PsychoOncology and Palliative Care: Potential Contributions

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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

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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
• Patients 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 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

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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

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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

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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

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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
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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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Psychospiritual Crisis of ILLNESS

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

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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

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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 care
• Meaning-centered therapies
• ? Frankl Meaning-Based
• Breitbart
• ? Dignity-Conserving
• Chochinov
• ? Meaning-Folkman
• Holland

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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

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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 Diagnoses Dementia Delirium Mood
disorder (depression) Adjustment disorder
(reactive anxiety/depression) Anxiety
disorder Substance abuse Personality disorder
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Treatment Guidelines for Social Work
Practical Problems housing, assistance Psychosoc
ial Problems family conflict communication cult
ure/language
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Treatment Guidelines for Pastoral Counseling
Death/afterlife Loss of faith/meaning Grief
Isolation from religious community Guilt Hopele
ssness
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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, 2001
• IOM Improving Palliative-Care

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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

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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

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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
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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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Research Directions - 2

• Cytokine-induced
• Sickness behavior in animals
• Several cancer-related symptoms

• Fatigue
• Pain
• Anxiety

• Depression
• Cognitive loss
• Weakness

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Research Directions - 3
C. Cleeland, et al, Cancer, 2003, Working Group
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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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IPOS Liaison to National Psycho-Oncology
Societies hollandj_at_mskcc.org www.apos-society.or
g
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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