Palliative Care in Oncology: The Patient and The Family

1
Palliative Care in OncologyThe Patient and The
Family

• Lauren Lambrecht, M3
• February 21, 2006

2
The Clinical Problem

• Many adults will have one or more chronic
  illnesses with which they will live for years
  before they die.
• These years are characterized by
• physical and psychological distress
• progressive functional dependence and frailty
• increased needs for family and external support
• Morrison, Sean, Meier, Diane. Palliative Care.
  NEJM 20043502582-2590.

3
Role of Palliative Care

• Palliative care aims to relieve suffering and
  improve the quality of life for patients with
  advanced illnesses and their families through
  specific knowledge and skills, including
• communication with patients and family members
• management of pain and other symptoms
• psychosocial, spiritual, and bereavement support
• coordination of an array of medical and social
  services
• Palliative care should be offered simultaneously
  with all other medical treatment.
• Morrison, Sean, Meier, Diane. Palliative Care.
  NEJM 20043502582-2590.

4
Communication

• Communicating with patients is a core skill of
  palliative medicine.
• Typically, clinicians elicit fewer than half of
  patients' concerns, consistently fail to discuss
  patients' values, goals of care, and preferences
  with regard to treatment.
• If physicians use specific communication skills
  in enhancing disclosure of the issues of concern
  to a patient, decreasing anxiety, assessing
  depression, and improving a patient's well-being
  and the level of the patient's and the family's
  satisfaction with the treatment.
• Make eye contact with patients, asking open-ended
  questions, respond to a patient's affect, and
  demonstrate empathy
• Morrison, Sean, Meier, Diane. Palliative Care.
  NEJM 20043502582-2590.

5
Adaptive Response to the Diagnosis of Cancer by
Patients

• Patients must adapt quickly to catastrophic news
• They must also control the level of emotional
  distress while making crucial treatment decisions
• Patients may experience reactions ranging from
• Extreme anxiety
• Sadness
• Fear
• Anger
• Numbness and lack of reactivity
• Guilt and attribution mechanisms
• Cognitively, patients may become highly focused,
  seeking information aggressively, or become
  confused, paralyzed, and unable to concentrate.
• Somatic complaints may increase, and there is
  often disruption of daily activity, appetite, and
  sleep
• Sadock, Benjamin J., Sadock, Virginia A. Kaplan
  Sadock's Comprehensive Textbook of Psychiatry.
  Lippincott Williams Wilkins, 2005.

6
Responsibilities of the Family

• Providing emotional support and
  containment-Family members are expected and
  expect themselves to contain their own reactions
  and to support the patient
• Sharing responsibility for decision making
• Concrete care taking families receive little
  help or training
• Meeting financial costs
• Absorbing social costs
• Maintaining stability
• Adapting to change
• Sadock, Benjamin J., Sadock, Virginia A. Kaplan
  Sadock's Comprehensive Textbook of Psychiatry.
  Lippincott Williams Wilkins, 2005.

7
Adaptive Response to Diagnosis by Families

• Sometimes, functional impairment that can rival
  or even exceed that of the patient
• Acutely
• Denial
• Pessimism
• Overvaluation
• Magical expectation
• Covert bargaining
• Disillusionment and anger
• Eventually, most families show generosity,
  courage, and resiliency
• However, as many as 25 to 30 percent would
  benefit from intervention
• Patients who reported having physicians who
  listened to the patient and caregiver reported
  fewer caregiver burdens
• Sadock, Benjamin J., Sadock, Virginia A. Kaplan
  Sadock's Comprehensive Textbook of Psychiatry.
  Lippincott Williams Wilkins, 2005.
• Emanuel EJ, Fairclough DL, Slutsman J, Emanuel
  LL. Understanding economic and other burdens of
  terminal illness the experience of patients and
  their caregivers. Ann Intern Med
  2000132451-459.

8
Interventions
9
References

• Sadock, Benjamin J., Sadock, Virginia A. Kaplan
  Sadock's Comprehensive Textbook of Psychiatry.
  Lippincott Williams Wilkins, 2005.
• Emanuel EJ, Fairclough DL, Slutsman J, Emanuel
  LL. Understanding economic and other burdens of
  terminal illness the experience of patients and
  their caregivers. Ann Intern Med
  2000132451-459.
• Morrison, Sean, Meier, Diane. Palliative Care.
  NEJM 20043502582-2590.