Guidelines for Social Work
Practical Problems housing, assistance Psychosoc
ial Problems family conflict communication cult
ure/language
22
Treatment Guidelines for Pastoral Counseling
Death/afterlife Loss of faith/meaning Grief
Isolation from religious community Guilt Hopele
ssness
23
  • NCCN Clinical Practice Guidelines for distress
    have been modified for end-of- life care they
    should be tested in a clinical setting
  • Holland Chertkov, 2001
  • IOM Improving Palliative-Care

24
Contributions to Care Burnout
  • Mental health of Staff
  • Physicians acknowledged feelings
  • (anger, frustration, depression)
  • Affect
  • Clinical decisions
  • Behavior with patients
  • Quality of care
  • Risk of burnout
  • Meier et al, 2002

25
Common Burnout Symptoms
  • PSYCHOLOGICAL
  • Frustration
  • Irritability
  • Tense, sad feeling
  • Anger
  • Withdrawn Numb
  • Detached emotionally
  • Cynical about work
  • PHYSICAL
  • Fatigue
  • Insomnia
  • Headaches
  • Back aches
  • Appetite change
  • GI disturbance

26
UK Study 476 Oncologists
Burnout Emotional exhaustion 31 Low personal
Accomplish 33 Diminished Empathy 23 Psychiatr
ic Disorder (GHI) 28 Ramirez et al,
BMJ, 1995
27
(No Transcript)
28
Research Directions - 1
  • Pro inflammatory cytokines as cause for fatigue,
    poor concentration, depression, anxiety
  • (? in pancreatic patients)

29
Research Directions - 2
  • Cytokine-induced
  • Sickness behavior in animals
  • Several cancer-related symptoms
  • Fatigue
  • Pain
  • Anxiety
  • Depression
  • Cognitive loss
  • Weakness

30
Research Directions - 3
C. Cleeland, et al, Cancer, 2003, Working Group
31
Research Directions - 4
  • Genetic contributions to chemo- related
    cognitive deficit
  • APOE4 allele
  • Fatigue (DYPD over expression)

32
  • .the secret of the care of the patient is in
    caring for the patient.
  • Peabody, JAMA
  • 1926

33
IPOS Liaison to National Psycho-Oncology
Societies hollandj_at_mskcc.org www.apos-society.or
g
34
8th WORLD CONGRESS PSYCHO-ONCOLOGY
"Multidisciplinary Psychosocial Oncology
Dialogue and Interaction"
18 - 21 October 2006 Palazzo del Cinema Venice,
Italy
Details will continue to be posted on the
conference website at www.ipos2006.it
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