Distress in Cancer Patients. Objectives Identify factors that increase a patient’s risk for...
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Distress in Cancer Patients. Objectives Identify factors that increase a patient’s risk for distress in cancer patients. Describe screening methods used
Objectives Identify factors that increase a patients risk for
distress in cancer patients. Describe screening methods used to aid
in the assessment and identification of distress in cancer
patients. Discuss interventions to manage distress in cancer
patients.
Slide 3
What is Distress?
Slide 4
Distress: Definition in Cancer Distress is a multifactorial,
unpleasant, emotional experience of a psychological (cognitive,
behavioral, emotional), social, and/or spiritual nature that may
interfere with the ability to cope effectively with cancer and its
treatment. It extends along a continuum, ranging from normal
sadness to panic and crisis. (NCCN Distress Management v.
2.2013)
Slide 5
Distress Prevalence Psychological distress varies by cancer
type and stage. One large study (4496 patients) reported a range of
29.6% - 43.4%. (Zabora et al., 2001) Another meta-analysis reported
30%-40% of patients with various types of cancer have some
combination of mood disorder. (Mitchell et al., 2011)
Slide 6
Depression and Anxiety Prevalence Reported range of depression
is 20% - 50% in patients with solid tumors, but as low a 8% in some
other studies. (Pasquini & Biondi, 2007) One large study of
consecutive, newly diagnosed patients across cancer types found
19.0% of patients had clinical levels of anxiety and another 22.6%
had subclinical symptoms (41.6% total)! Patients 50% of all cases.
(Linden et al., 2012)
Slide 7
History of Distress Screening
Slide 8
National Comprehensive Cancer Network (NCCN) First published
standards and guidelines for distress management in 1999
Not-for-profit alliance of 23 leading Cancer Centers Expert panels
produce evidence-based guidelines Consensus option Revised annually
Available for specific diseases and for supportive care
Slide 9
Standards of Care for Distress Management: NCCN Distress should
be recognized, monitored, documented and treated. All patients
should be screened at initial visit and at appropriate intervals.
Screening should identify level and nature of distress. Distress
should be managed according to clinical practice guidelines. (NCCN
Distress Management v. 2.2013)
Slide 10
Standards of Care for Distress Management: IOM and ONS The
Institute of Medicine (IOM) published Cancer Care for the Whole
Patient: Meeting Psychosocial Health Needs in 2008. Also in 2008,
ONS published a position paper, Psychosocial Services for Patients
with Cancer.
Slide 11
ACOS Commission on Cancer Standard 3.2 To be phased in
beginning in 2015, the American College of Surgeons Commission on
Cancer (ACoS CoC) Standard 3.2 The cancer committee develops and
implements a process to integrate and monitor on-site psychosocial
distress screening and referral for the provision of psychosocial
care. The timing of screening, method, tool used and referral
process are to be determined by each program Documentation and
compliance measurement must occur (American College of Surgeons,
2013)
Slide 12
Implementing Screening for Distress Joint Position Statement
ONS, in conjunction with APOS and AOSW, developed a joint position
statement Implementing Screening for Distress (2013)
Recommendations: Universal definition of distress needed Use of
validated tools for screening; screen broadly without focusing on
one particular symptom or one point in time Established processes
for communication of results When scores > distress threshold,
evaluation required with referrals for assessment and management as
need as part of routine care Cancer committee rep overseeing
screening program trained in identification and management of
distress in patients with cancer. (Oncology Nursing Society,
2013a)
Slide 13
Why is distress important? Distress influences cancer and its
treatment
Slide 14
Survivors tell us that their psychological concerns were as
important as their physical concerns, and that they were often not
recognized or addressed by their cancer care providers. (Institute
of Medicine, 2008)
Slide 15
Quality of Life In patients with higher distress o Functional
status is often poorer o More disability seen More somatic problems
are experienced, often resulting in more office visits and
cost
Slide 16
Treatment Adherence Depressed patients are often unable to
integrate their cancer diagnosis and treatment information. They
are less motivated towards self-care. They avoid health-promoting
behaviors. They demonstrate social isolation. They use community
resources less often. They have difficulty making plans and
decisions. They have greater difficulty tolerating treatment
side-effects. (DiMatteo & Haskard-Zolnierek, 2011)
Slide 17
Treatment Adherence (continued) A study of 293 early-stage
breast cancer patients who were treated for their depression were
more likely to complete adjuvant therapy than those in the
untreated arm. (Tuma, 2005)
Slide 18
Survival Increased mortality is associated with cancer and
coexisting depression Depression predicts mortality (Satin et al.,
2009) Compliance with treatment may account for the survival
differences.
Slide 19
Identifying Distress
Slide 20
Lifespan Risk factors for Distress Among those at highest risk
for distress are: Women Young Those 80 years Poor Marginally
educated Those with history of emotional / social problems
(Abrahamson, 2010 )
Slide 21
Increased Risk for Distress History of psychiatric
disorder/substance abuse Cognitive impairment Communication
barriers Severe co-morbid illnesses Social problems (e.g. family
conflict, living alone, limited support, financial problems,
history of abuse) Spiritual concerns (NCCN Distress Management v.
2.2013)
Slide 22
Cancer Type Risk Factors Cancers with highest prevalence of
psychological distress: Lung Brain Liver Pancreatic Head & Neck
(Zabora et al., 2001)
Slide 23
Creating a Screening Process
Slide 24
Process Considerations Who will screen Screening instrument
Timing: Vulnerable times (NCCN) include Finding suspicious symptom
Diagnosis & workup Awaiting treatment Change in treatment
modality End of treatment/ hospital discharge Recurrence or
progression Referral decisions and options Documentation (NCCN
Distress Management v. 2.2013)
Slide 25
Screening Tools
Slide 26
Impact of Screening Tools When screening for distress without
using screening tool: Doctors incorrect in determining distress 35%
of the time. (Fallowfield, et al. 2001) Doctors recognized severe
distress 36.6% of the time. (Sollner, 2001) Providers (including
nurses) did not acknowledge verbal cues of distress 43%of the time.
(Kennedy Sheldon et al., 2011)
Slide 27
( Reproduced with permission from the NCCN Clinical Practice
Guidelines in Oncology (NCCN Guidelines) for Distress Management
(V.2.2013). 2013 National Comprehensive Cancer Network, Inc. )
Slide 28
Name of Tool# of ItemsFocus of Measurement Distress Thermometer
& Problem List 0-10 rating plus 38 problems Distress and
problems related to distress Brief Symptom Inventory (BSI-18)
18Somatization, anxiety, depression, general distress Hospital
Anxiety & Depression Scale (HADS) 14Clinical depression &
anxiety Functional Assessment of Chronic Illness Therapy (FACIT)
274 domains of QOL Profile of Mood States (POMS) 656 mood
states
Slide 29
PSYCH-6 Relatively new tool for anxiety and depression
screening (2009) Comparable to HADS-T tool; subscale of SPHERE-12
scale Validated for use in oncology patients Shorter instrument
that is very accurate (Clover et al., 2009)
Slide 30
Evidence of moderate to severe distress on screening tool
Assessment by a primary team clinician to determine high risk
patients and Practical problems Family problems Emotional problems
Spiritual concerns Physical problems Referral Social Work Mental
Health Pastoral care Medical team
Slide 31
Case Scenario: Mrs. J Mrs. J; a 70 year old female with a
recent diagnosis of lung cancer Presents today complaining of
nausea, lack of appetite, and thick, blood tinged sputum and cough
Grandson drove Husband sitting quietly staring straight ahead
Slide 32
Case Scenario: Mrs. J (continued) Distress score: 5 Problems
identified as yes: Dealing with partner, depression, fears, worry,
eating, fatigue, nausea, sleep, and getting around
Slide 33
Measuring Compliance Quality Indicator examples: Medical Record
should show that the patients emotional well-being was assessed
within 1 month of the first visit with a medical oncologist If a
problem with emotional well-being was identified, documentation
shows that action was taken to address the problem, or an
explanation exists for inaction. (Jacobsen, 2010)
Slide 34
Suicide in Cancer Patients: Nursing Considerations
Slide 35
Suicide Risk Factors in the General Population History of
psychiatric disorder or substance abuse Family history of suicide
Few social supports Chronic disease Pain Older age, or youth Living
alone Unemployed Male gender
Slide 36
Cancer Specific Risk Factors for Suicide Hopelessness Advanced
stage of disease; poor prognosis Fear of the future Impaired
physical functioning Time since diagnosis (risk greatest in first
months) Cancer type: lung, oral, pharyngeal, prostate &
pancreatic Confusion/delirium Poorly controlled pain Presence of
deficit symptoms, (e.g., loss of mobility, loss of bowel and
bladder control, amputation, sensory loss, paraplegia, inability to
eat and to swallow) Feeling like a burden to others Loss of
autonomy Desire to control ones own death (National Cancer
Institute, 2013; Anguiano et al., 2011; Robson et al., 2010;
Recklitis et al., 2006)
Slide 37
Suicidal Thoughts Are relatively common; one review found a 21%
rate of suicidal ideation. (Cooke et al., 2013) Some cancer
patients experience a desire for hastened death: May be passive
wish. May represent request for assisted suicide. In patients with
moderate or severe distress, suicidal ideation should be
addressed.
Slide 38
Suicide Assessment Even when risk was identified, only 17% of
oncology nurses assessed for presence of a suicide plan. (Valente,
2010) Nurses are not alone in this skill deficit. Nurses recognize
they have limited skill and experience and are often uncomfortable
with suicide assessment.
Slide 39
Asking about Suicide Feeling down and depressed is not uncommon
for people with cancer. Let me know if you need extra support, I
can refer you to a counselor. Do you have thoughts of ending your
own life? Some people with cancer think about suicide; please let
me know if that is happening with you. You are telling me how
miserable you feel. Is it ever so bad you think about taking your
own life?
Slide 40
Maintaining Safety Every facility must have a policy in place
and method for crisis management and mental health referral.
Slide 41
Psychosocial Interventions for Distress
Slide 42
Many Factors Contribute to Distress Practical Concerns Family
Emotional Spiritual Physical Interventions should be geared to the
problem(s) identified as contributing to distress.
Slide 43
ONS Putting Evidence into Practice (PEP) Interventions Goal:
Identify and use evidence-based interventions for patient care and
teaching Assigned to recommendation categories based on level of
evidence available: Recommended for Practice Likely to be Effective
Benefits Balanced with Harm Effectiveness Not Established
Effectiveness Unlikely Not Recommended for Practice
Slide 44
PEP Interventions: Anxiety Recommended for Practice o
Supportive care Likely to Be Effective o Coaching, cognitive
behavioral therapy, massage, progressive muscle relaxation,
psychoeducational interventions Effectiveness Not Established o
Anxiolytics, art therapy, CAM. Exercise, hypnosis, music therapy,
reflexology, Reiki, TT, yoga (and others) Effectiveness Unlikely o
Information and orientation (Oncology Nursing Society, 2013b)
Slide 45
PEP Interventions: Depression Recommended for Practice o
Individual psychotherapy and supportive interventions,
psychoeducational interventions Likely to Be Effective o
Antidepressant, methylphenidate, mindfulness-based intervention,
relaxation Effectiveness Not Established o Aromatherapy, massage,
exercise, healing touch, hypnosis, certain Selective Serotonin
Reuptake Inhibitors (SSRIs) Effectiveness Unlikely o Reflexology
(Oncology Nursing Society, 2013c)
Slide 46
Family Member Concerns Family role changes Taking care of their
own needs Maintaining open communication with the patient Fears
that their own risk for cancer may be high Therefore, consider the
PEP interventions recommended and likely to be effective for
Caregivers: Cognitive behavioral interventions, psychoeducation,
psychotherapy, and supportive skills.
Slide 47
Survivor Considerations
Slide 48
Distress doesnt end when active treatment ends Many patients
continue treatment chronically. Distress also occurs post
treatment. Integration into new normal. Adherence to surveillance
demands.
Slide 49
Barriers to Distress Screening and Management
Slide 50
Nurse Identified Barriers include: Time to screen Privacy
Authority Comfort with emotional discussions Availability of
referral sources
Slide 51
Oncology nurses are key to achieving quality psychosocial care
for patients! We can screen, identify concerns, provide resources,
and consistently convey the importance of our patients emotional as
well as physical well-being. Conclusion
Slide 52
Full list of references included with your handouts
References
Slide 53
Caryl D. Fulcher MSN, RN, CNS-BC Clinical Nurse Specialist and
Team Leader Dept. Of Advanced Clinical Practice Duke University
Hospital Durham, North Carolina Special Thanks: Author
Slide 54
Sue Swanson RN, MS, CNS, AOCN Oncology Clinical Coordinator
University of Kansas Cancer Center Westwood, Kansas Special Thanks:
Expert Reviewer