Adaptation of family caregivers during the acute phase of adult BMT

Psychoneuroimmunology in multiple myeloma and autologous hematopoietic stem cell transplant: Opportunities for research among patients and caregivers

Multiple myeloma (MM) is an incurable cancer and is the leading indication for autologous hematopoietic stem cell transplantation (HSCT). To be eligible for HSCT, a patient must have a caregiver, as caregivers play a central role in HSCT preparation and recovery. MM patients remain on treatment indefinitely, and thus patients and their caregivers face long-term challenges including the intensity of HSCT and perpetual therapy after transplant. Importantly, both patients and their caregivers show heightened depressive and anxiety symptoms, with dyadic correspondence evidenced and caregivers' distress often exceeding that of patients. An extensive psychoneuroimmunology (PNI) literature links distress with health via immune and neuroendocrine dysregulation as well as biological aging. However, data on PNI in the context of multiple myeloma - in patients or caregivers - are remarkably limited. Distress in MM patients has been associated with poorer outcomes including higher inflammation, greater one year post-HSCT hospital readmissions, and worse overall survival. Further, anxiety and depression are linked to biological aging and may contribute to the poor long-term health of both patients and caregivers. Because MM generally affects older adults, individual differences in biological aging may represent an important modifier of MM biology and HSCT treatment outcomes. There are a number of clinical scenarios in which biologically younger people could be prescribed more intensive therapies, with potential for greater benefit, by using a personalized cancer therapy approach based on the quantification of physiologic reserve. Further, despite considerable psychological demands, the effects of distress on health among MM caregivers is largely unexamined. Within this context, the current critical review highlights gaps in knowledge at the intersection of HSCT, inflammation, and biological aging in the context of MM. Research in this area hold promise for opportunities for novel and impactful psychoneuroimmunology (PNI) research to enhance health outcomes, quality of life, and longevity among both MM patients and their caregivers.

Family Caregiver Experiences in the Inpatient and Outpatient Reduced-Intensity Conditioning Allogeneic Hematopoietic Cell Transplantation Settings: A Qualitative Study

Caregivers (ie, family and friends) are essential in providing care and support for patients undergoing hematopoietic cell transplantation (HCT) and throughout their recovery. Traditionally delivered in the hospital, HCT is being increasingly provided in the outpatient setting, potentially heightening the burden on caregivers. Extensive work has examined the inpatient HCT caregiving experience, yet little is known about how caregiver experiences may differ based on whether the HCT was delivered on an inpatient or outpatient basis, particularly during the acute recovery period post-HCT. This study explored the similarities and differences in caregiver experiences in the inpatient and outpatient settings during the early recovery from reduced-intensity conditioning (RIC) allogeneic HCT. We conducted semistructured interviews (n = 15) with caregivers of adults undergoing RIC allogeneic HCT as either an inpatient (n = 7) or an outpatient (n = 8). We recruited caregivers using purposeful criterion sampling, based on the HCT setting, until thematic saturation occurred. Interview recordings were transcribed and coded through thematic analysis using Dedoose v.9.0. The study analysis was guided by the transactional model of stress and coping and the model of adaptation of family caregivers during the acute phase of BMT. Three themes emerged to describe similar experiences for HCT caregivers regardless of setting: (1) caregivers reported feeling like they were a necessary yet invisible part of the care team; (2) caregivers described learning to adapt to changing situations and varying patient needs; and (3) caregivers recounted how the uncertainty following HCT felt like existing between life and death while also maintaining a sense of gratitude and hope for the future. Caregivers also reported distinct experiences based on the transplantation setting and 4 themes emerged: (1) disrupted routines: inpatient caregivers reported disrupted routines when caring for the HCT recipient while simultaneously trying to manage non-caregiving responsibilities at home and work, and outpatient caregivers reported having to establish new routines that included frequent clinic visits with the patient while altering or pausing home and work responsibilities; (2) timing of caregiver involvement: inpatient caregivers felt more involved in care after the patient was discharged from the HCT hospitalization, whereas outpatient caregivers were already providing the majority of care earlier in the post-transplantation period; (3) fear of missing vital information: inpatient caregivers worried about missing vital information about the patient's care and progress if not physically present in the hospital, whereas outpatient caregivers feared overlooking vital information that may warrant contacting the care team as they monitored the patient at home; and (4) perceived adequacy of resources to meet psychosocial and practical needs: inpatient caregivers reported having adequate access to resources (ie, hospital-based services), whereas outpatient caregivers felt they had more limited access and needed to be resourceful in seeking out assistance. Inpatient and outpatient HCT caregivers described both similar and distinct experiences during the acute recovery period post-HCT. Specific interventions should address caregiver psychosocial needs (ie, distress, illness uncertainty, communication, and coping) and practical needs (ie, community resource referral, preparedness for home-based caregiving, and transplantation education) of HCT caregivers based on setting.

Spirituality moderates the relationship between cancer caregiver burden and depression

OBJECTIVES

Cancer has become a chronic disease that requires a considerable amount of informal caregiving, often quite burdensome to family caregivers. However, the influence of spirituality on the caregivers' burden and mental health outcomes has been understudied. This study was to examine how caregiver burden, spirituality, and depression change during cancer treatment and investigate the moderating role of spirituality in the relationship between caregiver burden and depression for a sample of caregivers of persons with cancer.

METHODS

This secondary analysis used a longitudinal design employing 3 waves of data collection (at baseline, 3 months, and 6 months). Family caregivers completed the Caregiver Reaction Assessment, Spiritual Perspective Scale, and the PROMIS® depression measure. Linear mixed model analyses were used, controlling for pertinent covariates.

RESULTS

Spirituality, total caregiver burden, and depression remained stable over 6 months. More than 30% of the caregivers had mild to severe depressive symptoms at 3 time points. There was evidence of overall burden influencing depression. Of note was a protective effect of caregivers' spirituality on the relationship between depression and caregiver burden over time (b = -1.35, p = .015). The lower the spirituality, the stronger the relationship between depression and burden, especially regarding subscales of schedule burden, financial burden, and lack of family support.

SIGNIFICANCE OF RESULTS

Spirituality was a significant resource for coping with caregiving challenges. This study suggests that comprehensive screening and spiritual care for cancer caregivers may improve their cancer caregiving experience and possibly influence the care recipients' health.

Protocol for multi-site randomized trial of inpatient palliative care for patients with hematologic malignancies undergoing hematopoietic stem cell transplantation

BACKGROUND

Patients with hematologic malignancies undergoing hematopoietic stem cell transplantation (HSCT) commonly experience debilitating physical and psychological symptoms during a 3-4-week-hospitalization. During hospitalization, caregivers (i.e., family and friends) also endure immense emotional stress as they witness their loved one struggle with HSCT toxicities. Yet interventions to improve quality of life (QOL) and reduce psychological distress during HSCT are limited.

METHODS

We are conducting a multi-site randomized controlled trial of inpatient integrated palliative and transplant care versus usual care in 360 patients hospitalized for HSCT and their caregivers at three academic centers. Intervention participants meet with a palliative care clinician at least twice weekly during the HSCT hospitalization to address their physical and psychological symptoms. Patients assigned to usual care receive all supportive care measures provided by the HSCT team and could be seen by palliative care upon request. We assess patient QOL (Functional Assessment of Cancer Therapy (FACT) - Bone Marrow Transplant), depression and anxiety symptoms (Hospital Anxiety and Depression Scale), post-traumatic stress (PTSD) symptoms (PTSD checklist), symptom burden (Edmonton Symptom Assessment Scale), and fatigue (FACT-Fatigue) as well as caregiver-reported outcomes at baseline, 2 weeks, 3-months, 6-months, and 12-months post-HSCT. The primary endpoint is to compare QOL at week-2 during HSCT hospitalization between the two groups when patients typically experience their QOL nadir during HSCT.

CONCLUSIONS

This multi-site trial will define the role of palliative care for improving QOL and care for patients with hematologic malignancies undergoing HSCT and their caregivers.

A Mixed-Methods Feasibility Study: Eliciting ICU Experiences and Measuring Outcomes of Family Caregivers of Patients Who Have Undergone Hematopoietic Stem Cell Transplantation

The impact of an intensive care unit (ICU) admission on family caregivers of patients who have undergone hematopoietic stem cell transplantation (HSCT) has not been well described. Aims of this study were to determine the feasibility of conducting research with family caregivers of HSCT patients during an ICU admission and generate preliminary data about their experiences and engagement in care. Using a mixed-methods, repeated measures design, we collected data from family caregivers after 48 hr in the ICU (T1) and at 48 hr after transferring out of ICU (T2). Enrolling HSCT caregivers in research while in the ICU was feasible (10/13 consented; 9/10 completed data collection at T1); however, data collection at T2 was not possible for most caregivers. Caregiver distress levels were high, and engagement in care was moderate. The three themes that emerged from interviews (n = 5) highlighted that although HSCT family caregivers faced many challenges and received limited support during their ICU experience, they were able to access their own personal resources and demonstrated resilience.

Nondrug Intervention for Opportunistic Infections in Individuals With Hematological Malignancy: Systematic Review

BACKGROUND

Hematological malignancies disturb the blood, lymph nodes, and bone marrow. Taking medications for treating opportunistic infections (OIs) in these individuals may enhance the risk of medication interaction as well as adverse drug reactions.

OBJECTIVE

This review aims to evaluate the effectiveness of nondrug interventions in reducing OIs among patients with hematological cancers.

METHODS

The PubMed, CENTRAL (Cochrane Central Register of Controlled Trials), and Embase databases were searched on December 26, 2022, for all randomized controlled trials (RCTs). The primary endpoint was OIs. The quality of included studies was assessed by the Cochrane Risk-of-Bias tool.

RESULTS

A total of 6 studies were included in this review with 4 interventions: (1) types of mouthwash received, (2) presence of coating on central venous catheters (CVCs), (3) use of well-fitted masks, and (4) types of diet consumed. The results were presented in 8 different comparisons: (1) chlorhexidine-nystatin versus saline mouth rinse, (2) chlorhexidine versus saline mouth rinse, (3) nystatin versus saline mouth rinse, (4) chlorhexidine silver sulfadiazine-coated CVCs versus uncoated catheters, (5) well-fitted masks versus no mask, (6) amine fluoride-stannous fluoride versus sodium fluoride mouthwash, (7) low-bacterial diet versus standard hospital diet, and (8) herbal versus placebo mouthwash. No clear differences were reported in any of the outcomes examined in the first 3 comparisons. There were also no clear differences in the rate of catheter-related bloodstream infection or insertion site infection between the use of chlorhexidine silver sulfadiazine-coated CVCs versus uncoated catheters in the patients. Further, no significant differences were seen between patients who used a well-fitted mask and those without a mask in the incidence of OI. The all-cause mortality and mortality due to OI were similar between the 2 groups. There was no clear difference in all-cause mortality, although common adverse effects were reported in patients who used sodium fluoride mouthwash compared with those using amine fluoride-stannous fluoride mouthwash. There was no evidence of any difference in the incidence of possible invasive aspergillosis or candidemia between patients who consumed a low-bacterial diet and a standard diet. For the last comparison, no significant difference was seen between patients who received herbal and placebo mouthwash.

CONCLUSIONS

Very limited evidence was available to measure the effectiveness of nondrug interventions in hematological cancers. The effectiveness of the interventions included in this review needs to be evaluated further in high-quality RCTs in a dedicated setting among patients with hematological malignancies.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020169186; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=169186.

Feasibility & Acceptability of Patient and Family Directed Active Music Making during Pediatric Bone Marrow Transplant Process

(1) Background: Bone marrow transplant (BMT) is an aggressive and complex medical treatment for children with certain types of cancer and other diseases. The transplant process entails replacing the patient's diseased bone marrow with the healthy marrow of a donor. During the course of treatment, patients are isolated in their room to reduce the risk of infection. Patient's experience a variety of symptoms and side effects during the process including nausea, vomiting, diarrhea, mouth sores, fatigue, pain, discomfort, extreme muscle weakness, and emotional distress. Children often need a parent or caregiver present with them at all times throughout treatment. This process can cause significant stress and anxiety for the patient and their family. (2) Methods: This study explored the feasibility and acceptability of a patient and family directed active music making protocol during the BMT process. Ten patients, their parents, and family members participated in the study during the course of the BMT. (3) Results: Participants reported engaging in active music making 3-4 times per week and completed 121 journal forms reporting their music making experiences. They indicated using active music making to manage pain, discomfort, stress, anxiety, and boredom, foster relaxation and sleep, for enjoyment, and as a way to connect. (4) Conclusions: Patients, parents and family members reported feeling a sense of empowerment when engaged in making music to support their child or loved one.

Effect of family cohesion on symptom distress during hematopoietic stem cell transplantation

PURPOSE

Family may play an important role in hematopoietic stem cell transplantation (HSCT) recovery; however, little is known about the effect of family functioning on an individual's health. The purpose of this study was to examine the effect of family cohesion (family functioning) on the trajectory of HSCT recipients' symptom distress (symptom frequency and symptom bother) before, during, and after HSCT.

METHODS

Secondary analysis was conducted using data collected from178 individuals who underwent HSCT. Longitudinal parallel process (LPP) modeling was used to examine how family cohesion and HSCT-associated symptoms (symptom frequency and symptom bother) change over time, and how these longitudinal changes relate to each other.

RESULTS

The trajectory of family cohesion predicted the trajectories of HSCT-associated symptom frequency and bother. HSCT recipients who experienced higher family cohesion at baseline (T1) showed lower symptom frequency (p < .01) as well as symptom bother (p < .01) at T1. This trajectory analysis also showed that HSCT recipients who had improved family cohesion over time reported decrease in symptom frequency (p < .01) as well as bother (p < .01) over time.

CONCLUSION

Findings indicate that higher family cohesion predicts decrease in symptom distress over the HSCT trajectory. Interventions aimed at enhancing family cohesion have the potential to lower HSCT recipients' symptom distress. Further research is needed to understand the critical role of family cohesion and family functioning and their relationship with HSCT symptom distress prevention, early detection, and risk stratification.

Facilitators and obstacles to couples' intimacy after hematopoietic stem cell transplantation: a qualitative study

To identify perceived factors related to intimacy following HSCT.

Qualitative descriptive design.

Patients diagnosed with hematological cancer, 6 months into their HSCT recovery, and their partners.

Semi-structured interviews were conducted with 18 participants (nine patients and their partners). A thematic analysis was carried out.

Couples reported various obstacles to intimacy, such as emotional obstacles (i.e. negative emotions, emotional mismatch), the length of the disease, its treatments and side effects, and the patient's physical condition. Couples also reported facilitators to intimacy, such as using emotional facilitators (e.g. showing empathy), fostering open communication or sharing common experience of the disease.

This study highlights specific factors that influence couples' intimacy in the context of HSCT.Implications for Psychosocial Providers: Couples' intervention delivered in cancer care should be adapted by focusing on specific factors that maintain or enhance couples' intimacy.

Anxiety and Depression Symptoms in Caregivers Prior to Hematopoietic Stem Cell Transplantation (HCT)

Family and friends caring for hematopoietic stem cell transplantation (HCT) recipients experience substantial disruptions in daily life as they prepare for transplant. These disruptions may increase their psychological distress, yet little research has described the extent of this distress. The goals of the present study were to characterize rates of anxiety and depression symptoms immediately prior to HCT and their relationship with modifiable caregiving domains. We conducted a secondary analysis of cross-sectional data of caregivers of patients undergoing HCT. Caregivers completed self-report measures to assess 8 domains of caregiving (Caregiver Oncology Quality of Life Questionnaire) and anxiety and depression symptoms (Hospital Anxiety and Depression Scale [HADS]) prior to transplant. Scores ≥8 on the HADS anxiety and depression subscales signified clinically significant symptoms. We used multivariable regression models adjusting for age, sex, caregiver relationship, and HCT type to examine the associations between caregiving domains and anxiety and depression symptoms. We enrolled 193 caregivers (median age = 60 years, 70.0% female, 52.3% allogeneic transplant). A majority of participants were providing care for a spouse (79.8%), followed by a child (7.8%) or parent (5.2%). On average, caregivers reported more anxiety (mean = 7.04, SD = 3.94) than depression symptoms (mean = 4.18, SD = 3.49), with 46.6% and 16.1% endorsing clinically significant anxiety and depression symptoms, respectively. Caregiver anxiety was associated with worse physical well-being, less leisure time, and poorer coping (Ps < .05). Caregiver depression symptoms were associated with worse physical well-being and less leisure time (Ps < .05). Caregivers of HCT recipients experience substantial psychological distress, particularly anxiety, prior to transplant. This distress is linked to modifiable caregiving domains. Study findings identify possible targets for psychosocial interventions aimed at managing caregiver anxiety and depression symptoms as well as highlight the need for intervention early during the course of transplant.

Harnessing mobile health technology to support long-term chronic illness management: exploring family caregiver support needs in the outpatient setting

OBJECTIVE

Family caregiving is an important public health issue, particularly with the aging population. In recent years, mobile health (mHealth) technology has emerged as a potential low-cost, scalable platform to address caregiver support needs, and thereby alleviate the burden on caregivers. This study sought to examine the support needs of family caregivers in their lived experiences of outpatient care to inform the development of a future mHealth intervention.

MATERAILS AND METHODS

We conducted 20 semi-structured interviews in 2 outpatient hematopoietic cell transplant (HCT) clinics at a large academic medical center in the Midwestern United States. A thematic analysis was performed to define emerging themes.

RESULTS

Qualitative data analysis identified 5 primary themes that HCT caregivers faced: (I) lifestyle restrictions due to the patient's immunocompromised state; (II) Unmet needs due to limitations in the current resources, including unfamiliar medical tasks without necessary trainings; and (III) caregivers' adaptive strategies, including reformation of social relationships with family and friends. Based on these findings, we suggest 3 design considerations to guide the development of a future mHealth intervention.

CONCLUSIONS

The findings herein captured the family caregiver's lived experiences during outpatient care. There was broad agreement that caregiving was challenging and stressful. Thus, effective and scalable interventions to support caregivers are needed. This study provided data to guide the content and design of a future mHealth intervention in the outpatient setting.

Social frailty predicts worse outcomes in patients with multiple myeloma: A novelty in an old approach

Social frailty, defined as the loss of social roles and networks in the community, has never been evaluated in patients with multiple myeloma (MM). This study aimed to evaluate the usefulness of social frailty as a predictor of survival in MM. We retrospectively reviewed 237 consecutive patients with MM from 2009 to 2019. Activities of daily living (ADL), the instrumental ADL score, the Charlson Comorbidity Index, and factors to evaluate social relationships were routinely assessed at the time of initial diagnosis and first hospitalization at our center by hematological clinicians, nurses, and rehabilitation staff. Social frailty was evaluated using five social factors and was defined as a score of at least 2 points. Overall, 69 (30.0%) patients were defined as socially frail, with a median score of 0. Those who were socially frail showed significantly shorter progression-free and overall survival than those who were not. Using the International Staging System, International Myeloma Working Group frailty score, and social frailty, we developed two staging systems, and these further demonstrated the importance of assessing frail patients with MM. Our findings have identified the usefulness for evaluating social frailty; however, to confirm our results, an independent study with larger patient numbers with an entirely prospective assessment is needed to confirm their results.

Caregivers' Out-of-Pocket Expenses and Time Commitment Following Hematopoietic Stem Cell Transplantation at a Rural Cancer Center

The emotional and physical toll on caregivers of cancer patients is well documented, but research evaluating the financial burdens and time commitments of caregivers is limited. We suspected that the rural location of our cancer center would intensify these burdens for caregivers. We conducted a prospective trial to assess the out-of-pocket expenses and time commitment of caregivers of hematopoietic stem cell transplantation recipients within the first 4 weeks after discharge from the hospital from a National Cancer Institute (NCI)-designated comprehensive cancer center. These results show that caregivers of autologous recipients paid out-of-pocket expenses of $196 over 4 weeks. If lost wages were included, the expenses increased to $736 during this period. Caregivers of allogeneic recipients had out-of-pocket expenses of $110 in 4 weeks, or a total of $610 when lost wages were included. In the month after discharge from the hospital, caregivers traveled a median distance of 450 miles or 560 miles, depending on whether the patient received an autologous transplant or an allogeneic transplant, respectively. These results demonstrate a compelling need to address caregiver support, given the significant financial out-of-pocket expenses and time commitment.

Multimodal psychosocial intervention for family caregivers of patients undergoing hematopoietic stem cell transplantation: A randomized clinical trial

BACKGROUND

Caregivers of patients undergoing hematopoietic stem cell transplantation (HCT) experience an immense caregiving burden before, during, and after HCT.

METHODS

We conducted an unblinded, randomized trial of a psychosocial intervention (BMT-CARE) for caregivers of patients undergoing autologous and allogeneic HCT at Massachusetts General Hospital. Caregivers were randomly assigned to BMT-CARE or usual care. BMT-CARE was tailored to the HCT trajectory and integrated treatment-related education and self-care with cognitive-behavioral skills to promote coping. Caregivers assigned to BMT-CARE met with a trained interventionist (a psychologist or a social worker) in person, via telephone, or via videoconferencing for 6 sessions starting before HCT and continuing up to day +60 after HCT. The primary endpoint was feasibility, which was defined as at least 60% of eligible caregivers enrolling and completing 50% or more of the intervention sessions. We assesed caregiver quality of life (QOL; Caregiver Oncology Quality of Life Questionnaire), caregiving burden (Caregiver Reaction Assessment), psychological distress (Hospital Anxiety and Depression Scale), self-efficacy (Cancer Self-Efficacy Scale-Transplant), and coping (Measures of Current Status) at baseline and 30 and 60 days after HCT. We used mixed linear effect models to assess the effect of BMT-CARE on outcomes longitudinally.

RESULTS

We enrolled 72.5% of eligible caregivers (100 of 138), and 80% attended 50% or more of the intervention sessions. Caregivers randomized to BMT-CARE reported improved QOL (B = 6.11; 95% CI, 3.50-8.71; P < .001), reduced caregiving burden (B = -6.02; 95% CI, -8.49 to -3.55; P < .001), lower anxiety (B = -2.18; 95% CI, -3.07 to -1.28; P < .001) and depression symptoms (B = -1.23; 95% CI, -1.92 to -0.54; P < .001), and improved self-efficacy (B = 7.22; 95% CI, 2.40-12.03; P = .003) and coping skills (B = 4.83; 95% CI, 3.04-6.94; P < .001) in comparison with the usual-care group.

CONCLUSIONS

A brief multimodal psychosocial intervention tailored for caregivers of HCT recipients is feasible and may improve QOL, mood, coping, and self-efficacy while reducing the caregiving burden during the acute HCT period.

Comparison of quality of life and depression between hematopoietic stem cell transplantation survivors and their spouse caregivers

Background

Hematopoietic stem cell transplantation (HSCT) is an exhausting process that impacts both the patient and caregiver.

Methods

This was a cross-sectional, HSCT survivor-spouse caregiver matching study to determine quality of life (QoL) and depression among HSCT survivors and their caregivers. QoL and depression were measured with the World Health Organization Quality of Life: Brief Version (26 items) and the 9-item Patient Health Questionnaire, respectively. Data from 97 married couples were analyzed.

Results

There were no significant differences in overall QoL and psychological, social, and environmental health between survivors and spouse caregivers (P=0.345, 0.424, 0.415, and 0.253); however, physical QoL was better in the spouse caregiver group (P=0.011). There was no difference in mean depression scale scores (5.3 vs. 5.1, P=0.812) or proportion of severe depression (15.6% vs. 13.7%, P=0.270) between the two groups. We found that family income had a significant impact on overall QoL and environmental health among spouse caregivers (P=0.013 and 0.023), and female gender, co-morbidities, and family income were the important factors associated with depression among spouse caregivers (P=0.007, 0.017 and 0.049).

Conclusion

This study found that there were no significant differences in QoL or level of depression between HSCT survivors and their spouse caregivers. Family income, gender, and co-morbidities showed significant association with spouse caregiver distress.

Effects of Social Support Source and Effectiveness on Stress Buffering After Stem Cell Transplant

BACKGROUND

This study used the social support effectiveness framework to examine whether effective social support buffered the relationship between stressful life events and distress among hematopoietic stem cell transplant (HSCT) survivors and whether that buffering effect depended on the type of caregiver who provided it (partner versus non-partner caregivers).

METHODS

A total of 275 HSCT survivors completed measures of the effectiveness of their caregiver's support-social support effectiveness (SSE)-distress, and stressful life events. Hierarchical linear regression was used to analyze a three-way interaction between stressful life events, caregiver SSE, and caregiver type on distress.

RESULTS

After controlling for covariates, the three-way interaction of stressful life events, caregiver SSE, and caregiver type was significant (b = - 0.21, SE = 0.00, p < 0.001). Among partnered survivors, more stressful life events were associated with greater distress (B = 0.03, SE = 0.01, p = 0.045) when caregiver SSE was low. There was no association between stressful life events and distress when caregiver SSE was average (B = 0.01, SE = 0.01, p = 0.50) or high (B = - 0.01, SE = 0.02, p = 0.61). Among non-partnered survivors, there was a positive association between stressful life events and distress regardless of caregiver SSE.

CONCLUSIONS

Average or highly effective caregiver support buffered effects of stressful life events on distress among partnered survivors. There was no evidence that support at any level of effectiveness buffered stressful life events among non-partnered survivors. Findings highlight the importance of measuring social support effectiveness and source of support among HSCT survivors.

Quality of life and mood of older patients with acute myeloid leukemia (AML) receiving intensive and non-intensive chemotherapy

Older patients with AML face difficult treatment decisions as they can be treated either with 'intensive' chemotherapy requiring prolonged hospitalization, or 'non-intensive' chemotherapy. Although clinicians often perceive intensive chemotherapy as more burdensome, research is lacking on patients' quality of life (QOL) and psychological distress. We conducted a longitudinal study of older patients (≥60 years) newly diagnosed with AML receiving intensive (cytarabine/anthracycline combination) or non-intensive (hypomethylating agents) chemotherapy. We assessed patients' QOL [Functional-Assessment-of-Cancer-Therapy-Leukemia] and psychological distress [Hospital-Anxiety-and-Depression-Scale] at baseline and 2, 4, 8, 12, and 24 weeks after diagnosis. We enrolled 75.2% (100/133) of eligible patients within 72-hours of initiating intensive (n = 50) or non-intensive (n = 50) chemotherapy. Patient QOL improved over time (β = 0.32, P = 0.013). At baseline, 33.3% (33/100) and 30.0% (30/100) of patients reported clinically significant depression and anxiety symptoms, respectively, with no differences between groups. Patients' depression symptoms did not change over time, while their anxiety symptoms decreased over time (β = -0.08, P < 0.001). Patient-reported QOL, depression and anxiety symptoms did not differ significantly at any time point between those who received intensive versus non-intensive chemotherapy. Older patients with AML experience improvements in their QOL and anxiety while undergoing treatment. Patients receiving intensive and non-intensive chemotherapy have similar QOL and mood trajectories.

Psychological Considerations in Hematopoietic Stem Cell Transplantation

BACKGROUND

In recent decades, advances in transplantation medicine, and improved posttransplant care have reduced morbidity and mortality from hematopoietic stem cell transplantations (HSCTs). However, patients undergoing HSCT report a high prevalence of psychological distress, which can negatively impact recovery, function, and health outcomes, including mortality and higher risk of graft vs. host disease. Appropriate assessment and management of these psychological symptoms lead to better engagement with treatment and a variety of superior health outcomes.

OBJECTIVE

We provide a narrative review of the psychological challenges that accompany HSCT and suggest management approaches to equip psychiatric consultants involved in the care of this patient population.

METHODS

We reviewed published work in PubMed, PsycInfo, and Scopus electronic databases on the common psychological challenges in HSCT, their vulnerability factors, as well as practical interventions for managing these challenges.

RESULTS

We outline the phases of the HSCT hospitalization and discuss common psychological challenges, such as depression, delirium, and post-traumatic stress reactions that accompany HSCT. We suggest an approach to psychiatric consults during the HSCT hospitalization and discuss practical interventions for managing psychological challenges in this population.

CONCLUSIONS

Though pharmacological and behavioral interventions have been successfully used to treat psychosocial challenges in HSCT, further research is needed to understand the optimal psychiatric assessment tools, treatment strategies, and the long-term psychiatric care needed to address psychiatric comorbidities in this growing patient population.

Adaptation of Coping Together - a self-directed coping skills intervention for patients and caregivers in an outpatient hematopoietic stem cell transplantation setting: a study protocol

Background

Despite numerous reports of significant distress and burden for hematopoietic stem cell transplantation (HSCT) patients and caregivers (CGs), HSCT-specific coping interventions remain rare. The few in use lack specificity and are often not easily accessible or cost-effective. Whereas the development of new interventions is resource-intensive, theory-informed adaptation of existing evidence-based interventions is promising. To date, no HSCT-specific intervention has relied on a formal adaptation approach.

Methods

Using the Center for Disease Control and Prevention’s Map of Adaptation, this two-phase qualitative descriptive study seeks to understand the perceptions of HSCT patients, CGs, individually, and in dyads, and clinicians about Coping Together (CT) for the preliminary adaptation (Phase 1), and then explores perceptions of the modified intervention in additional mixed sample (Phase 2). Six to ten participants including outpatients, CGs and dyads and five to seven HSCT clinician participants will be recruited for Phase 1. For Phase 2, 14 to 16 participants including outpatients, CGs and dyads will be recruited. Individual and dyadic semi-structured interviews will take place between 100 and 130 days post-HSCT. Verbatim transcripts will be analyzed using content analysis.

Discussion

It is paramount to have HSCT-specific supportive interventions that address patients’ and CGs’ multidimensional and complex needs. The timely involvement of key stakeholders throughout the adaptation process is likely to optimize the relevance and uptake of such tailored intervention.

Trial registration

This study is registered on October 6, 2016 in ClinicalTrials.gov at (identifier number NCT02928185).

Caregiver Sleep and Patient Neutrophil Engraftment in Allogeneic Hematopoietic Stem Cell Transplant: A Secondary Analysis

BACKGROUND

Caregiving for allogeneic hematopoietic stem cell transplant (Allo-HSCT) patients can be significantly burdensome. Caregiver well-being often mirrors patients' suffering. However, to our knowledge, this dyadic relationship has not been linked to patient outcome.

OBJECTIVE

Caregiver's objective and subjective sleep and overall distress before transplantation were hypothesized to be related to patient's time to engraftment in secondary analyses.

METHODS

Dyads (N = 124) were Allo-HSCT patients (mean [SD] age, 49.2 [12.7] years) and their caregivers (mean [SD] age, 52.7 [12.3] years). Caregiver's subjective sleep quality was measured via the Pittsburgh Sleep Quality Index, objective sleep was measured by actigraphy, and distress was measured by combining validated psychological measures.

RESULTS

Both caregiver reports of worse sleep (β = .22; P < .05) and objective measurement of caregiver sleep patterns (higher sleep efficiency; less time awake after sleep onset) collected before engraftment significantly predicted shorter time to patient engraftment (β values = -.34 and .29, respectively; P values < .05). Caregiver distress was unrelated to engraftment (β = .14; P = .22).

CONCLUSIONS

Despite limitations in available patient data, these findings appear to link caregiver well-being to patient outcome. This underscores the interrelatedness of the patient-caregiver dyad in Allo-HSCT. Future research should examine psychological and biomedical mediators.

IMPLICATIONS FOR PRACTICE

Given that caregiver well-being during the peritransplantation period was associated with patient outcome in this study, such findings highlight the need to address caregiver and patient well-being during Allo-HSCT. There may be potential to improve patient outcome by focusing on the caregiver, which nursing staff is well positioned to monitor.

Correlates of anxiety and depression symptoms among patients and their family caregivers prior to allogeneic hematopoietic cell transplant for hematological malignancies

PURPOSE

Given the complexities and risks of allogeneic HCT, patients and their family caregivers may experience elevated psychological distress, including symptoms of anxiety and depression, in anticipation of the procedure. Patients and caregivers also bring with them their pre-HCT experiences of diagnosis, prior treatment, and associated burdens, thus potentially compounding their acute distress. Identification of clinical, psychosocial, and sociodemographic factors related to pre-HCT distress would allow targeting of patients and caregivers who may require assistance during the HCT process.

METHODS

Consecutive patients (n = 111) and their caregivers (n = 110) completed measures of anxiety, depression, cancer distress, perceived threat, perceived control, self-efficacy, relationship quality, and physical quality of life in the week before HCT. Multivariate linear regression analysis was used to identify factors associated with patient and caregiver anxiety or depression, including disease type, donor type, and patient and caregiver sociodemographic, health-related, and psychosocial factors.

RESULTS

Family caregivers had higher levels of anxiety and depression symptoms than patients. Thirty percent of caregivers vs. 17% of patients met criteria for clinically significant anxiety and a lesser amount (5% for both) met criteria for clinically significant depression. Patient anxiety was related to younger age (b = - 0.22, p = 0.005) and greater cancer-related distress (b = 0.59, p < 0.001), while caregiver anxiety was related to lower self-efficacy (b = - 0.19, p = 0.011) and greater cancer-related distress (b = 0.58, p < 0.001). Similarly, patient depression was related to lower perceived control (b = - 0.17, p = 0.050), greater cancer-related distress (b = 0.34, p = 0.005), and lower physical functioning (b = - 0.26, p = 0.008), while caregiver depression was related to greater cancer-related distress (b = 0.46, p < 0.001).

CONCLUSIONS

Family caregivers may be more emotionally vulnerable than patients before HCT and in need of additional assistance. Cancer-related distress was the strongest correlate of anxiety and depression in both patients and caregivers, suggesting that distress related to their cancer experience and its consequences plays a major role in their emotional functioning prior to HCT.

Follow the Yellow Brick Road: Self-management by Adolescents and Young Adults After a Stem Cell Transplant

BACKGROUND

Stem cell transplant (SCT) is a major life event that can have long-term psychosocial consequences for the entire family. It is unknown the degree to which the psychosocial characteristics associated with SCT influence self-management behaviors and health outcomes in adolescents and young adults (AYAs).

OBJECTIVE

The study had the following aims: (1) to describe how AYAs manage their care regimen post-SCT and (2) to explore self-management facilitators, barriers, processes, and behaviors within individual, family, community, and healthcare system domains.

INTERVENTIONS/METHODS

A grounded theory study was conducted to understand the process AYAs use to manage their care after SCT. Semistructured individual interviews were conducted, digitally recorded, and transcribed verbatim. Data were coded to consensus and analyzed using constant comparison methods.

RESULTS

A sample of 17 AYAs (13-25 years old at transplant) and 13 caregivers (dyads) participated in the study. Initially, the participants experienced a tornado of activities, information, and emotions. Support from family, friends, and healthcare providers empowered families to manage their care, maintain a positive attitude, and approach a "normal" life.

CONCLUSIONS

Monotony, managing symptoms, and isolation were the hardest obstacles for AYAs throughout the process. Families discussed managing their care activities by developing routines that got easier with time.

IMPLICATIONS FOR PRACTICE

Nurses play an instrumental role in AYA self-management practices by providing information, education, and social support. Psychosocial issues were prominent in the self-management process and should be addressed in future research and interventions with AYAs and caregivers.

The Caregiver's Role Across the Bone Marrow Transplantation Trajectory

BACKGROUND

Approximately 50 000 people undergo bone marrow transplants (BMTs) each year worldwide. With the move to more outpatient and home care, family caregivers are playing an ever-increasing role. However, there is little information regarding the needs and well-being of caregivers of individuals undergoing BMT.

OBJECTIVE

The study purpose was to gain a better understanding of the BMT experience across the trajectory from the perspective of the family caregiver.

METHODS

Qualitative interviews were conducted with 15 family caregivers during and 4 months after BMT. Interviews were recorded, transcribed verbatim, and analyzed using a content analysis approach.

RESULTS

Uncertainty and need for more information were 2 major underlying themes noted across the early BMT trajectory. Caregivers reported feeling overwhelmed and juggling multiple roles, including (a) "interpreter," which included obtaining and translating medical information to their partner, family, and social network; (b) "organizer," which included arranging and coordinating medical appointments (pre- and post-BMT) for the patient, but also juggling the needs of immediate and extended family members; and (c) "clinician," which included assessing and identifying changes in their significant other, with many reporting that they had to be "vigilant" about or "on top of" any changes. Caregivers also reported the most challenging aspects of their role were to "be strong for everyone" and "finding balance."

CONCLUSIONS

Our results underscore the unique needs of family caregivers as a consequence of BMT.

IMPLICATIONS FOR PRACTICE

A greater understanding of the adaptation of caregivers will lead to the development of effective interventions for families going through BMT.

Preliminary efficacy of a brief family intervention to prevent declining quality of life secondary to parental bone marrow transplantation

The primary purpose of this research was to develop and evaluate the efficacy and feasibility of a brief, cost-effective family-focused intervention to promote adaptive coping and quality of life throughout a parent's bone marrow transplantation (BMT). Targeted outcomes were cohesion, decreased use of avoidance coping, open communication and effective management of emotional distress. Participants included an intervention group of 31 families and 29 families in a control group who received usual care. Each family included the BMT recipient, a partner/caregiver and children 10-18 years old. The intervention included two dyadic sessions for the BMT recipient and the partner/caregiver, one individual session for the caregiver and two digital video discs (DVDs) for children. Statistical analyses indicated that the intervention had a positive impact on at least one aspect of the adaptation of each family member. Caregivers reported the most distress but benefitted least from the intervention, whereas recipients and children reported improvement in distress. Ratings of satisfaction/acceptability were high, with 97% responding that they would recommend the intervention to others. Plans for future research include increased intervention intensity for the caregiver, a larger more diverse sample and implementation over an extended period post BMT.

Family members' life situation and experiences of different caring organisations during allogeneic haematopoietic stem cells transplantation-A qualitative study

The aim of this study was to describe family members' life situation and experiences of care in two different care settings, the patient's home or in hospital during the acute post-transplantation phase after allogeneic haematopoietic stem cell transplantation (HSCT). Data were collected through semi-structured interviews with 14 family members (seven women and seven men). An inductive qualitative content analysis was used to analyse the data. The majority of the family members' (n = 10) had experiences from home care. The findings show the family members' voice of the uncertainty in different ways, related with the unknown prognosis of the HSCT, presented as Being me being us in an uncertain time. The data are classified into; To meet a caring organisation, To be in different care settings, To be a family member and To have a caring relationship. Positive experiences such as freedom and security from home care were identified. The competence and support from the healthcare professionals was profound. Different strategies such as adjusting, having hope and live in the present used to balance to live in an uncertain time. The healthcare professionals need to identify psychosocial problems, and integrate the psychosocial support for the family to alleviate or decrease anxiety during HSCT, regardless of the care setting.

User-Centered Design Groups to Engage Patients and Caregivers with a Personalized Health Information Technology Tool

Health information technology (IT) has opened exciting avenues for capturing, delivering and sharing data, and offers the potential to develop cost-effective, patient-focused applications. In recent years, there has been a proliferation of health IT applications such as outpatient portals. Rigorous evaluation is fundamental to ensure effectiveness and sustainability, as resistance to more widespread adoption of outpatient portals may be due to lack of user friendliness. Health IT applications that integrate with the existing electronic health record and present information in a condensed, user-friendly format could improve coordination of care and communication. Importantly, these applications should be developed systematically with appropriate methodological design and testing to ensure usefulness, adoption, and sustainability. Based on our prior work that identified numerous information needs and challenges of HCT, we developed an experimental prototype of a health IT tool, the BMT Roadmap. Our goal was to develop a tool that could be used in the real-world, daily practice of HCT patients and caregivers (users) in the inpatient setting. Herein, we examined the views, needs, and wants of users in the design and development process of the BMT Roadmap through user-centered Design Groups. Three important themes emerged: 1) perception of core features as beneficial (views), 2) alerting the design team to potential issues with the user interface (needs); and 3) providing a deeper understanding of the user experience in terms of wider psychosocial requirements (wants). These findings resulted in changes that led to an improved, functional BMT Roadmap product, which will be tested as an intervention in the pediatric HCT population in the fall of 2015 (ClinicalTrials.govNCT02409121).

Prognostic understanding, quality of life and mood in patients undergoing hematopoietic stem cell transplantation

Little is known about how patients undergoing hematopoietic stem cell transplantation (HCT) and their family caregivers (FC) perceive their prognosis. We examined prognostic understanding in patients undergoing HCT and their FC and its relationship with quality of life (QOL) and mood. We conducted a longitudinal study of patients (and FC) hospitalized for HCT. We used a questionnaire to measure participants' prognostic understanding and asked the oncologists to estimate patients' prognosis prior to HCT. We assessed QOL and mood weekly and evaluated the relationship between prognostic understanding, and QOL and mood using multivariable linear mixed models. We enrolled 90 patients undergoing (autologous (n=30), myeloablative (n=30) or reduced intensity allogeneic (n=30)) HCT. About 88.9% of patients and 87.1% of FC reported it is 'extremely' or 'very' important to know about prognosis. However, 77.6% of patients and 71.7% of FC reported a discordance and more optimistic prognostic perception compared to the oncologist (P<0.0001). Patients with a concordant prognostic understanding with their oncologists reported worse QOL (β=-9.4, P=0.01) and greater depression at baseline (β=1.7, P=0.02) and over time ((β=1.2, P<0.0001). Therefore, Interventions are needed to improve prognostic understanding, while providing patients with adequate psychological support.

Exploring palliative care provision for recipients of allogeneic hematopoietic stem cell transplantation who relapsed

PURPOSE/OBJECTIVES

To quantify the characteristics of patients who die in the hospital from relapse after allogeneic hematopoietic stem cell transplantation (alloHSCT), explore palliative care integration and end-of-life (EOL) care, and benchmark standards of care.

DESIGN

Retrospective chart review cohort study; a cross-sectional survey design guided a national survey.

SETTING

A chart review was conducted in a large tertiary hospital in Australia. The survey was distributed to leading alloHSCT centers in Australia and New Zealand.

SAMPLE

The chart review sample group was patients in the hematology department who had received an alloHSCT, relapsed, and died in the hospital (N = 40). The survey sample group was the most advanced nurse involved in patient care at each facility (N = 14).

METHODS

A quantitative data collection tool created for chart review, as well as patient notes written by the physician, were examined. The quantitative data collection tool was created for the survey, which was conducted via email or telephone.

MAIN RESEARCH VARIABLES

The chart review measured patient demographics, palliative care integration, EOL care, and symptoms. Survey topics included services available, referrals to palliative care services, EOL discussions, and symptom management.

FINDINGS

About half of the patients were seen by the palliative care service. Many patients experienced severe symptoms in the terminal phase. Survey participants felt EOL discussions were left until the terminal phase. Participants believed early palliative care integration was beneficial for patients and their family.

CONCLUSIONS

The chart review demonstrated late integration of palliative care and poor standards of EOL care. Survey results reiterated this and reflected that nurses are supportive of earlier integration of palliative care and improving EOL care.

IMPLICATIONS FOR NURSING

Palliative care should be integrated earlier, and nursing roles have the potential to address unmet needs for these patients.

Sleep problems and psychological distress in family members of patients with hematological malignancies in the Japanese population

Patients with cancer frequently suffer from insomnia symptoms, and additionally, their family members also often experience these symptoms. The aim of this study was to investigate the prevalence of insomnia symptoms in both family members and patients with hematological malignancies. We conducted an observational cross-sectional study using a clinical self-reported questionnaire for sleep conditions, depressive symptoms (two-question method), and worries (five items that originated from the Brief Cancer Worry Inventory). One hundred twelve family members and 153 patients were investigated. A t test and Chi-square test were used to compare the prevalence of insomnia and depressive symptoms between family members and patients. Logistic regression was used to determine whether insomnia symptoms or worries related to patients' disease had an impact on depressive symptoms. The presence of insomnia symptoms in family members (87 %) was significantly higher than that in patients (60 %, p < 0.001). The prevalence of depressive mood and anhedonia in family members were 55 and 34 %, respectively, and these values were higher than those in patients (43 and 28 %, respectively). Insomnia symptoms and worries about present/prospective disease conditions were significantly associated with depressive mood (insomnia symptoms, odds ratios (OR) 4.3, confidence intervals (CI) 1.2-15.2, p = 0.025; worries, OR 4.4, CI 1.0-19.3, p = 0.048). Taken together, our results demonstrated that insomnia symptoms and depressive symptoms are highly prevalent in family members as well as in patients with hematological malignancies.

Caregiver burden among primary caregivers of patients undergoing peripheral blood stem cell transplantation: a cross sectional study

PURPOSE

This study aimed to identify caregiver burden and influencing factors on the burden in primary caregivers of peripheral blood stem cell transplantation patients within 2-12 months following transplant, indicating early recovery period after discharge.

METHOD

This descriptive cross sectional study was carried out at hematopoietic stem cell transplantation outpatient units of three university hospitals in Turkey. A total of 55 patient and caregiver dyads were recruited and interviewed. The data were collected using questionnaires developed by the researchers and caregiver burden was measured with the Zarit Burden Interview.

RESULTS

The mean score of Zarit Burden Interview was 28.41 (SD = 13.90). Patients' symptoms including nausea and self depreciation feeling were related to greater caregiver burden. Self-depreciation was referred to feeling undervalued. The mean score of the tool was significantly higher in caregivers who have not been educated beyond primary school and also caregivers who had lower income. Caregivers who supported their patients to fulfill physical needs and who did not receive help for meeting patients' psychological needs had statistically more elevated levels of burden. Moreover, the extent of care giving activities undertaken was positively correlated with caregiver burden scores. While positive impact of the care giving process on family relations decreased caregiver burden; negative effect increased the burden.

CONCLUSIONS

This study suggests that caregiver burden of primary caregivers caring for peripheral blood stem cell transplantation patients varies by education, income status, and the extent of care giving activities undertaken. Changes in family ties and relations due to care giving effected caregiver burden.

Caregiving experiences predict changes in spiritual well-being among family caregivers of cancer patients

OBJECTIVE

Although enhanced spiritual well-being has been linked to positive mental health outcomes among family caregivers of cancer patients, little is known regarding predictors of spiritual well-being in this population. The current study aimed to examine caregiving experiences as predictors of change in family caregivers' spiritual well-being during the initial months following the patient's cancer diagnosis.

METHODS

Seventy family caregivers of newly diagnosed cancer patients (74% female, mean age = 59 years) participated in this longitudinal survey. Caregivers completed baseline questionnaires shortly before staying with the patient at an American Cancer Society Hope Lodge. Baseline questionnaires assessed caregiving experiences (i.e., self-esteem related to caregiving, family support for providing care, impact of caregiving on finances, and impact of caregiving on one's schedule). In addition, caregivers' spiritual well-being (i.e., meaning in life, peace, and faith) was assessed at baseline and 4-month follow-up.

RESULTS

In univariate analyses, all caregiving experiences studied were associated with one or more aspects of spiritual well-being at 4-month follow-up. However, in the multivariate analysis, the only caregiving experience associated with aspects of spiritual well-being at 4-month follow-up was caregivers' perceptions of family support. Specifically, lack of family support was associated with lower levels of meaning and peace.

CONCLUSIONS

Findings point to the importance of family support in facilitating the search for meaning and peace shortly after a loved one's cancer diagnosis and suggest that interventions targeting caregivers' support system may enhance their spiritual well-being.

Psychiatric and psychosocial challenges in patients undergoing haematopoietic stem cell transplants

Haematological malignancies are often treated with haematopoietic stem cell transplants (HSCT). The disease and its treatment are challenging and life threatening, as they not only affect the recipients, but also their families. This review highlights the available data on the psychological, psychiatric and social impact of these illnesses and their treatment on recipients and families. There are robust data that correlate HSCT with emotional distress, as emotional and physical functioning significantly affect quality of life. Psychiatric co-morbidity including anxiety, depression, adjustment and post-traumatic stress disorder, delirium and cognitive deficits have been reported at different stages in the transplant process. This review will highlight the psychosocial and clinical research findings relevant to HSCT patients and will summarize recommendations for future psychosocial research in this population.

The experience of caring for a spouse undergoing hematopoietic stem cell transplantation: opening Pandora's box

BACKGROUND

Hematopoietic stem cell transplantation (HSCT) is a major treatment option for patients with hematological malignancies. Spouses are frequently asked to provide physical, psychological, and emotional support in both the acute care and outpatient settings, yet few studies have explored the nature and implications of their caring work beyond the acute care phase.

OBJECTIVE

The aims of this exploratory study were to (1) highlight the effect of caregiving on the psychosocial health and well-being of spouses of HSCT recipients; (2) highlight the level of caregiver burden, depression, and/or secondary trauma experienced by spousal caregivers of HSCT recipients; and (3) identify when spouses are most vulnerable to caregiver burden, depression, and/or secondary trauma. METHOD/METHODOLOGICAL APPROACH: A mixed-method exploratory study was undertaken. Participants were followed over 1 year from immediately before transplantation to 1 year after transplantation. Descriptive statistics and thematic analysis highlighted the effect of spousal caregiving on psychosocial health and well-being.

RESULTS

Eleven spouses participated in the study. Caregivers experienced caregiver burden, psychological distress (depression), and risk for secondary traumatic stress at 3 points in time over 1 year from before transplantation to 1 year after transplantation.

CONCLUSIONS

Findings suggest that spouses may be at risk for adverse psychological effects as a result of their role in providing care for a partner undergoing HSCT.

IMPLICATIONS FOR PRACTICE

Nurses need to integrate regular psychosocial assessments of caregivers to recognize the early signs of distress and intervene to support and promote psychosocial health and well-being.

A survey of the supportive care needs of informal caregivers of adult bone marrow transplant patients

PURPOSE

This study aims to describe the supportive care needs of informal caregivers (ICG) of adult bone marrow transplant (BMT) patients. In addition, we explored relationships between levels of unmet need, psychological morbidity and patient and ICG characteristics.

METHODS AND SAMPLE

We invited patients within 24 months of BMT to participate in a cross-sectional survey. Consenting patients asked their ICG to complete and return the questionnaire booklet. Measures included the Supportive Care Needs Survey Partners and Carers and General Health Questionnaire.

KEY RESULTS

Two hundred patients were approached, and 98 completed questionnaires were received (response rate = 49 %). We found high unmet need and psychological morbidity among ICGs and an association between ICG unmet need and psychological morbidity. Patient functioning, particularly anxiety and depression, sexual dysfunction and resumption of usual activities impacted on ICG unmet need and psychological morbidity. No associations were found between ICG unmet need and psychological morbidity and the following variables: type of BMT, time from BMT, ICG gender, number of dependents and patient age.

CONCLUSION

ICG of BMT patients have high levels of unmet need and psychological morbidity in the months that follow a BMT. This highlights the importance of thorough needs assessment to ensure limited resources are targeted to those most in need.

Long-term follow-up of informal caregivers after allo-SCT: a systematic review

Currently, more than 40000 patients undergo allogeneic hematopoietic SCT (HSCT) annually throughout the world, and the numbers are increasing rapidly. Long-term survival after allogeneic-HSCT (allo-HSCT) has also improved significantly since its inception over 40 years ago due to improved supportive care and early recognition of long-term complications. In long-term follow-up after transplantation, the focus of care moves beyond cure of the original disease to late effects and quality of life. Nearly one-fourth of the long-term survivors are likely to have chronic consequences of HSCT, which require frequent help by caregivers, particularly informal caregivers such as spouses, partners or children. The physical and psychosocial consequences for patients undergoing HSCT have been extensively reported. There has, however, been far less investigation into the long-term follow-up of caregivers of HSCT recipients. This article provides an overview on addressing caregiver issues after HSCT. The rapidly growing population of long-term HSCT survivors creates an obligation not only to educate patients and physicians about the late complications observed in patients but also to follow up caregivers for their psychosocial support needs.

Social correlates of distress following hematopoietic stem cell transplantation: exploring the role of loneliness and cognitive processing

This study investigated whether loneliness and cognitive processing explain the influence of negative (social constraints) and positive (emotional support) relationship qualities on cancer survivors' distress. Participants were 195 cancer survivors who had undergone hematopoietic stem cell transplantation. Path analysis supported the hypothesis that loneliness and cognitive processing would mediate the association between social constraints and distress. Only loneliness mediated the association between emotional support and distress - an indirect effect significant only when support came from family and friends rather than a partner. Findings suggest that addressing social constraints may enhance cancer survivors' adjustment.

Informal caregivers of hematopoietic cell transplant patients: a review and recommendations for interventions and research

BACKGROUND

Informal caregivers (ICs) for medically fragile hematopoietic cell transplantation (HCT) patients are a vital unrecognized population supporting the transplant patient along the illness continuum. The long transplant recovery period shifts a greater burden of care to the patient's IC. Assessment of HCT caregivers' quality of life (QOL) and health status is critical to implementation of timely intervention and support.

METHODS

A literature search using several search strategies covering 1980 to 2010 identified studies on ICs of HCT patients. These studies were summarized within the caregiver concepts of QOL, role, and resources. Findings of this review were used to create recommended interventions and identify implications for further research.

RESULTS

Although limited, research on ICs of hematopoietic call transplant patients provides beginning evidence for clinical interventions to support this caregiver population. Interventions created focus on education, psychosocial support, and self-care.

CONCLUSIONS

Although limited randomized trials of interventions have been reported, descriptive studies provide evidence for creating intervention content that addresses the needs of ICs of HCT patients. Testing of these interventions and additional areas of research are identified.

IMPLICATIONS FOR PRACTICE

Beginning descriptive evidence provides the basis for interventions for ICs of HCT patients. These interventions support caregiver QOL and role implementation, depending on individual caregivers' resources and needs. Further evaluation and clinical research are needed.

The cancer family caregiving experience: an updated and expanded conceptual model

OBJECTIVE

The decade from 2000 to 2010 was an era of tremendous growth in family caregiving research specific to the cancer population. This research has implications for how cancer family caregiving is conceptualized, yet the most recent comprehensive model of cancer family caregiving was published ten years ago. Our objective was to develop an updated and expanded comprehensive model of the cancer family caregiving experience, derived from concepts and variables used in research during the past ten years.

METHODS

A conceptual model was developed based on cancer family caregiving research published from 2000 to 2010.

RESULTS

Our updated and expanded model has three main elements: 1) the stress process, 2) contextual factors, and 3) the cancer trajectory. Emerging ways of conceptualizing the relationships between and within model elements are addressed, as well as an emerging focus on caregiver-patient dyads as the unit of analysis.

CONCLUSIONS

Cancer family caregiving research has grown dramatically since 2000 resulting in a greatly expanded conceptual landscape. This updated and expanded model of the cancer family caregiving experience synthesizes the conceptual implications of an international body of work and demonstrates tremendous progress in how cancer family caregiving research is conceptualized.

Data mining of mental health issues of non-bone marrow donor siblings

Background

Allogenic hematopoietic stem cell transplantation is a curative treatment for patients with advanced hematologic malignancies. However, the long-term mental health issues of siblings who were not selected as donors (non-donor siblings, NDS) in the transplantation have not been well assessed. Data mining is useful in discovering new findings from a large, multidisciplinary data set and the Scenario Map analysis is a novel approach which allows extracting keywords linking different conditions/events from text data of interviews even when the keywords appeared infrequently. The aim of this study is to assess mental health issues on NDSs and to find helpful keywords for the clinical follow-up using a Scenario Map analysis.

Findings

A 47-year-old woman whose younger sister had undergone allogenic hematopoietic stem cell transplantation 20 years earlier was interviewed as a NDS. The text data from the interview transcriptions was analyzed using Scenario Mapping. Four clusters of words and six keywords were identified. Upon review of the word clusters and keywords, both the subject and researchers noticed that the subject has had mental health issues since the disease onset to date with being a NDS. The issues have been alleviated by her family.

Conclusions

This single subject study suggested the advantages of data mining in clinical follow-up for mental health issues of patients and/or their families.

Effectiveness of partner social support predicts enduring psychological distress after hematopoietic stem cell transplantation

OBJECTIVE

Hematopoietic stem cell transplant (HSCT) survivors who are 1 to 3 years posttransplant are challenged by the need to resume valued social roles and activities--a task that may be complicated by enduring transplant-related psychological distress common in this patient population. The present study investigated whether transplant survivors who receive adequate social support from their spouse or intimate partner experience lower distress.

METHOD

Effects of receiving a greater quantity of partner support (a common approach to studying enacted support) were compared with effects of receiving more effective partner support (i.e., support that more closely matches their needs in terms of its quantity and quality). Men and women (N = 230) who were 1 to 3 years posttransplant completed measures of partner support quantity (Manne & Schnoll, 2001), partner social support effectiveness (Rini & Dunkel Schetter, 2010), and psychological distress (Brief Symptom Inventory; Derogatis & Spencer, 1982). Potential medical and sociodemographic confounds were controlled in analyses.

RESULTS

As hypothesized, survivors reported less distress when they received more effective partner support (p < .001). Quantity of partner support was not associated with distress (p = .23). An interaction revealed that when partner support was effective, the quantity of support survivors received was not associated with their distress (p = .90); however, when partner support was ineffective, receiving a greater quantity of partner support was associated with substantially elevated distress (p = .002).

CONCLUSIONS

Findings suggest that clinical approaches to addressing or preventing enduring distress after HSCT should target features of partner support related to its appraised effectiveness.

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.

Informal caregiving in Hematopoietic Blood and Marrow Transplant patients

PURPOSE

Hematopoietic cell transplant patients are among the most vulnerable and acutely ill cancer populations (Bevans et al., 2008). The responsibility of caring for the daily physical and psychosocial needs of these patients after transplant is placed mostly on family caregivers (Williams, 2007). The purpose of this descriptive correlational research study was to describe caregiving experiences of 56 caregivers of HCT patients 3-12 months following transplant. METHODS & SAMPLE: Patients and caregivers were recruited from two west coast regional transplant programs in the United States. Variables studied were: relationship quality, rewards of caregiving, predictability, role strain, patient function, caregiving activities, and caregiver quality of life (QOL).

KEY RESULTS

Results indicated that all areas of role strain are significantly negatively correlated with caregiver's QOL. Predictability was negatively associated with problem solving and emotional strain indicating that as the level of predictability of the situation decreases, caregiver strain and problem solving increase. Predictability was positively correlated to caregiver QOL indicating that as the situation is more predictable caregiver QOL increases. Emotional strain, problem-solving strain, and usual care strain were significantly positively related, indicating that emotional strain and problem-solving strain increased together. As usual care strain increased, so did problem-solving strain and emotional strain.

CONCLUSIONS

Suggestions for interventions include assessing and responding to caregiver issues such as emotional strain, problem-solving strain, usual care strain, unpredictability, and QOL. Examples of caregiver-focused interventions include providing timely appropriate information about these caregiver concerns including elements that make the caregiving situation predictable, and incorporating best practices for preventing and minimizing caregiver emotional strain.

An individualized dyadic problem-solving education intervention for patients and family caregivers during allogeneic hematopoietic stem cell transplantation: a feasibility study

BACKGROUND

Allogeneic hematopoietic stem cell transplantation (HSCT) generates multiple problems that vary in complexity and create significant distress for both patients and their caregivers. Interventions that address patient and family caregiver distress during allogeneic hematopoietic stem cell transplantation (HSCT) have not been tested.

OBJECTIVE

To evaluate the feasibility of conducting an individualized dyadic problem-solving education (PSE) intervention during HSCT and estimate a preliminary effect size on problem-solving skills and distress.

METHODS

The PSE intervention consisted of 4 sessions of the Prepared Family Caregiver PSE model. Data were collected with an interventionist log, subject interviews and standardized questionnaires.

RESULTS

Of the 34 adult dyads screened, 24 were ineligible primarily because of being non-English-speaking (n = 11) and inconsistent caregivers (n = 10). Ten dyads (n = 20) were enrolled, and 8 dyads (n = 16) completed the intervention. Of the 31 sessions, 29 were completed (94%). Worsening patient condition was the primary reason for sessions to be incomplete. Patients attended 90% of the sessions; caregivers attended 74%. Reasons for missed sessions included patient symptom distress and limited caregiver availability. Dyads reported being very satisfied (mean, 4.8 [SD, 1.8]; range, 1-5), stating "an opportunity to talk" and "creative thinking" were most beneficial.

CONCLUSION

Results suggest that dyads can participate in PSE during HSCT and view it as beneficial. Participants identified the active process of solving problems as helpful.

IMPLICATIONS FOR PRACTICE

Targeted interventions that promote effective, meaningful behaviors are needed to guide patients and caregivers through HSCT. Future research recommendations include testing a version of PSE with fewer sessions, including spousal and nonspousal caregivers and those who are non-English speaking.