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L.A. Mas Lopez
Moderator of
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ED 08 - Talking with Patients (ID 8)
- Event: WCLC 2015
- Type: Education Session
- Track: Palliative and Supportive Care
- Presentations: 4
- Moderators:L.A. Mas Lopez, N. Pilnik
- Coordinates: 9/08/2015, 14:15 - 15:45, 108+110+112
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ED08.01 - Transitioning to End of Life Care: Who Should Lead the Discussion? (ID 1802)
14:20 - 14:40 | Author(s): D. Handel
- Abstract
Abstract not provided
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ED08.02 - The Art of Taking Care of Patients, The Art of Giving Bad News (ID 1803)
14:40 - 15:00 | Author(s): A. Oton
- Abstract
- Presentation
Abstract:
For some health professionals, communicating bad news is one of the most frequent tasks of their daily work. Conversations on new diagnosis of a dismal disease, discontinuation of therapy due to disease progression or end-of-life care goals are some examples of discussions that oncologists and other health professionals are responsible for everyday with patients and caregivers. However, despite the frequency of these conversations, few health professionals are properly trained in how to conduct difficult conversations in an effective and yet compassionate manner. Navigating through these difficult conversations with thoughtfulness are crucial moments on the patient-physician relationship. The way in how these conversations are delivered have a direct impact on how the patient will perceive and react to the situation and it might make the difference between failure and success of this relationship. Communicating bad news demonstrates personal courage and integrity and when conducted in the right way, increases patient’s confidence and trust on the oncologist and his ability to make the right decisions during the patient’s journey. In addition, empathic communication can influence patient’s satisfaction with care, quality of life and ultimately patient’s outcome. Some studies have reported that the most valued qualities in nurses and doctors communicating bad news –from the patient’s perspective, are: recognition (how the oncologist respond to the gravity of the news), guiding (what patient would like to get after news are delivered) and responsiveness (oncologist’s ability to sense patient’s need). Learning how to communicate bad news effectively with patients and family members is an essential requirement on becoming a successful and contemporary health professional. During this lecture we will review some communication strategies on how to efficiently lead these conversations with our patients. References: Baile WF, et al. Curr Opin Oncol 2005, Jul;17(4):331-5 Fujmori M, et al. J Clin Oncol 2014 jul 10;32(20):2166-72 Back AL, et al. Oncologist 2011;16(3):342-50 Baile WF, et al. Oncologist 2000; 5(4):302-11 Girgis A, at al. Aust N Z J Surg 1997 Nov;67(11):775-80
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ED08.03 - Depression, The Silent Killer (ID 1804)
15:00 - 15:20 | Author(s): L. Ubillos
- Abstract
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Abstract:
Background: Emotional reactions are natural and expected in individuals experiencing cancer and confronting the end of their lives, the differentiation between a normal and appropriate reaction to dying versus a psychiatric disorder such as major depression can be clinically difficult to differentiate. Depression is a common mental health problem in palliative cancer patients, unfortunately misunderstood, underdiagnosed, and undertreated. Depression is a major cause of suffering among patients with advanced disease or terminal illness like cancer. Depressive syndromes are correlated with a reduced quality of life, greater difficulty in managing the course of the patient's illness, decreased adherence to treatment, and earlier admission to inpatient or hospice care. It amplifies pain and other symptoms, and causes worry in family members and friends. Patients with advanced illness who suffer from depressive syndromes are also at high risk of suicide and suicidal ideation, and they have an increased desire for a hastened death. The recognition and diagnosis of patient depression, is often delayed in the course of the disease. Prevalence and risk factors: The reported prevalence of major depression in individuals with cancer varies from 3 to 38 percent. This wide variability is explained by the lack of agreement as to appropriate diagnostic criteria to be used in the setting of advanced illness, differences in patient populations, and variation in assessment methods. In general, rates are higher in populations with advanced cancer, greater levels of disability, and/or unrelieved pain. In several studies, younger cancer patients have higher rates of depressive disorders and self-reported distress. While depression is twice as common in women as compared to men in the general population, gender is not consistently reported to be a risk factor for depression in cancer patients. A prior history of depression is a risk factor for major depression in cancer patients. The presence of uncontrolled symptoms, particularly pain, is a major risk factor for depression and suicide among patients with cancer. The incidence of depression also depends upon the patient's particular illness. Among cancer patients, those with head and neck and pancreatic cancers are at a particularly high risk. Certain factors associated with the patient's illness or its treatment may be associated with depression. Central nervous tumors or metastasis to the central nervous system can cause depression. Other causes of depression in cancer patients include toxins created by the tumor, autoimmune reactions, and nutritional deficiencies. Depression can also represent an adverse effect from certain treatments, including glucocorticoids, chemotherapy drugs (vincristine, vinblastine, interferon and tamoxifen) as well as radiotherapy to the brain or head and neck. Patients who have high levels of spiritual well-being tend to be less depressed. The beneficial aspects of religion related primarily to spiritual well-being rather than to formal religious practice. Screening and diagnosis: Screening for depression should be carried out in all palliative care patients given the high prevalence of symptoms. Expert recommendations state that every patient with cancer should be screened for depression at initial diagnosis and thereafter as clinically indicated, especially with changes in cancer status or treatment. There are many tools to identify vulnerable patients by screening, Patient Health Questionnaire (PHQ-2) and PHQ-9 can identify deserving cases a deeper interview. Depressed mood, sadness, grief, and anticipatory feelings of loss are all appropriate responses to advanced disease and dying, however, feelings of hopelessness, helplessness, worthlessness, guilt, lack of pleasure, and suicidal ideation are indicators of depressive syndromes in these patients. Although most used criteria for diagnosing major depression in non- oncology patients is the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the most widely used for cancer patients is the substitutive approach of Endicott. This scale replaces four of the DSM-IV somatic criteria thought most likely attributable to medical illness or its treatment (ie, change of weight/appetite, sleep disturbance, loss of energy/fatigue, difficulty thinking or concentrating) with cognitive substitutes (depressed appearance, social withdrawal, brooding/self-pity/pessimism, and lack of reactivity in situations that would normally be pleasurable) Treatment: Unfortunately, some data suggest most cancer patients with depressive syndromes are undertreated. The first step in treating depression is to relieve uncontrolled symptoms, particularly pain and potentially reversible general medical cause of depressed mood. If depression persists once these are identified and controlled, specific therapy is warranted. Treatment should be tailored to the individual needs of the patient. In addition to drug therapy, effective psychosocial interventions include individual or group psychotherapy, cognitive-behavioral therapy, existential therapy, and self-help groups. There are no randomized trials that specifically address the benefit of psychotherapy for palliative care patients with depression. As a result, therapy for depression in these patients is generally based upon the larger evidence on effective treatments in patients of primary care populations with either no physical illness or less severe medical conditions. The agents used most commonly in palliative care patients are psychostimulants, selective serotonin reuptake inhibitors (SSRIs), and tricyclic antidepressants (TCAs), these drugs are an important option for treatment of depression at the end of life because they take effect quicker than other classical drugs. Other advantages as their more favorable side effect profile and the markedly lower danger with overdose, led to the recomendation of the American College of Physicians in the 2008 clinical practice guidelines for initial treatment of depression in primary care patients, to initiate an SSRI, serotonin and norepinephrine reuptake inhibitors SNRI, or atypical antidepressant in this group of patients. Meyer HA. et al. Palliat Med 2003; 17:604 Portenoy LK. et al. Qual Life Res 1994; 3:183 Wilson KG. et al. J Pain Symptom Manage 2007; 33:118 Akechi T. et al. J Clin Oncol 2004; 22:1957 DeFlorio ML. et al. Depression 1995; 3:66 Endicott J. Cancer 1984; 53:2243 Andersen B. et al. J Clin Oncol 2014; 32:1605 Qaseem et al. Ann Intern Med. 2008;149(10):725
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ED08.04 - Coping Mechanisms for People with Lung Cancer and their Families (ID 1805)
15:20 - 15:40 | Author(s): N. Doyle
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Abstract:
ln the UK, lung cancer has one of the lowest 5 year survival rates of all cancers (8.8% of men and 11.1% of women are alive 5 years after their diagnosis) whilst only 30% of people live for more than one year following their diagnosis (Macmillan, 2014). This poor outlook can have a profound impact on the quality of life of those affected by the disease (LCA, 2015). However, helping people and their families cope with the impact and consequences of the disease and its treatment can make a substantial difference to the quality of their lives. In this context coping might be regarded as a means of understanding and regulating the emotions in response to stress but it might also be viewed as solving problems and adapting lifestyles and behaviour through goal setting and seeking information and help. By adopting a structured and planned approach to care, the healthcare professional can enhance the coping capability of the person with cancer and their families and thereby directly contribute to their quality of life. This approach can be seen in the Recovery Package. Data from the London Cancer Alliance reveals that the top ten concerns for the person with lung cancer are a mix of physical and psychological issues including breathlessness, fatigue, anxiety, weight loss, sleeping, finances, walking, pain, eating and transport. People with lung cancer have the highest number of unmet needs out of all cancer patients, mainly due to higher psychological support and physical/daily living support needs (Li et al, 2006). Depression levels tend to be higher for people with lung cancer compared to cancer patients with other types of cancer (Fischer et al, 2010). Self reported sexual concerns are common in people with lung cancer and are related to shortness of breath and emotional distress (Reese et al, 2011) whilst people with lung cancer experience higher levels of pain compared with patients with other types of cancer (Fischer et al, 2010) Link et al (2005) discuss the work of Lazarus and Folkman, and their ‘Transactional model of distress and coping’ which suggests that people respond to stressful situations by a primary appraisal (where they evaluate the significance of the stressor) and a secondary appraisal (where they evaluate their ability to change the situation and manage their emotions). It is at these key junctures that effective interventions might be best employed. The Recovery Package allows the identification and selection of suitable interventions which can be tailored to meet the specific needs of people with cancer and their families. In the UK the report ‘Taking Action to Improve Outcomes (NCSI, 2013) envisaged that care should be designed with the following key aims: Providing information and support from the point of diagnosis Promoting recovery Sustaining recovery Managing the consequences of treatment Supporting people with active and advanced disease These key aims underpin The Recovery Package which is a series of key interventions which, when delivered together, can greatly improve outcomes for people living with and beyond cancer. The Recovery Package is made up of an assessment of holistic needs and the development of a care plan to address these issues; a treatment summary that explains to the General Practitioner and individual what treatment has taken place; a cancer care review by the General Practitioner within 6 months of diagnosis; attendance at a health and wellbeing educational event. The Recovery Package The success of the Recovery Package depends upon the creation of a partnership with the individual and the focus of care is on supporting self-management after a cancer diagnosis. This is underpinned by effective assessment. Holistic needs assessment acknowledges that coping strategies are mediated by social context and that the quality and quantity of the person’s support can be quite variable. The assessment works by gathering and discussing information in order to develop an understanding of what the person living with and beyond cancer knows, understands and needs. It is focused on the whole person and the entirety of his/her needs including the physical, emotional, spiritual, mental, social, and environmental needs of the individual. The process culminates when the assessment results are used to inform a care plan. Holistic assessment tools offer front-line health service staff a structured yet collaborative way to elicit people’s concerns and, with adequate training and informational resources, respond to these concerns effectively, efficiently and humanely. By integrating the assessment of very understandable emotional concerns within a holistic treatment review there is less likelihood that psychological difficulties become pathologised by professionals or seen as a source of shame for those living with and beyond cancer (Brennan et al, 2012). Lung cancer is often characterised by rapid deterioration and a complex interplay of symptoms, concerns and worries and health care professionals can play a critical role in choice of coping strategy (which can be used to help people to more actively participate in their care) (Link et al, 2005). This can be helped by a structured and planned approach to care such as The Recovery Package.
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