Title: Psycho-Oncology and Palliative Care: Potential Contributions
1Psycho-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)
3HISTORICAL BARRIERS 1
- Double Stigma
- Patients not told their diagnosis and
psychological responses could not be explored - Mental disorders/illness long feared and
stigmatized
4HISTORICAL 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
5Basic to Psycho-Oncology Research
- Developed and validated quantitative measures
of subjective symptoms
- QOL
- Core and disease specific modules
- Pain
- Fatigue
- Distress
- Anxiety
- Depression
- Delirium
6Barriers 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
7Barriers 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
8Barriers 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
9Advanced 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
10EXISTENTIAL 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
13Psychospiritual Crisis of ILLNESS
- Loss of meaning
- Loss of control (helpless)
- Need for connection to some larger whole,
greater than self - J. Kass, 1996
14Spiritual 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
15DISTRESS 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
16Contributions to Care - 1
- Psychological interventions unique for
palliative care - Meaning-centered therapies
- ? Frankl Meaning-Based
- Breitbart
- ? Dignity-Conserving
- Chochinov
- ? Meaning-Folkman
- Holland
17Folkman-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
18Contributions 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
19Contributions 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
20Treatment Guidelines for Mental Health
Professionals
DSM-IV Diagnoses Dementia Delirium Mood
disorder (depression) Adjustment disorder
(reactive anxiety/depression) Anxiety
disorder Substance abuse Personality disorder
21Treatment Guidelines for Social Work
Practical Problems housing, assistance Psychosoc
ial Problems family conflict communication cult
ure/language
22Treatment 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
24Contributions 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
25Common 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
26UK 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)
28Research Directions - 1
- Pro inflammatory cytokines as cause for fatigue,
poor concentration, depression, anxiety - (? in pancreatic patients)
29Research Directions - 2
- Cytokine-induced
- Sickness behavior in animals
- Several cancer-related symptoms
- Depression
- Cognitive loss
- Weakness
30Research Directions - 3
C. Cleeland, et al, Cancer, 2003, Working Group
31Research 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
33IPOS Liaison to National Psycho-Oncology
Societies hollandj_at_mskcc.org www.apos-society.or
g
348th 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