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Psycho-Oncology and Palliative Care: Potential Contributions

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1 Psycho-Oncology and Palliative Care: Potential Contributions
* 07/16/96 Psycho-Oncology and 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 *

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)

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 Patient’s self-report was considered unreliable (only observer ratings reliable) Social science methods were not understood by basic scientists

5 Basic to Psycho-Oncology Research
* 07/16/96 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 I’m 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 Requires Coping 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

DIAGNOSIS OF CANCER ADVANCING DISEASE; DNR; HOSPICE RECURRENCE OF DISEASE COMPLETION TREATMENT DEATH INITIAL N.E.D. TERMINAL PALLIATIVE “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

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 Religious Beliefs 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 Psychosocial Problems family conflict communication culture/language

22 Treatment Guidelines for Pastoral Counseling
Death/afterlife Loss of faith/meaning Grief Isolation from religious community Guilt Hopelessness

23 NCCN Clinical Practice Guidelines for
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% Psychiatric Disorder (GHI) 28% Ramirez et al, BMJ, 1995


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 C. Cleeland, et al, Cancer, 2003, Working Group
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
“….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

"Multidisciplinary Psychosocial Oncology: Dialogue and Interaction" October 2006 Palazzo del Cinema Venice, Italy Details will continue to be posted on the conference website at

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