Measurement of psychological distress in palliative care

Electronic Health Record Tracking of Psychosocial Care in the Context of Serious Illness: A Narrative Review

Objective: The electronic health record (EHR) has emerged as a fundamental tool but has focused on physical care delivery. Psychosocial screenings and interventions are central to palliative care that supports whole person care models; however, EHR innovations to capture psychosocial care have not been optimized. Material and Methods: A narrative review was conducted from 2009 to March 2023. EMBASE, PubMed, and PsychINFO were queried to identify articles that discussed EHR tracking of psychosocial care in palliative care. Results: Eight articles met inclusion criteria representing a broad range of works in palliative care. Three themes emerged in the narrative review: (a) quality improvement strategy to support EHR tracking in collaboration with key stakeholders, (b) clarification of psychosocial domains for documentation and measurement, and (c) lack of standardization in data collection tools and processes. Discussion: This narrative review contributes to a limited body of literature on EHR extraction of complex sources of distress in palliative care. The designation of four domains (social history and distress, psychological symptoms, spiritual needs, and patients' goals and preferences) defines psychosocial practice aligned with palliative care quality metrics. Recommendations highlight the importance of shared priorities and collaboration with key stakeholders to fully execute on the clinical utility of EHRs. Future work will continue to evaluate data collection tools and systematic approaches to capture psychological needs and social environment and its impact on health outcomes and quality of life. Conclusion: This review will expand on opportunities for automated reporting of psychosocial care in the context of seriously ill.

Needs Analysis for The Development of a Manual in Palliative Care for Malaysia: An Islamic Psychospiritual Approach

This study explicates an Islamic approach to palliative care based on the results of a needs analysis regarding the development of an Islamic psychospiritual manual of palliative care alongside related elements. This article represents the first phase of a three-phase study using the design and development research (DDR) approach developed by Richey and Klein to study for design and development of manual either needed or otherwise. This project is a quantitative study that uses purposive sampling through a questionnaire instrument to investigate 210 participants from the general population in Malaysia that have experience in taking care of terminally ill patients. The findings of the study indicated that the majority of participants agreed with the development of an Islamic psychospiritual manual with mean values (x̅) of 4.57 and 4.66. Concurrently, the findings showed that the hierarchy of emphasis in terms of the elements to be included in the manual starts with emotional support, which exhibited the highest mean rate (x̅), followed by faith in God, spiritual and religious support, self and physical management, trauma management and social support. The correlations indicated that all the elements to be included in the manual were significant.

Psychosocial intervention in palliative care: What do psychologists need to know

Emotional and existential suffering is prevalent in advanced diseases and psychologists have valuable skills to support people in this time of life. Yet, psychologists are rarely integrated in palliative care and relevant training is sparse. Being integrated in other areas of health, it is likely that we will be supporting these patients, whether integrated in a specialized team or not. This article is meant to serve psychologists, already skilled in the art and science of psychosocial intervention, who may find themselves supporting patients with advanced disease. Relevant history of palliative care is provided to elucidate palliative philosophy and approach. Evidence-based existential interventions will be reviewed. Integration of psychological models and both palliative theory and practice is provided to support palliative-appropriate case conceptualizations. Finally, case examples are provided throughout to help readers reconcile their existing practice in this domain of care.

Characteristics and Effectiveness of Individual Psychotherapy for Palliative and End-of-Life Care: A Literature Review for Randomized Controlled Trials

OBJECTIVE

The introduction of psychotherapy in palliative and end-of-life care settings has become increasingly common and is effective in decreasing many psychological problems. This review reports the characteristics and effectiveness of individual psychotherapeutic interventions for patients receiving palliative and end-of-life care. In addition, the review reports the effectiveness of psychotherapies considering the expected life expectancy.

METHODS

The PubMed, Google Scholar, and Cochrane Library databases were searched for English-language articles published between January 2000 to May 2023.

RESULTS

Twenty-six studies were included and classified into a total of nine types of psychotherapies, namely, dignity therapy (DT), life review therapy, narrative therapy, managing cancer and living meaningfully (CALM), individual meaning-centered psychotherapy, meaning and purpose therapy, meaning-making therapy, meaning-of-life therapy, and cognitive therapy.

CONCLUSION

Most of the psychotherapies provided to patients receiving palliative and end-of-life care showed effectiveness in the reduction of negative emotions and positive factors related to end-of-life issues. Most studies targeted patients with advanced cancer; however, studies on DT did not limit the target group to patients with cancer. Considering the expected life expectancy, CALM was found to be suitable for patients receiving early palliative care.

Psychosocial Distress Screening Among Interprofessional Palliative Care Teams: A Narrative Review

With increased need for palliative care and limited staffing resources, non-social workers are increasingly responsible for screening for urgent psychosocial distress. The National Consensus Project guidelines call for all palliative care team members to be competent in screening across domains. Yet, in contrast to an abundance of evidence-informed tools for palliative social work assessments, standardization for interprofessional psychosocial screening is lacking. This lack of standardized practice may lead to harmful disparities in care delivery. The purpose of this narrative review is to examine current literature on evidence-informed practices for psychosocial screening within palliative care. Google Scholar, a university Summon library search engine, and prominent palliative care journals were searched using the same phrases to locate articles for inclusion. Each article was reviewed and synthesized across common themes. Although an abundance of validated screening tools exists for outpatient oncology-specific settings, there is minimal guidance on psychosocial screening tools intended for specialty palliative care. The most oft-cited tools have been met with concern for validity across diverse palliative care populations and settings. Additional research is needed to operationalize and measure brief psychosocial screening tools that can be validated for use by interprofessional palliative care teams, a stepping-stone for increased equity in palliative care practice.

Accelerated transcranial magnetic stimulation for psychological distress in advanced cancer: A phase 2a feasibility and preliminary efficacy clinical trial

BACKGROUND

Psychological and existential suffering affects many people with advanced illness, and current therapeutic options have limited effectiveness. Repetitive transcranial magnetic stimulation (rTMS) is a safe and effective therapy for refractory depression, but no previous study has used rTMS to treat psychological or existential distress in the palliative setting.

AIM

To determine whether a 5-day course of "accelerated" rTMS is feasible and can improve psychological and/or existential distress in a palliative care setting.

DESIGN

Open-label, single arm, feasibility, and preliminary efficacy study of intermittent theta-burst stimulation to the left dorsolateral prefrontal cortex, 600 pulses/session, 8 sessions/day (once per hour) for 5 days. The outcomes were the rates of recruitment, completion of intervention, and follow-up (Feasibility); and the proportion of participants achieving 50% improvement on the Hamilton Depression Rating Scale (HDRS) or Hospital Anxiety and Depression Scale (HADS) 2 weeks post-treatment (Preliminary Efficacy).

SETTING/PARTICIPANTS

Adults admitted to our academic Palliative Care Unit with advanced illness, life expectancy >1 month and psychological distress.

RESULTS

Due to COVID-19 pandemic-related interruptions, a total of nine participants were enrolled between August 2021 and April 2023. Two withdrew before starting rTMS, one stopped due to clinical deterioration unrelated to rTMS, and six completed the rTMS treatment. Five of six participants had a >50% improvement in HDRS, HADS-Anxiety, or both between baseline and the 2 week follow up; the sixth died prior to the 2-week follow-up. In this small sample, mean depression scores decreased from baseline to 2 weeks post-treatment (HDRS 18 vs 7, p = 0.03). Side effects of rTMS included transient mild scalp discomfort.

CONCLUSIONS

Accelerated rTMS improved symptoms of depression, anxiety, or both in this small feasibility and preliminary efficacy study. A larger, sham-controlled study is warranted to determine whether rTMS could be an effective, acceptable, and scalable treatment in the palliative setting.

TRIAL REGISTRATION

NCT04257227.

A transdiagnostic systematic review and meta-analysis of ketamine's anxiolytic effects

BACKGROUND

Ketamine may be effective in treating symptoms of anxiety, but the time profile of ketamine's anxiolytic effect is ill-defined. This systematic review and meta-analysis investigated the anxiolytic effect of ketamine at different time points across a range of clinical settings.

METHODS

Electronic databases were searched to capture randomised control trials measuring the anxiolytic effects of ketamine in contexts including mood disorders, anxiety disorders and chronic pain. Meta-analyses were conducted using a random-effects model. The correlations between (1) improvements in mean anxiety and depression scores, and (2) peak dissociation and improvements in mean anxiety scores were also assessed.

RESULTS

In all, 14 studies met inclusion criteria. Risk of bias was high in 11 studies. Ketamine significantly reduced anxiety scores compared to placebo at acute (<12 h; standard mean difference (SMD): -1.17, 95% confidence interval (CI) [-1.89, -0.44], p < 0.01), subacute (24 h; SMD: -0.44, 95% CI [-0.65, -0.22], p < 0.01) and sustained (7-14 days; SMD: -0.40, 95% CI [-0.63, -0.17], p < 0.01) time points. Exploratory analyses revealed improvements in anxiety and depression symptoms correlated at both subacute (R2 = 0.621, p = 0.035) and sustained time points (R2 = 0.773, p = 0.021). The relationship between peak dissociation and improvement in anxiety was not significant.

CONCLUSIONS

Ketamine appears to offer rapid and sustained anxiety symptom relief across a range of clinical settings, with anxiolytic effects occurring within the first 12 h of administration and remaining effective for 1-2 weeks. Future studies could explore the effects of ketamine maintenance therapy on anxiety symptoms.

A Systematic Review and Bayesian Network Meta-Analysis Investigating the Effectiveness of Psychological Short-Term Interventions in Inpatient Palliative Care Settings

This paper reviews and summarises the evidence of short-term psychosocial interventions (up to 12 sessions delivered within less than eight weeks) on anxiety, depression, and emotional distress in palliative patients in inpatient settings. We screened publications from the following five databases, Embase, PubMed, PsycINFO, Web of Science, and CINAHL, from their inception to 10 September 2021. The eligible studies included controls receiving standard palliative care, actively treated controls, and wait-list controls. Nine studies met the eligibility criteria and reported the effects of five psychosocial interventions in a total of N = 543 patients. We followed PRISMA-guidelines for outcome reporting and the Cochrane Risk of Bias Assessment Tool for assessing study quality. This paper used the network meta-analysis to compare multiple treatments by providing greater statistical power and the cross-validation of observed treatment effects, using the R package BUGSnet. Compared to control groups, the following psychosocial interventions in inpatient settings showed to be superior: life review interventions were the best ranked treatment for improving anxiety and distress, while the top ranked treatment for reducing depression was outlook intervention. The short-term psychosocial interventions investigated in this meta-analysis, especially life review intervention, are feasible and can potentially improve anxiety, depression, and distress in palliative inpatients and should therefore be offered in inpatient settings.

"Song of Life": Results of a multicenter randomized trial on the effects of biographical music therapy in palliative care

BACKGROUND

Awareness for the importance of psychological and spiritual needs in patients with terminal diseases has increased in recent years, but randomized trials on the effects of psychosocial interventions are still rare.

AIM

To investigate the efficacy of the "Song of Life" music therapy intervention regarding the emotional and psycho-spiritual dimensions of quality of life.

DESIGN

Patients were randomly assigned to either "Song of Life" or a relaxation intervention. "Song of Life" is a novel three-session music therapy intervention working with a biographically meaningful song. Primary outcome was the improvement in psychological quality of life. Secondary outcomes included spiritual well-being, ego-integrity, momentary distress, and global quality of life and the explorative assessment of treatment satisfaction (patient and family member version). Intention-to-treat analysis was conducted including adjustment for multiple testing in secondary outcomes.

SETTING/PARTICIPANTS

Between December 2018 and August 2020, 104 patients receiving specialized palliative care were recruited from two palliative care wards.

RESULTS

No significant differences were found regarding psychological and global quality of life, but "Song of Life" participants reported significantly higher spiritual well-being (p = 0.04) and ego-integrity (p < 0.01), as well as lower distress (p = 0.05) than patients in the control group. Both patients' and family members' treatment satisfaction was higher after "Song of Life" with large between-group effect sizes on items asking for meaningfulness (d = 0.96) and importance (d = 1.00).

CONCLUSIONS

Our findings provide evidence that "Song of Life" is an effective and meaningful biographical music therapy intervention to facilitate psycho-spiritual integration in terminally ill patients.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS)-DRKS00015308 (date of registration: September 7th 2018).

Validation of the Death and Dying Distress Scale in patients with advanced cancer

BACKGROUND

Distress about dying and death is an important clinical and research outcome in advanced cancer. A 15-item Death and Dying Distress Scale (DADDS) measure has undergone preliminary validation, but full validation in a large sample has not previously been reported. We investigated its psychometric characteristics and responsiveness to a therapeutic intervention.

METHODS

This is a secondary analysis of baseline data obtained from a randomized controlled trial of psychotherapeutic intervention for patients with advanced cancer. Participants (n = 386) completed the DADDS, and measures of depression, anxiety, demoralization, quality of life (including preparation for end of life), spirituality, attachment security, and symptom burden.

RESULTS

A confirmatory factor analysis revealed factors related to "Finitude" and to "Dying." Both factors showed good internal consistency (Cronbach α = 0.861-0.949). DADDS scores were significantly higher in females, those with lower income and not working. Construct validity was demonstrated by a positive correlation between DADDS and demoralization (r = 0.569-0.679), and a negative correlation with preparation for the end of life (r = -0.475 to -0.678). At 6 months, intervention participants with moderate DADDS scores at baseline reported significantly lower DADDS scores on both factors compared to usual care.

CONCLUSIONS

The DADDS is a valid and brief two-factor measure that assesses distress related to the shortness of time and to the process of dying. The total and factor scores have utility in the clinical and research assessment of death-related distress in patients with advanced cancer.

Expression of existential suffering in two patients with advanced cancer in an acute palliative care unit

BACKGROUND

Recognizing and managing existential suffering remains challenging. We present two cases demonstrating how existential suffering manifests in patients and how to manage it to alleviate suffering.

CASE DESCRIPTION

Case 1: A 69-year-old man with renal cell carcinoma receiving end-of-life care expressed fear of lying down "as he may not wake up." He also expressed concerns of not being a good Christian. Supportive psychotherapy and chaplain support were provided, with anxiolytic medications as needed. He was able to express his fear of dying and concern about his family, and Edmonton Symptom Assessment System scores improved. He died peacefully with family at bedside. Case 2: A 71-year-old woman presented with follicular lymphoma and colonic obstruction requiring nasogastric drain of fecaloid matter. Initially, she felt that focusing on comfort rather than cure symbolized giving up but eventually felt at peace. Physical symptoms were well-controlled but emotionally she became more distressed, repeatedly asking angrily, "Why is it taking so long to die?." She was supported by her family through Bible readings and prayers, but she was distressed about being a burden to them. An interdisciplinary approach involving expressive supportive counseling, spiritual care, and integrative medicine resulted in limited distress relief. Owing to increasing agitation, the patient and family agreed to titrate chlorpromazine to sedation. Her family was appreciative that she was restful until her death.

CONCLUSION

Existential suffering manifests through multiple domains in each patient. A combination of pharmacologic and non-pharmacologic techniques may be needed to relieve end-of-life suffering.

Exploring the psychological impact of life-limiting illness using the Attitude to Health Change scales: A qualitative focus group study in a hospice palliative care setting

OBJECTIVE

Practitioners are often reluctant to engage in conversations that acknowledge patient's health concerns. This can affect patient and family carer psychological well-being. The Attitude to Health Change scales, adapted from the validated Adult Attitude to Grief scale, may have potential to address the psychological impact of illness and facilitate conversations in palliative care. To explore how health and social care professionals experience using the Attitude to Health Change Scales within hospice settings.

METHODS

Qualitative focus groups with practitioners currently using the Attitude to Health Change scales in three UK hospices. Two researchers conducted the interviews, developed the thematic framework and independently coded the transcripts using a framework analysis approach.

RESULTS

Three focus groups (n = 21 practitioners). The scale was used to assess and reassess levels of vulnerability and resilience to identify the need for support and to facilitate structured in-depth conversations. Factors that influenced scale implementation included the following: practitioner personal comfort and training; patient and family carer willingness to engage with the scales and having a practitioner "champion" within the organisation.

CONCLUSION

This exploratory work has identified the potential value of the scales for assessment and to facilitate conversations. Further research needs to incorporate the views of patients and family carers.

Agency, Autonomy and Euthanasia

Agency is the human capacity to freely choose one's thoughts, motivations and actions without undue internal or external influences; it is distinguished from decisional capacity. Four well-known conditions that can deeply affect agency are depression, demoralization, existential distress, and family dysfunction. The study reviews how they may diminish agency in persons whose circumstances may lead them to consider or request euthanasia or assisted suicide. Since agency has been a relatively neglected dimension of autonomous choice at the end of life, it is argued that to respect the autonomy of individuals, it is essential to establish their agency.

“Truly holistic?” Differences in documenting physical and psychosocial needs and hope in Portuguese palliative patients

Objective

Palliative care (PC) aims to improve patients' and families' quality of life through an approach that relieves physical, psychosocial, and spiritual suffering, although the latter continues to be under-assessed and under-treated. This study aimed to describe the prevalence of physical, psychosocial, and hope assessments documented by a PC team in the first PC consultation.

Method

The retrospective descriptive analysis of all first PC consultations registered in our anonymized database (December 2018–January 2020), searching for written documentation regarding (1) Edmonton Symptom Assessment Scale (ESAS) physical subscale (pain, tiredness, nausea, drowsiness, appetite, shortness of breath, constipation, insomnia, and well-being), (2) the single question “Are you depressed?” (SQD), (3) the question “Do you feel anxious?” (SQA), (4) feeling a burden, (5) hope-related concerns, (6) the dignity question (DQ), and (7) will to live (WtL).

Results

Of the 174 total of patients anonymously registered in our database, 141 PC home patients were considered for analysis; 63% were male, average age was 70 years, the majority had malignancies (82%), with a mean performance status of 52%. Evidence of written documentation was (1) ESAS pain (96%), tiredness (89%), nausea (89%), drowsiness (79%), appetite (89%), shortness of breath (82%), constipation (74%), insomnia (72%), and well-being (52%); (2) the SQD (39%); (3) the SQA (11%); (4) burden (26%); (5) hope (11%); (6) the DQ (33%); and (7) WtL (33%).

Significant differences were found between the frequencies of all documented items of the ESAS physical subscale (29%), and all documented psychosocial items (SQD + SQA + burden + DQ) (1%), hope (11%), and WtL (33%) (p = 0.0000; p = 0.0005; p = 0.0181, respectively).

Significance of results

There were differences between documentation of psychosocial, hope, and physical assessments after the first PC consultation, with the latter being much more frequent. Further research using multicenter data is now required to help identify barriers in assessing and documenting non-physical domains of end-of-life experience.

Psychological Interventions for Patients With Advanced Disease: Implications for Oncology and Palliative Care

A growing body of research demonstrates the feasibility and efficacy of psychological interventions for adult patients with advanced cancer. Findings from quantitative studies of psychotherapeutic interventions with primary psychological outcomes for such patients are reviewed here and recommendations for best practice are made. We consider these interventions according to three broad phases in which they are most commonly applied: soon after diagnosis of advanced cancer, when living with the disease, and at or near the end of life. Cumulative evidence from well-designed studies demonstrates the efficacy of psychosocial interventions for patients with advanced disease to relieve and prevent depression, anxiety, and distress related to dying and death, as well as to enhance the sense of meaning and preparation for end of life. Individual and couple-based interventions have been proven to be most feasible, and the development and use of tailored and validated measures has enhanced the rigor of research and clinical care. Palliative care nurses and physicians can be trained to deliver many such interventions, but a core of psychosocial clinicians, including social workers, psychologists, and psychiatrists, is usually required to train other health professionals in their delivery and to ensure their quality. Few of the interventions for which there is evidence of effectiveness have been routinely incorporated into oncology or palliative care. Advocacy on the basis of this evidence is required to build psychosocial resources in cancer treatment settings and to ensure that psychological care receives the same priority as other aspects of palliative care in oncology.

Pain, fatigue, anxiety and depression in older home-dwelling people with cancer

Aim

Globally, cancer incidence counts for more than 14 million cases and the number increases with age. The aim of this study was to investigate the occurrence of pain, fatigue, anxiety and depression in association with demographic and clinical factors.

Design

A cross-sectional descriptive design was used.

Methods

We performed descriptive statistics to analyse the questionnaires completed from 174 older home-dwelling people with cancer.

Results

The people with cancer reported low occurrence of pain, fatigue, anxiety and depression. We found strong correlation between anxiety and depression. Women reported significantly higher scores of anxiety and depression than men. A higher pain score was associated with higher scores of fatigue and anxiety.

Conclusions

Home care personnel meeting older home-dwelling people with cancer should emphasize these people' mental health problems and be aware that pain, fatigue and anxiety may occur at the same time.

Distress in delirium: causes, assessment and management

Purpose

Delirium is a common clinical syndrome associated with increased physical and psychological morbidity, mortality, inpatient stay and healthcare costs. There is growing interest in understanding the delirium experience and its psychological impact, including distress, for patients and their relatives, carers and healthcare providers.

Methods

This narrative review focuses on distress in delirium (DID) with an emphasis on its effect on older patients. It draws on qualitative and quantitative research to describe patient and environmental risk factors and variations in DID across a number of clinical settings, including medical and surgical inpatient wards and end of life care. The article provides an overview of the available distress assessment tools, both for clinical and research practice, and outlines their use in the context of delirium. This review also outlines established and emerging management strategies, focusing primarily on prevention and limitation of distress in delirium.

Results

Both significant illness and delirium cause distress. Patients who recall the episode of delirium describe common experiential features of delirium and distress. Relatives who witness delirium also experience distress, at levels suggested to be greater than that experienced by patients themselves. DID results in long-term psychological sequelae that can last months and years. Preventative actions, such pre-episode educational information for patients and their families in those at risk may reduce distress and psychological morbidity.

Conclusions

Improving clinicians’ understanding of the experience and long term psychological harm of delirium will enable the development of targeted support and information to patients at risk of delirium, and their families or carers.

Introducing psychology services to advanced cancer patients: A randomized double-blind trial

CONTEXT

Psychology services utilization in cancer patients remains low due to barriers such as patient/caregiver acceptance of counseling.

OBJECTIVE

We aimed to determine if the manner of introducing psychology services impacted patients' acceptance of services and to identify factors associated with acceptance and barriers to psychology utilization.

METHODS

In this double-blind randomized cross-over trial, cancer patients with no prior psychology services observed two video vignettes: (a) physician introducing counselor and psychology services to the patient (PI) and (b) counselor introducing psychology services alone (CI). A counterbalanced design was used to control for order effects. After viewing both videos, patients completed a survey regarding preference, attitudes, and barriers for psychology services. Patients and investigators were blinded to the purpose of the study and content and order of videos, respectively. We hypothesized that patients would prefer physician introduction of counselor.

RESULTS

One hundred patients participated: 40 (40%) expressed no difference, 34 (34%) preferred PI, and 26 (26%) preferred CI (P > .2). Younger patients (less than 40 years) either preferred PI (86%) or had no preference (14%, P = .01). Most reported awareness of available psychology services (N = 63), and half (N = 50) were offered psychology services by their physician. Only 40 (40%) and 43 (43%) patients felt psychology services would be helpful for them and their family/caregivers, respectively. Patients who perceived psychology as helpful for self or family had higher anxiety (P = .01 and P = .006, respectively).

CONCLUSIONS

No significant difference was found in patient preference of introducing psychology services except in patients less than 40 years old who preferred PI.

Self-Management Interventions for Psychological Distress in Adult Cancer Patients: A Systematic Review

Psychological distress is prevalent among cancer patients, who may be vulnerable to distress at times of transition, such as a change in symptom experience, employment, or goal of treatment. Independently, both psychological distress and transitions impair patients' quality of life, and together their adverse impact may be intensified. Self-management allows patients to engage in tasks that influence the disease experience and can include strategies to help mitigate distress associated with transitions. The purpose of this systematic review was to examine research on the relationship between self-management interventions and distress in adult cancer patients receiving active tumor-directed therapy. From a search of seven electronic databases, 5,156 articles were identified; however, nine studies met inclusion criteria. Our review suggested that self-management interventions may help address psychological distress in patients receiving cancer treatment but that the current evidence is not robust enough to support a definitive conclusion.

Characteristics and Outcomes of Psychology Referrals in a Palliative Care Department

CONTEXT

Psychologists can provide unique contributions to interdisciplinary palliative care. Despite research indicating high distress in palliative care cancer patients, little has been reported regarding the feasibility and practice of psychology in this setting.

OBJECTIVES

To review the integration of clinical psychology practice in a palliative care department at a major comprehensive cancer center.

METHODS

Retrospective chart review of 1940 unique cancer patients (6451 total patient contacts) referred for psychology services provided by clinical psychologists in palliative care from September 1, 2013 to February 29, 2016.

RESULTS

Psychologists provided services to 1644 inpatients (24% of palliative care inpatients) and 296 outpatients (19% of palliative care outpatients). Most of them (85%) received services in the inpatient setting. Most patients were females (57%) and white (68%) with a variety of cancer diagnoses. Adjustment disorders were the most prevalent in both settings with significant differences in other Diagnostic and Statistical Manual of Mental Disorders (5th Edition) diagnoses by service location (P < 0.0001). Psychological assessment (86%) and supportive expressive counseling (79%) were the most frequent services provided in the initial consult. Duration of initial visit was significantly longer in outpatient (median 60 minutes) compared with inpatient setting (median 40 minutes) (P < 0.0001). No significant differences were noted between settings regarding the median number of counseling sessions per patient; however, most (70%) only received one or two sessions. Over time, total patient encounters increased in the inpatient setting (P < 0.0001), whereas session lengths in both settings significantly decreased (P < 0.0001).

CONCLUSION

Palliative care psychology services successfully integrated into an interdisciplinary palliative care department and rapidly grew in both inpatient and outpatient settings.

Core Symptoms of Major Depressive Disorder among Palliative Care Patients

A valid method to diagnose depression in palliative care has not been established. In this study, we aim to determine the prevalence of depression and the discriminant validity of the items of four sets of diagnostic criteria in palliative care. This is a cross-sectional study on 240 palliative care patients where the presence of depression was based on the Diagnostic and Statistical Manual of Mental Disorders, DSM⁻IV Criteria, Modified DSM⁻IV Criteria, Cavanaugh Criteria, and Endicott's Criteria's. Anxiety, depression, and distress were measured with Hospital Anxiety and Depression Scale and Distress Thermometer. The prevalence of depression among the palliative care patients was highest based on the Modified DSM⁻IV Criteria (23.3%), followed by the Endicott's Criteria (13.8%), DSM⁻IV Criteria (9.2%), and Cavanaugh Criteria (5%). There were significant differences (p < 0.05) in the depressive symptoms showed by DSM⁻IV item 1 (dysphoric mood), item 2 (loss of interest or pleasure), and Endicott's criteria item 8 (brooding, self-pity, or pessimism) among the palliative patients, even after adjustment for the anxiety symptoms and distress level. We found that dysphoric mood, loss of interest, and pessimism are the main features of depression in palliative patients. These symptoms should be given more attention in identifying depression in palliative care patients.

Changes in Distress Measured by the Distress Thermometer as Reported by Patients in Home Palliative Care in Germany

AIM

To identify changes in distress as reported by patients in a home palliative care program over a 2-week period.

METHODS

Prospective study in West Germany with consecutive patients cared for at home by a palliative care specialty team. Exclusion criteria were patients under 18 years of age, mentally or physically not able to complete the assessment questionnaires, or unable to comprehend German language. Distress was measured using the distress thermometer (DT); sociodemographic and medical data were collected from the patients' records.

RESULTS

One hundred three participated in the study (response rate of 69%) and 39 participants completed DT at 2-week follow-up (T₁; response rate = 38%; mean age = 67; female = 54.4%; married = 67%; living home with relatives = 60.2%; oncological condition = 91.3%; Karnofsky performance status [KPS] 0-40 = 18.9%, KPS 50-70 = 70.3%, KPS >80 = 10.8%). The mean DT score at the first visit (T₀) was 5.9 (2.3), with 82.1% of the participants scoring DT ≥5. At the 2-week follow-up (T₁), mean DT score was 5.0 (2.0), with 64.1% scoring DT ≥5, showing a statistically significant difference between T₀ and T₁. Comparing the single scores at T₀ and T₁ of each participant, the difference in DT scores was -0.9 (2.27).

CONCLUSION

The DT is a useful tool for screening severity and changes in psychological distress as well as sources of distress. The DT detected change in self-reported distress within a short treatment period, indicating success or failure of the palliative care treatment approaches.

'Worried to death': the assessment and management of anxiety in patients with advanced life-limiting disease, a national survey of palliative medicine physicians

Background

Anxiety adversely affects quality of life and is common in adults with advanced life-limiting disease. There are no UK-wide guidelines on the assessment and management of anxiety in this specific population and there is little evidence regarding drug treatments. This study aimed to explore how palliative care physicians assess and manage anxiety in their patients, and to identify barriers encountered.

Methods

A cross-sectional survey was undertaken of all physicians working in specialist palliative care in the UK who were members of the Association for Palliative Medicine. This was conducted in February 2014 using an online questionnaire.

Results

The response rate was 23% (230/980) and 61% of respondents were consultants. Most did not use tools to screen for anxiety (87%) and almost all used the clinical interview to diagnose anxiety (99%). Only 8% used psychiatric criteria. Most physicians reported difficulties managing anxiety (93%). Only 33% thought they had adequate training in this area. Most had difficulty accessing psychological and/or psychiatric services (71%, 64% respectively). The majority used a combination of pharmacological and non-pharmacological treatments for anxiety. The most frequently prescribed first-line medications for patients with a prognosis of days to weeks were benzodiazepines (93%), usually lorazepam. The use of benzodiazepines over antidepressants was statistically significant (p < 0.001). For patients with a prognosis of months, antidepressants were most frequently prescribed first-line (60%), significantly more than benzodiazepines (p < 0.001). However, benzodiazepine use was still common in this prognostic group with 47% prescribing it first-line, sometimes in combination with an antidepressant.

Conclusion

This is the first national survey on the assessment and management of anxiety in palliative care. Findings demonstrate the infrequent use of screening tools, variation in prescribing practice, potentially inappropriate use of benzodiazepines for patients with a prognosis of months, training gaps and poor access to psychological and psychiatric services in the UK. This highlights the need for formal training, further research into the pharmacological management of anxiety in this population and evidence-based national guidance to support clinical decision-making and service development.

Psychological Effects of Group Hypnotherapy on Breast Cancer Patients During Chemotherapy

The purpose of this study was to evaluate the effect of group hypnotherapy on anxiety, depression, stress, self-esteem, optimism, and social support during chemotherapy, in patients with breast cancer, compared with a control group with standard medical care. Hypnotherapy consisted of 24 sessions that included suggestions to encourage relaxation, self-esteem, the resolution of past traumatic events, physical healing, and optimism. Results show that the hypnotherapy group significantly decreased anxiety, distress, increased self-esteem, and optimism in the first 12 sessions. However, at the end of the 24 sessions, only self-esteem and optimism remained significant compared with the control group. The convenience of using hypnotherapy to encourage optimism and self-esteem in patients with breast cancer during chemotherapy treatment is discussed given its protective effect on health.

Screening for symptom burden and supportive needs of patients with glioblastoma and brain metastases and their caregivers in relation to their use of specialized palliative care

PURPOSE

Patients with brain tumors have a high symptom burden and multiple supportive needs. Needs of caregivers are often unattended. This study aims to determine screening-based symptom burden and supportive needs of patients and caregivers with regard to the use of specialized palliative care (SPC).

METHODS

Seventy-nine patients with glioblastoma and brain metastases and 46 caregivers were screened with standardized questionnaires following diagnosis and 2 months later. The screening assessed symptom burden, quality of life (QoL), distress, and supportive needs.

RESULTS

The most relevant symptoms were drowsiness, tiredness, and low well-being (53-58%). The most prevalent patient supportive needs were the need for information about available resources, the illness, and possible lifestyle changes (50-56%). The most prevalent caregiver needs were information about the illness, lifestyle changes, and about available resources (56-74%). Patients who received SCP and their caregivers had higher symptom burden and supportive needs than those without SPC. They reported moderate improvement in pain, distress, and QoL, while patients without SPC also improved their QoL, but had small to moderate deteriorations in pain, drowsiness, nauseas, well-being, and other problems. Distress of caregivers with SPC improved with moderate to large effect sizes but still was on a high level and remained stable for those without SPC.

CONCLUSIONS

Symptom burden and supportive needs were high, but even more caregivers than patients expressed high distress and supportive needs. SPC appears to reach the target group, both patients and caregivers with elevated symptom burden. Targeted interventions are needed to improve tiredness and drowsiness.

Preparation for the end of life and life completion during late-stage lung cancer: An exploratory analysis

Objective:

Our aim was to explore preparation for the end of life (EoL) and life closure among persons with advanced metastatic lung cancer. Understanding quality of life through the lens of preparation and completion is important since the trajectory of lung cancer can be relatively short, often leading to application of cancer-directed therapies near death without the opportunity for advance planning or palliative care. Clinical research is needed to understand the kinds of distress specific to older adults with advanced lung cancer that are amendable to palliative care interventions.

Method:

We employed an exploratory cross-sectional design to examine psychosocial and existential concerns among a purposive sample (N = 30) of advanced lung cancer patients using the “end-of-life preparation” and “life completion” subscales of the Quality of Life at the End of Life (QUAL–E) questionnaire. Nonparametric methods were employed to analyze preparation, completion, global quality of life (QoL), and the associations among depressive symptoms, preparation, completion, and global QoL.

Results:

Higher scores on life completion were associated with better global QoL, and with items related to transcendence, communicative acts, and interpersonal relationships demonstrating important contributions. The perception of being a future burden on family members was the greatest concern within the preparation domain. Depressive symptoms were not associated with preparation, completion, or global QoL.

Significance of Results:

Psychosocial and existential issues contribute to QoL at the EoL among older adults with late-stage lung cancer during cancer-directed therapy, concurrent care, and hospice. The role of preparation, especially self-perceived burden, merits further research early on in the oncological setting. The preparation and life completion subscales of the QUAL–E are feasible clinical tools for facilitating dyadic communication about sensitive topics in the palliative care setting.

How much psychological distress is experienced at home by patients with palliative care needs in Germany? A cross-sectional study using the Distress Thermometer

Objective:

The aims of the present study were (1) to describe the prevalence of psychosocial distress in palliative care patients living at home and the related factors, and (2) to test implementation of the Distress Thermometer (DT) within a home-based palliative care service.

Method:

Ours was a 15-month prospective study beginning in September of 2013 in western Germany with consecutive patients cared for by a home care palliative care service. The research was implemented during the first visit by the home care team. Patients were excluded if they were under 18 years of age, mentally or physically unable to complete the assessment questionnaires as judged by their healthcare worker, or unable to understand the German language. During the first encounter, the Distress Thermometer (DT), a Problem List (PL), and a structured questionnaire for evaluation were applied and sociodemographic and medical data collected.

Results:

A total of 103 patients (response rate = 70%; mean age = 67; female = 54%; married = 67%; oncological condition = 91%; Karnofsky Performance Status [KPS] score 0–40 = 34%, 50–70 = 60%, >80 = 6%) were included. The incidence of distress (DT score ≥4) was 89.3% (mean = 6.3 ± 2.5). No statistical association was found between level of distress and sociodemographic or medical factors. The five most reported problems were “fatigue” (90%), “getting around” (84%), “eating” (63%), “bathing/dressing” (60%), and “sleep” (57%). The number of problems reported correlated with level of distress (ρ = 0.34). The DT was comprehensible, and 80% considered its completion as unremarkable, while 14% found it “relieving.”

Significance of results:

A significant proportion of patients treated at home reported symptoms of distress. The most oft-mentioned problems were physical and emotional in nature. The findings of our study highlight the importance of creating new concepts and structures in order to address the psychosocial needs of patients in home care with palliative needs.

Pain behind bars: the epidemiology of pain in older jail inmates in a county jail

BACKGROUND

The number of older jail inmates in poor health is increasing rapidly. Among older adults, pain is common and leads to greater acute care use. In jail, pain management is complicated by concerns about misuse and diversion. A lack of data about the prevalence and management of pain in older jail inmates limits our ability to develop optimal palliative care strategies for this population.

OBJECTIVE

To describe the prevalence of and factors associated with pain and analgesic use in a population of older jail inmates.

DESIGN

Cross-sectional study. χ(2) tests assessed association between characteristics, pain, and analgesic use.

SETTING/SUBJECTS

Two hundred ten jail inmates age 55 or older.

MEASUREMENTS

"Severe frequent pain" defined as "severe or very severe" pain experienced "frequently or constantly" using the validated Memorial Symptom Assessment Scale. Medical conditions, substance use, and analgesic treatment determined through self-report and jail medical records.

RESULTS

Participants' mean age was 59 years; 69% had multimorbidity; 75% reported any pain; 39% reported severe frequent pain. Report of severe frequent pain was associated with multimorbidity, functional impairment, and pre-jail acute care use (p<0.05), but not with substance use (57% versus 56%, p=0.89). Within a week of their interview, most participants with severe frequent pain had received an analgesic (87%) and many received an opioid (70%).

CONCLUSION

High rates of pain in a rapidly growing population of older jail inmates with multimorbidity and functional impairment suggest that jails are an important site for assessing symptom burden and developing appropriate palliative care interventions.

Assessment of spiritual suffering in the cancer context: A systematic literature review

OBJECTIVE

An important goal of cancer medicine is relief of patients' suffering. In view of the clinical challenges of identifying suffering patients, we sought to identify valid instruments for assessing the spiritual suffering of people diagnosed with cancer.

METHOD

A systematic review of the literature was conducted in the Medline, Embase, the Cochrane Library, and PsycINFO databases seeking assessment instruments that measure either suffering or one of its synonyms or symptoms. The psychometric properties of the identified measures were compared.

RESULTS

A total of 90 articles were identified that supplied information about 58 measures. The constructs examined were: suffering, hopelessness/demoralization, hope, meaning, spiritual well-being, quality of life where a spiritual/existential dimension was included, distress in the palliative care setting and pain, distress or struggle of a spiritual nature. The Pictorial Representation of Illness and Self Measure (PRISM) (patient completed) was the most promising measure identified for measuring the burden of suffering caused by illness due to its ease of use and the inclusion of a subjective component.

SIGNIFICANCE OF RESULTS

Although the appropriateness of any measure for the assessment of spiritual suffering in cancer patients will depend on the context in which it is intended to be utilized, the PRISM is promising for measuring the burden of suffering due to illness.

Patterns of dignity-related distress at the end of life: a cross-sectional study of patients with advanced cancer and care home residents

BACKGROUND

To provide effective palliative care in different settings, it is important to understand and identify the sources of dignity-related distress experienced by people nearing the end of life.

AIM

To describe and compare the sources of dignity-related distress reported by cancer patients and care home residents.

DESIGN

Secondary analysis of merged data. Participants completed the Patient Dignity Inventory (assessing 25 sources of dignity-related distress) and measures of quality of life and depression.

SETTING/PARTICIPANTS

A total of 45 adult patients with advanced cancer referred to hospital-based palliative care teams in London, United Kingdom, and 60 residents living in one of 15 care homes in London.

RESULTS

Care home residents were older and had poorer functioning. Both groups reported a wide range of dignity-related problems. Although the number or problems reported on the Patient Dignity Inventory was similar for the two groups (mean (standard deviation): 5.9 (5.5) for cancer patients and 4.1 (4.3) for care home residents, p = 0.07), there was a tendency for more cancer patients to report some existential problems. Experiencing physically distressing symptoms and functional limitations were prevalent problems for both groups. Patient Dignity Inventory problems were associated with poorer performance status and functioning for residents, with age and cognitive impairment for cancer patients and with poorer quality of life and depression for both groups.

CONCLUSION

Although characteristics of the samples differed, similarities in the dignity-related problems reported by cancer patients and care home residents support research suggesting a common pathway towards death for malignant and non-malignant disease. A wider understanding of the sources of dignity-related distress would help clinicians provide more effective end-of-life care.

Mindfulness-Based Supportive Therapy (MBST)

Objective:

To develop a mindfulness-based palliative psychotherapy to address psychoexistential suffering in palliative care.

Conceptualization:

First, a theory of suffering was formulated by merging 2 models of suffering from 2 thematic analyses of 20 palliative care patients and 15 informal caregivers. Second, the results from a secondary thematic analysis of suffering caused by health care interactions were conceptualized into a psychotherapy framework. Third, principles of mindfulness were incorporated into the framework to form a mindfulness-based psychotherapy.

Results:

Mindfulness-based supportive therapy (MBST) was developed with the following 5 components of presence, listening, empathy, compassion, and boundary awareness.

Conclusion:

We believe that MBST is a potentially useful psychological intervention in palliative care, specifically designed to address psychoexistential suffering of terminally ill patients.

Anger: a common form of psychological distress among patients at the end of life

Psychological distress is common in palliative care patients and their families, and anger is a complex component of distress experienced by many patients at the end of life. Anger can be a form of tension release, as well as a coping mechanism for the patient and a way to disguise fear and anxiety. The interdisciplinary team are responsible for recognising psychological distress in patients, assessing their needs, and providing adequate psychological support. Although a certain level of psychological distress such as anger is expected in terminally ill patients owing to their situation, such responses may also be dysfunctional. This paper aims to highlight the challenges and complexities of adequately assessing and supporting palliative care patients who are presenting with psychological distress in the form of anger, in order to relieve their suffering and assist them in resolving their issues and improving their quality of life. Anger can be difficult to treat, and for some patients can be more distressing than some physical symptoms. Hence this paper also aims to offer anger management guidance to palliative care practitioners.

Psico-Oncologia: atuação do psicólogo no Hospital de Câncer de Barretos

A Psico-Oncologia surgiu a partir da necessidade do acompanhamento psicológico ao paciente com câncer, a sua família e à equipe que o acompanha. O papel do psicólogo em oncologia propõe o apoio psicossocial e psicoterapêutico diante do impacto do diagnóstico e de suas consequências e mostra a possibilidade de auxílio para melhor enfrentamento e qualidade de vida do doente e de seus familiares. O objetivo deste relato consiste em descrever a atuação desenvolvida por psicólogos do Serviço de Psicologia do Hospital de Câncer de Barretos/Fundação Pio XII - SP, uma instituição médica especializada em oncologia.

Depression and anxiety in palliative care inpatients compared with those receiving palliative care at home

OBJECTIVE

This study compared the prevalence of anxiety and depression as measured on the Hospital Anxiety and Depression Scale (HADS) in palliative care patients being treated at home with those being treated as inpatients.

METHOD

The participants were palliative care patients being treated at home (n = 46) and palliative care inpatients (n = 46). Subjects were assessed for functionality on the Karnofsky Performance Status Scale (KPS) and anxiety and depression were measured on the HADS.

RESULTS

The results showed that ~20% of all patients were depressed and anxious as measured on the HADS, regardless of the cutoff criteria. There was no significant difference in depression and anxiety between the two groups when socioeconomic status and functionality were controlled for. Functionality, as measured on the KPS, was uniquely a predictor of depression, and younger patients were shown to have greater anxiety.

SIGNIFICANCE OF RESULTS

The results suggest that home-based palliative care patients and palliative care inpatients should receive equal psychological support, and that clinicians need to be aware of the psychological vulnerability of younger and less-functional patients. The prevalence of depression and anxiety indicates that all palliative care patients should be screened for psychological distress, to identify those who need further assessment and treatment.

The Beck Depression Inventory (BDI-II) and a single screening question as screening tools for depressive disorder in Dutch advanced cancer patients

Purpose

Depression is highly prevalent in advanced cancer patients, but the diagnosis of depressive disorder in patients with advanced cancer is difficult. Screening instruments could facilitate diagnosing depressive disorder in patients with advanced cancer. The aim of this study was to determine the validity of the Beck Depression Inventory (BDI-II) and a single screening question as screening tools for depressive disorder in advanced cancer patients.

Methods

Patients with advanced metastatic disease, visiting the outpatient palliative care department, were asked to fill out a self-questionnaire containing the Beck Depression Inventory (BDI-II) and a single screening question “Are you feeling depressed?” The mood section of the PRIME-MD was used as a gold standard.

Results

Sixty-one patients with advanced metastatic disease were eligible to be included in the study. Complete data were obtained from 46 patients. The area under the curve of the receiver operating characteristics analysis of the BDI-II was 0.82. The optimal cut-off point of the BDI-II was 16 with a sensitivity of 90% and a specificity of 69%. The single screening question showed a sensitivity of 50% and a specificity of 94%.

Conclusions

The BDI-II seems an adequate screening tool for a depressive disorder in advanced cancer patients. The sensitivity of a single screening question is poor.

Meaning in life in palliative care patients

CONTEXT

The construct "meaning in life" (MiL) has recently raised the interest of clinicians working in psycho-oncology and end-of-life care and has become a topic of scientific investigation.

OBJECTIVES

The aim of this study was to compare MiL in palliative care (PC) patients with a representative sample of the German population.

METHODS

In this cross-sectional study, all PC patients treated in the PC inpatient unit and through the PC consult service at Ludwig-Maximilians-University Hospital, Munich, from May 2005 to July 2007 were eligible to participate. Patients were interviewed by a doctoral student, psychologist, or physician, all previously trained to administer the Schedule for Meaning in Life Evaluation (SMiLE) in a standardized way. In the SMiLE, respondents first list individual areas that provide meaning to their life before rating their current level of importance and satisfaction with each area. Overall indices of weighting (IoW, range 20-100), satisfaction (IoS, range 0-100), and weighted satisfaction (IoWS, range 0-100) are calculated.

RESULTS

One hundred PC patients completed the SMiLE: the IoS was 70.2 ± 19.7, the IoW was 84.7 ± 11.5, and the IoWS was 72.0 ± 19.4. The representative sample (n=977) scored significantly higher in the IoS (82.8 ± 14.7) and IoWS (83.3 ± 14.8) but not in the IoW (85.6 ± 12.3). Compared with healthy individuals, PC patients are more likely to list partner, friends, leisure, spirituality, well-being, nature/animals, and pleasure as meaningful areas. Examining the satisfaction ratings, it is noteworthy that PC patients' satisfaction scores are fairly high (and not lower than their healthy counterparts') in a number of domains: family, partner, home/garden, spirituality, and finances. On the other hand, they score significantly lower in nature/animals, leisure, friends, well-being, altruism, work, pleasure, and health.

CONCLUSION

These findings underscore the potential of the SMiLE for identifying areas that are particularly important to individuals, and that can be targeted by the PC team to improve overall life satisfaction at the end of life.