A review of distress and its management in couples facing end-of-life cancer

Improving the well-being of couples facing cancer: a review of couples-based psychosocial interventions

The purpose of this review article is to assess the available scientific evidence on the effects of couples-based psychosocial interventions for couples when one spouse faces cancer. For the present study, we conducted an extensive search of three electronic databases using a comprehensive search strategy. The literature search identified 14 studies evaluating couples intervention where one partner is facing cancer. Among them, eight studies concluded there was overall improvement for patients and eight studies reported overall improvement for partners, whereas an additional five studies showed partial improvement for patients and three demonstrated partial improvements for partners. Taken in the aggregate, these studies illustrated partial effectiveness--most had some positive results--but with clear limitations in terms of how many aspects of psychosocial well-being changed, lack of equal effectiveness for both patients and their partners, or limited maintenance of improvements over time, a common concern with brief psychosocial interventions. Although couples-based interventions may facilitate emotional support and dyadic coping, how these psychosocial interventions should be delivered, at what point in the illness and treatment they should be delivered, and how long they should continue remain as future challenges.

The experience of caregivers of hematological cancer patients undergoing a hematopoietic stem cell transplant: a comprehensive literature review

OBJECTIVE

Hematopoietic stem cell transplant (HSCT) is a demanding procedure with associated physical and psychological sequelae that affects patients and their families. Caregivers to HSCT patients not only have to cope with the life-threatening nature of the disease and treatment, but they also have care-giving responsibilities. This study reviews the literature on the psychosocial impact of being a caregiver to a HSCT patient.

METHODS

A critical review of the literature published before June 2010 was conducted. Databases searched included CINAHL, Medline, PsycInfo, and Academic Search Complete, as well as a comprehensive reference review. Studies that pertained to caregivers of children (under the age of 18) undergoing a HSCT or caregivers to patients with non-hematological malignancies were excluded. Sixteen quantitative research articles and three qualitative research articles were reviewed and analyzed.

RESULTS

Caregiver distress is highest pre-transplant and decreases over time, and caregivers display distress levels comparable to or higher than patients' reported distress levels. Predictors of caregiver distress include female gender, elevated subjective burden, and higher patient symptom distress. Caregivers reported uncertainty, fear of the future, juggling patients' needs with their own, and difficulties adapting to role changes; however, they also reported positive aspects to care giving, such as personal growth and developing a more positive relationship with the patient.

CONCLUSIONS

There are many limitations to the current research and future directions should include both members of the dyad to evaluate the reciprocal relation between caregiver and patient variables, as well as theory-driven research and research with direct clinical applications.

Return home at the end of life: Patients' vulnerability and risk factors

Although most of the people in good health questioned about the subject said they would like to die at home, in the western world between 60 and 80% of deaths occur in hospital. Most authors consider that the indispensable conditions for a return home are the patient's desire and presence of the family and caregivers with the appropriate skills. The assessment of other factors predictive of a return home is inadequate. The aim of this study is to clarify how the return home is influenced by the vulnerability of the patient at the end of life, and by that of the family and caregivers. We carried out a multicentric, observational, prospective, exhaustive and longitudinal epidemiological study (three months follow-up), including 146 patients hospitalized at the end of their life and desiring to return home. For these patients the caregivers respected their freedom to choose to die at home in over half the cases (56%). Their overall vulnerability (personal, family context and caregivers) had a significant influence on the return home. This overall vulnerability was in fact identified as applying in 40% of the clinical situations, and made the possibility of a return home 50% less likely.

Utility and use of palliative care screening tools in routine oncology practice

Palliative care, which seeks to alleviate suffering and optimize quality of life, is an increasingly recognized and valued medical subspecialty. With its focus on identifying and managing symptoms and problems encountered in expected functional decline, the domain of palliative care overlaps significantly with that of oncology, where patients typically experience a host of disease- and treatment-related effects. Assessment instruments have been developed and validated in the context of both disciplines, but oncology may benefit from the inclusion of palliative care screening instruments specifically developed for patients with advanced, life-limiting illnesses. New methods of screening, particularly technology-based ones such as electronic data capture, allow greater flexibility across care settings and longitudinal data capture for ongoing evaluation. This article reviews frequently used and available screening instruments for common palliative needs in cancer patients and provides an example of a novel technology-based screening approach to quickly identify and address a critical patient concern.

Bereavement care: some clinical observations

The needs of cancer patients' bereaved carers require attention. Although the majority of bereaved individuals manage to cope with their loss, a minority remain distressed and suffer serious prolonged disruption of their lives. The Yale Bereavement Study has revealed a specific syndrome, prolonged grief disorder. The diagnostic criteria of this disorder are outlined and several clinical illustrations are presented. Preliminary evidence suggests that cognitive-behaviour therapy (CBT) can be effective in the management of prolonged grief disorder. An example of the use of CBT is provided together with some useful clinical guidelines.

Acceptability of the Distress Thermometer and Problem List to community-based telephone cancer helpline operators, and to cancer patients and carers

BACKGROUND

Cancer can be a distressing experience for cancer patients and carers, impacting on psychological, social, physical and spiritual functioning. However, health professionals often fail to detect distress in their patients due to time constraints and a lack of experience. Also, with the focus on the patient, carer needs are often overlooked. This study investigated the acceptability of brief distress screening with the Distress Thermometer (DT) and Problem List (PL) to operators of a community-based telephone helpline, as well as to cancer patients and carers calling the service.

METHODS

Operators (n = 18) monitored usage of the DT and PL with callers (cancer patients/carers, >18 years, and English-speaking) from September-December 2006 (n = 666). The DT is a single item, 11-point scale to rate level of distress. The associated PL identifies the cause of distress.

RESULTS

The DT and PL were used on 90% of eligible callers, most providing valid responses. Benefits included having an objective, structured and consistent means for distress screening and triage to supportive care services. Reported challenges included apparent inappropriateness of the tools due to the nature of the call or level of caller distress, the DT numeric scale, and the level of operator training.

CONCLUSIONS

We observed positive outcomes to using the DT and PL, although operators reported some challenges. Overcoming these challenges may improve distress screening particularly by less experienced clinicians, and further development of the PL items and DT scale may assist with administration. The DT and PL allow clinicians to direct/prioritise interventions or referrals, although ongoing training and support is critical in distress screening.

Intimacy processes and psychological distress among couples coping with head and neck or lung cancers

OBJECTIVE

Couples coping with head and neck and lung cancers are at increased risk for psychological and relationship distress given patients' poor prognosis and aggressive and sometimes disfiguring treatments. The relationship intimacy model of couples' psychosocial adaptation proposes that relationship intimacy mediates associations between couples' cancer-related support communication and psychological distress. Because the components of this model have not yet been evaluated in the same study, we examined associations between three types of cancer-related support communication (self-disclosure, perceived partner disclosure, and protective buffering), intimacy (global and cancer-specific), and global distress among patients coping with either head and neck or lung cancer and their partners.

METHOD

One hundred and nine patients undergoing active treatment and their partners whose average time since diagnosis was 15 months completed cross-sectional surveys.

RESULTS

For both patients and their partners, multilevel analyses using the actor-partner interdependence model showed that global and cancer-specific intimacy fully mediated associations between self- and perceived partner disclosure and distress; global intimacy partially mediated the association between protective buffering and distress. Evidence for moderated mediation was found; specifically, lower levels of distress were reported as a function of global and cancer-specific intimacy, but these associations were stronger for partners than for patients.

CONCLUSIONS

Enhancing relationship intimacy by disclosing cancer-related concerns may facilitate both partners' adjustment to these illnesses.

Examination of couples' attachment security in relation to depression and hopelessness in maritally distressed patients facing end-stage cancer and their spouse caregivers: a buffer or facilitator of psychosocial distress?

PURPOSE

The purpose of this study is to determine levels of depression and hopelessness and to explore the relationship between attachment security and psychosocial distress in patients with metastatic/recurrent cancer and spouse-caregivers, experiencing marital distress.

METHODS

Couple-participants were from a pilot study and a larger clinical trial prior to randomization. Participation required that one partner endorsed marital distress on the Revised Dyadic Adjustment Scale (RDAS). Outcome measures included the Beck Depression Inventory-II (BDI-II), Beck Hopelessness Scale (BHS), and Experiences in Close Relationships Inventory.

RESULTS

Caregivers, compared with their matched ill-partners, had significantly higher scores on the RDAS (<distress) after taking sex, avoidance, and anxiety into account. Fifty-two percent of patients and 33% of caregivers scored above the BDI-II cut-off (≥ 15) for depression, with patients and females reporting higher levels of depression compared to caregivers and males. Thirty-three percent of patients and 24% of caregivers scored above the BHS cut-off (≥ 8) for hopelessness, with males and patients displaying significantly higher mean scores compared with females and caregivers. There was a significant interaction effect of sex and avoidance for RDAS; as the male avoidance subscale score increased, the female caregiver RDAS declined (>distressed).

CONCLUSIONS

Marital distress may be amplified within insecure attachment bonds, especially among avoidant male patients and their female caregivers, which may influence caregiving/care-receiving. We offer unique, preliminary support for identifying couples at risk to help reduce suffering and complicated bereavement in the terminal cancer population. Further research that include larger studies, are needed to determine relationships among attachment and psychosocial outcomes.

Childhood trauma, attachment style, and a couple's experience of terminal cancer: Case study

Objective:

The primary objective of this article is to elucidate the significance of psychosocial distress and risk in a sub-population of end-stage cancer patients and their spouse caregivers who present with an especially challenging attachment style and histories of childhood trauma. The case study presented highlights the need to both identify and offer an empirically validated couple–based intervention, along with a multi-disciplinary team approach over the trajectory of the illness and at end of life.

Method:

A validated marital protocol (emotionally focused couple therapy [EFT]) is modified for this population and conducted by an EFT-trained psychologist as part of a pilot investigation as to the feasibility and effectiveness of EFT for the terminal cancer population. Measures of marital distress, depression, hopelessness, and attachment security are completed at baseline and subsequent intervals, as reported in another publication. Attachment insecurity and the exquisitely intimate relationship with caregiving and care receiving are underscored, given the couple's traumatic childhood history.

Results:

The couple described herein, followed from diagnosis of metastatic disease to end of life illuminates the potential effectiveness of a modified EFT protocol, and underscores the need to both identify and intervene with a population potentially at significantly high risk for marital distress, suicidality, depression, and hopelessness.

Significance of Results:

The benefits of a multidisciplinary team is evident as the patient's symptoms of physical distress increased toward end of life and she returned to earlier behaviors, namely suicidal ideation and an attempt to alleviate her experience of suffering. The strength of the marital bond, possibly as a result of the intervention, and the efforts of the multidisciplinary team approach, demonstrate potential to mitigate a catastrophic end of life and a complicated spousal bereavement. This case study adds to the current empirical literature in an area that is currently under-studied and under-reported.

Depression in husbands of breast cancer patients: relationships to coping and social support

PURPOSE

The purpose of the present study was to examine depression in husbands of women with breast cancer, as depression is typically as high in husbands as in patients, and impacts functioning in both.

METHODS

We compared husbands of patients to husbands of women without chronic illness on depressive symptoms with the Center for Epidemiological Studies Depression Scale, social support with the Interpersonal Support Evaluation List, and coping with the Ways of Coping Questionnaire. Using the stress and coping model, we examined whether coping mediated social support and depression differently by group, as has been found in the literature.

RESULTS

Husbands of patients reported higher scores on the measure of depression and lower use of problem-focused coping, while groups reported equivalent social support. Escape-avoidance coping emerged as a full mediator between social support and depression in husbands of patients, but only a partial mediator in comparison husbands. Accepting responsibility coping partially mediated social support and depression in both groups. Low social support appears particularly detrimental in husbands of patients as it is associated with ineffective coping and depression.

CONCLUSIONS

Findings suggest that among husbands of patients, social support relates to depression only through its relationship with coping, indicating healthcare providers should direct attention and intervention to the coping strategies employed by husbands with low social support.

Feasibility of brief psychological distress screening by a community-based telephone helpline for cancer patients and carers

Background

Up to one-third of people affected by cancer experience ongoing psychological distress and would benefit from screening followed by an appropriate level of psychological intervention. This rarely occurs in routine clinical practice due to barriers such as lack of time and experience. This study investigated the feasibility of community-based telephone helpline operators screening callers affected by cancer for their level of distress using a brief screening tool (Distress Thermometer), and triaging to the appropriate level of care using a tiered model.

Methods

Consecutive cancer patients and carers who contacted the helpline from September-December 2006 (n = 341) were invited to participate. Routine screening and triage was conducted by helpline operators at this time. Additional socio-demographic and psychosocial adjustment data were collected by telephone interview by research staff following the initial call.

Results

The Distress Thermometer had good overall accuracy in detecting general psychosocial morbidity (Hospital Anxiety and Depression Scale cut-off score ≥ 15) for cancer patients (AUC = 0.73) and carers (AUC = 0.70). We found 73% of participants met the Distress Thermometer cut-off for distress caseness according to the Hospital Anxiety and Depression Scale (a score ≥ 4), and optimal sensitivity (83%, 77%) and specificity (51%, 48%) were obtained with cut-offs of ≥ 4 and ≥ 6 in the patient and carer groups respectively. Distress was significantly associated with the Hospital Anxiety and Depression Scale scores (total, as well as anxiety and depression subscales) and level of care in cancer patients, as well as with the Hospital Anxiety and Depression Scale anxiety subscale for carers. There was a trend for more highly distressed callers to be triaged to more intensive care, with patients with distress scores ≥ 4 more likely to receive extended or specialist care.

Conclusions

Our data suggest that it was feasible for community-based cancer helpline operators to screen callers for distress using a brief screening tool, the Distress Thermometer, and to triage callers to an appropriate level of care using a tiered model. The Distress Thermometer is a rapid and non-invasive alternative to longer psychometric instruments, and may provide part of the solution in ensuring distressed patients and carers affected by cancer are identified and supported appropriately.

Recruitment and retention of palliative cancer patients and their partners participating in a longitudinal evaluation of a psychosocial retreat program

OBJECTIVE

The negative impact of a palliative cancer diagnosis on the quality of life of patients and their partners is well documented. Unfortunately, research on interventions to improve psychological and spiritual well-being of these couples has been considered impractical because of the deleterious influence of disease progression on participation. This study evaluated the feasibility of offering the Tapestry Retreat, an intensive psychosocial intervention for palliative care patients and their partners.

METHODS

Participants in the Tapestry Retreat included 15 patients with advanced breast, prostate, or colon cancer and their partners (n = 30). Also included was a natural history group consisting of 20 patients and their partners (n = 40). All couples completed questionnaires related to quality of life, distress, marital satisfaction, and existential concerns at baseline, after the retreat or 1 month after baseline, and then again at 3, 6, 9, and 12 months.

RESULTS

Patients in the Tapestry group were significantly more likely to be women who had received prior psychological support and were less comfortable with their finances. Partners attending the Tapestry retreat were also more likely to have received prior psychological support.

SIGNIFICANCE OF RESULTS

Despite issues with recruitment and retention, retreat participation was considered feasible. Recommendations for future research are discussed.

The importance of relationships in the experience of cancer: a re-working of the policy ideal of the whole-systems approach

PURPOSE OF THE RESEARCH

This paper outlines the importance of interpersonal familial relationships in how people experience cancer.

METHODS AND SAMPLE

This paper draws on data from a longitudinal, qualitative study which aimed to explore the experiences of people with cancer within the first year following diagnosis. The sample included fifteen men with colorectal cancer, 3 women with colorectal cancer, twelve women with breast cancer, nine women with gynaecological cancer, six women with lung cancer, eleven men with lung cancer and ten men with prostate cancer. Four people died during the course of the study and ten people chose to withdraw.

KEY RESULTS

Close interpersonal relationships were clearly core mediating features in how the illness was experienced; for example, presenting for symptom investigation was often the result of ongoing interaction and debate between partners. We use the idea of the 'joint ownership of cancer' to elucidate the role of relationships in experiencing and understanding the disease. We propose a re-working of the notion of a whole-systems approach to include not just partnership working within health and social care agencies, but centralising the patient's interpersonal relationships as critical in each aspect of their experience of cancer.

CONCLUSIONS

The findings are discussed in terms of the need for service delivery and research to be mindful of the relational aspects and implications of illness. Nurses can play a key role in how this is operationalised in supporting people affected by cancer in the context of their relationships.

Hopelessness as a predictor of depressive symptoms for breast cancer patients coping with recurrence

OBJECTIVE

The Hopelessness Theory of Depression provides the framework to test feelings of hopelessness and social support as predictors of depressive symptoms in women recently diagnosed with a recurrence of breast cancer.

METHODS

Patients (N=67) were assessed within weeks of receiving their recurrence diagnosis (initial) and again 4 months later (follow-up).

RESULTS

Controlling for their current physical and depressive symptoms, hopelessness at diagnosis was a significant predictor of the maintenance of depressive symptoms among patients. A corollary of the theory was also confirmed: social support (i.e. the presence/absence of a romantic partner) interacted with hopelessness.

CONCLUSIONS

Women who reported feelings of hopelessness and who were alone (i.e. without a partner) were especially vulnerable to later depressive symptoms. The data provide support for the Hopelessness Theory and suggest factors conferring risk for depressive symptoms for those coping with a worsened cancer prognosis.

Screening cancer patients' families with the distress thermometer (DT): a validation study

Although family members of cancer patients are at great risk of experiencing psychological distress, clinical tools to assist with recognizing and intervening with appropriate psychosocial care are sparse. This study reports on the first validation of the distress thermometer (DT) as a screening instrument for symptoms of depression and anxiety in family members of cancer patients. The DT was administered with the Hospital Anxiety and Depression Scale (HADS) in a sample of 321 family members. Receiver operating characteristics (ROC) demonstrated that the DT has good diagnostic utility relative to the HADS (area under the curve= 0.88 relative to the HADS anxiety scale; 0.84 relative to the HADS depression scale, respectively). The ROC curves indicate that using a cut-off of 4/5 maximizes sensitivity (86.2% HADS anxiety scale; 88.2% HADS depression scale) and specificity (71.2% HADS anxiety scale; 67.6% HADS depression scale); however, the alternative lower cut-off of 3/4 increases sensitivity (94.1% for both scales) and hence reduces the risk of missing distressed family members (specificity is 62.9% for HADS anxiety scale; 59.1% for HADS depression scale). The results offer validation of the DT for screening family members of cancer patients and support its use for clinical assessment. Distress screening with DT for family members of cancer patients is a promising and efficient approach to integrating family members in the program of care and provides the first step toward meeting their unmet needs with referral for supportive services.

The assessment and management of family distress during palliative care

PURPOSE OF REVIEW

In the advanced stages of illness, families manage multiple caregiving demands while facing the emotional task of preparing for the loss of their loved one. Palliative care settings are well suited to identifying families at risk for elevated distress, and providing support as they navigate this process. This review summarizes current research in the assessment and management of family distress at the end of life.

RECENT FINDINGS

The recent literature on families of terminally ill cancer patients has provided a more precise description of the relational and cultural factors that contribute to family distress. Studies eliciting the perspectives of family members on what is needed at the end of life affirm the importance of supportive communication and continuity of psychosocial care into bereavement. Other developments include efforts to establish guidelines for conducting family meetings in the palliative care setting, and to train palliative care practitioners in family-centered assessment techniques. Finally, there is a limited but growing evidence base for the utility of delivering family-focused psychosocial interventions during palliative care.

SUMMARY

The knowledge gained from current research on what is most salient to family members during palliative care is critical for ensuring effective delivery of supportive services and collaborative engagement in those services.

Intimacy and relationship processes in couples' psychosocial adaptation to cancer

The authors highlighted the importance of viewing cancer from a relationship perspective. This perspective not only considers the marital relationship as a resource that individual partners draw upon but also highlights the importance of focusing attention onto the relationship and engaging in communication behaviors aimed at sustaining and/or enhancing the relationship during stressful times. On the basis of existing conceptualizations, empiric research on couples and cancer, and the authors' perspective on the literature, they formulated the relationship intimacy model of couples' psychosocial adaptation to cancer as a first step toward building a framework for researchers and clinicians to inform their work in this area. The model proposes that patients and their partners engage in behaviors that either promote or undermine the level of closeness in their relationship and that the closeness of the marital relationship is an important determinant of patient and partner psychologic adaptation to cancer. Preliminary data from a couples' intimacy-enhancing intervention for breast cancer patients and their partners supported the model. Of the 25 couples who consented to participate in the intervention and completed the preintervention surveys, 15 couples completed all 5 sessions, and 12 couples completed the follow-up survey. The current results suggested that the intervention improved patient and partner perceptions of the closeness of their relationship and reduced their distress. The authors also discuss limitations of the relationship intimacy model as well as future directions for empiric and clinical research on couples' psychosocial adaptation to cancer.

Dying with cancer, living well with advanced cancer

INTRODUCTION

There are 1.7 million deaths from cancer in Europe each year and by 2020 the World Health Organisation (WHO) estimates that, globally, more than 15 million people will experience cancer and 10 million will die from it each year. Furthermore, as new therapies are developed, people are living longer with cancer than in the past, and the population with cancer will be older.

MATERIALS AND METHODS

We used epidemiologically based needs assessment approaches to estimate the number of people in Europe with symptoms and problems, published data and reviews to appraise treatment options, issues of communication, family care, bereavement and socio-demographic factors affecting care, and a European survey to consider the types of services. In addition, we used systematic literature review data to appraise the effectiveness of services and factors affecting place of death.

RESULTS

The quality of life of virtually all cancer patients with advanced disease is impaired by one or more symptoms, emotional, social, spiritual and communication concerns. Patients have a median of 11 symptoms. In Europe there are up to 1.6 million patients with pain each year, and in around one third of these it will be severe, requiring complex treatment. Almost an equal number are affected by fatigue, and more than 1 in 2 are affected by anxiety and/or depression, breathlessness, insomnia, nausea, constipation and/or anorexia. There is a complex interaction of factors affecting place of death--related to illness, the individual and environment--and although most people want to die at home, in most countries the majority of cancer patients die in hospital. In response to patient and family needs, systematic review shows the effectiveness of palliative care services. However, the distribution of services across Europe is inequitable.

CONCLUSION

Palliative care is becoming increasingly recognised as a vital component of cancer care, but requires investment in research, education and services, incorporating appropriate needs assessment and outcome measurements.