Cancer, Distress, and Compassionate Carehsc.ghs.org/wp-content/uploads/2014/09/PDF... · on the...
Transcript of Cancer, Distress, and Compassionate Carehsc.ghs.org/wp-content/uploads/2014/09/PDF... · on the...
Cancer, Distress, and
Compassionate Care September 24, 2014
Regina Franco, NP MSN
Manager of Center for Integrative
Oncology & Survivorship
Cancer Institute, Greenville Health System
Objectives
• By the end of this session, the attendee will understand
the concepts of:
– Compassionate care and cancer care delivery in survivorship
– Distress assessment and management
– Post-traumatic stress and growth, benefit finding
• The attendee will also be able to describe the:
– Value of compassionate care and distress assessment in other
disease management
What I’ll be Discussing
• What is compassionate care and how does a survivorship
program deliver that care?
• How do we assess and assist with distress even if it is not
necessarily associated with a cancer diagnosis?
– what affects a patient’s level of distress
• What is post-traumatic stress(PTS) or growth(PTG)
experienced by a cancer patient?
– when can PTS or PTG occur
– how to help manage PTSD and encourage benefit finding
Compassionate care
– Traumatized by personal
events & global perception of
cancer
– Healthcare is happy if patients
are “cured” but fails to look at
the aftercare side
– Second most traumatic time in
a cancer patients journey
would be upon completion of
treatment
What does it mean for those who have experienced
traumatic events such as a cancer diagnosis?
As Good as New?
“Whatever our wishes, the person who
has come through a cancer experience
is indelibly affected by it. The Humpty
Dumpty idea of ‘as good as new’- a
powerfully appealing notion for cancer
patients- simply does not pertain. For
better and for worse, physically and
emotionally, the experience leaves an
impression. No matter how long we live
cancer patients are survivors- once
wary and relieved, bashful and proud.”
Compassionate care
– Patient centered care- patient has
autonomy
– Patient empowerment- arming
them with knowledge
– Behavior-based interviewing
– Multidisciplinary approach
– Addressing the caregiver
as well as the patient
What is the compassionate care model in a survivorship program?
Addressing and Managing
Distress
Psychological Distress
“Social and emotional needs are as important as medical needs in the
face of a cancer diagnosis.” – Dr. Larry Gluck.
“Emotional distress has been recognized as a critical 6th vital sign
in medical care…routine screening of all patients may allow a fair distribution of
resources and carries potential for long-term cost savings.“ ( Linden)
1
Respiration
Temperature
Pain
Heart Rate
Blood Pressure
Distress
Psychological Distress
• “One third of the cancer
population experiences distress
and may profit from early
psychosocial intervention”
• Distress, in the context of cancer,
has been defined as “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, its physical
symptoms, and its treatment”
Distress Social
Financial
Spiritual
Vachon, Mary. "Psychosocial Distress and
Coping After Cancer Treatment."Cancer
Nursing 29.Supplement (2006): 26-31
Distress
• Distress can lead to:
– decreased quality of life
– poor health behaviors
– increased utilization of
medical services
– increased mortality.
– Lower satisfaction with
medical care
• Distress isn't always due to
a cancer diagnosis, could
be due to:
– Financial burdens
– Family dynamic
– Relationship issues
• CoC mandates after 2015:
– Any oncologist must ask if
patient experiences any level of
distress
– This important question must be
asked at least one
– If you ask, you must have a
means of managing that stress
• “Although at least one third of
the cancer populated
experiences distress, only
10% receive any
psychosocial therapy”
(Vachon, 2006)
Survivorship Clinic:
Case Study of AK
• African American female, age 60 at diagnosis
• Stage IIIA breast cancer, long-term diabetic
• Mastectomy, reconstruction planned
• Two rounds of chemotherapy (6 cycles,17 cycles)
• Radiation
• Endocrine Therapy
Clinic Visit Assessment for AK
• Height 5’5”, weight 230 lbs, BMI 38.3
• Dependent on cane, difficulty with ADL
• Right arm and trunk lymphedema
• Fatigue level 9, pain level 4,
distress inventory 44
“ I quit church when I was diagnosed, I stay at home all day, I
don’t want anyone to see me like this”
“Dr. says it will take 4 surgeries to repair my breast. I hate my
appearance! I’m bald, fat, and only have one breast now”
“I am a bother to you all, and I am not worth the time you all
are giving me”
Clinic Interventions for AK
• Nurse navigator consults with NP and Social Worker
• Interdisciplinary visit for crisis intervention and counseling
• Referrals to lymphedema/PT, dietician and social worker,
schedule consultations and follow-up visits
• Dietician individual counseling, diabetic-appropriate diet and
recommends Healthy Weigh Class at CIOS (3 sessions)
• Social worker individual counseling (3)
• Lymphedema/PT provides education on lymph drainage
techniques, skin care, compression garments, therapeutic
exercise (6)
AK Progress after SCP Visit
• Actively participated in group nutrition classes and complying
with nutritional counseling: “ I have been using a calorie
counting book with my daughter to record my food intake”
• Exercise: “ I am using a stationary bike with my daughter”
• Referred to RCP for balance and gait training
• Referred to Brownell Center for evaluation, medication
adjustment
• Poor body image and distress related to public appearance
remain: “ I don’t want to go back to church yet… I don’t want
everyone asking where I’ve been and why I’m bald”
Distress Thermometer
GHS-Distress Inventory
11
Please circle the answer that best applies to each questions based on your feelings over the last week:
1)I feel Sad.
2) I am anxious
3) I worry about being able to pay all of my bills.
4) I feel too tired to do all the things that I need or want to do.
5)I feel isolated.
6) I am having difficulty finding meaning and purpose in my life.
7) I feel distressed by changes in my appearance.
8) The quality of intimacy with my spouse or partner has declined.
9) I have trouble sleeping.
10) I feel a lack of emotional support by my family.
11) My ability to carry out my activities of daily living has been impacted by my cancer diagnosis
(i.e. managing daily schedules, getting to appointments, housekeeping, personal hygiene, caring for children)
12) Since my cancer treatment I feel physical discomfort (If you have not started your cancer treatment or are not
receiving treatment for cancer please circle 0).
Distress management
• Use of multidisciplinary care models is imperative
• Must have a programmatic approach- knowledge of
community support groups and programs within the
survivorship clinic
• Cancer patients who speak to their doctors about their
emotional health have higher rates of psychosocial care
and feel more satisfied with their cancer treatment.(onc
issue)
• Asking the question is biggest thing, must also be able to
provide assistance depending upon their response
Post-Traumatic Stress and
Post-Traumatic Growth
Post-Traumatic Stress
• Post-traumatic stress
disorder (PTSD) is a clinical
anxiety disorder that occurs
following an intensely
threatening, traumatic event
• Symptoms of PTSD have
been found in up to 50% of
cancer patients
• PTSD has been associated
with higher depression rates
and lower quality of life
among cancer patients and
survivors Morrill, E. Forrest, et al “The Interaction of Post-
traumatic Growth and Post-traumatic Stress
Symptoms in Predicting Depressive Symptoms
and Quality of Life." Psycho-Oncology 17.9
(2008): 948-53
PTSD can lead to
Post-Traumatic Growth
• “Distressing or harmful events can lead to negative
outcomes, such as post-traumatic stress symptoms(PTSS),
but they can also lead to positive outcomes, a experience
termed post-traumatic growth”(Morrill,2008)
• Patients can often immediately respond to a cancer
diagnosis with positive reinterpretation which is reflected by
PTG.
– This is a great “teachable moment” for the provider to encourage
positivity throughout cancer treatment.
Post-Traumatic Growth
• First two years imperative to
addressing possibilities of
benefit finding and PTG
because by year five
patients have normalized
• Great opportunity for change
of behavior
• We need a healthcare
system with behavior based
interviewing and skills to
support change behavior
Dimensions of PTG
• Dimensions of PTG include:
– Enhanced personal relationships
– Positive change in life priorities
– Appreciation for life
– Personal strength
– Spirituality
• Growth resulting from a cancer diagnosis, treatment, and
survivorship is not uncommon
• It has been reported that 60 to 95% of cancer survivors
experience post traumatic growth (Morrill, 2008)
PTG in Cancer Patients
• PTS has been linked to QOL and depression, but post-
traumatic growth (PTG) can affect how heavily those variables
magnify PTS( post traumatic stress)
• PTG may even act as a resource to help cope with some of the
stressors experienced by cancer patients • Cancer survivors use positive reinterpretation to reframe their
traumatic experience as a transition, a way to perceive potential
benefits such as :
– Relationships with others
– New possibilities
– Personal strength
– Spiritual change
Morrill, E. Forrest, et al “The Interaction of Post-traumatic
Growth and Post-traumatic Stress Symptoms in
Predicting Depressive Symptoms and Quality of
Life." Psycho-Oncology 17.9 (2008): 948-53
Benefit Finding
• Benefit finding is “the identification of specific benefits from
adversity and PTG as experiencing a significant positive
change as a result of a major life crisis” (Garland, 2007)
• Study done on a heterogeneous group of cancer patients found
that an increase of benefit finding was due to younger age,
higher stage of cancer, and greater perceived threat
• Examples of benefit finding:
– Smoking cessation groups
– Diet and exercise classes
– Participating in research projects
– Music and art therapy
– Medication and mindfulness
Summary
• Second most traumatic time in a cancer patient’s journey is
upon completion of treatment
– Must have a patient centered approach to deliver compassionate care
empowering the patient with a multidisciplinary approach
• Distress has been recognized as the critical 6th vital sign
– Need to have programmatic approach to address the effects of distress
on the physical and emotional health of cancer patients
• Even though up to 50 % of cancer patients experience
symptoms of post-traumatic stress, traumatic events often lead
to post-traumatic growth seen in 60-95% of patients
– Need to have a health care system to support change of behavior
necessary for this to occur
Survivor-Centered Care
is Essential
Education Alone is NOT Enough
– need programs
Need skilled multi-disciplinary team to make the Right Referrals for the
Right Patient
Finally, all of these components optimize a survivors’ ability to
evaluate their own lifestyles better “teachable moment” and to embrace
change behavior
Survivors are more likely to participate in their
own care if they feel we are addressing their
needs
One size does not fit all