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Many patients undergoing diagnosis, evaluation and treatment of cancer have significant emotional, physical and spiritual symptoms. Although some of these symptoms can be part of a normal reaction, they can become pathologic and adversely affect patients’ normal activities. Research results have shown that many of these symptoms are not addressed because they are unrecognized by oncologists. These symptoms are associated with poor quality of life and treatment noncompliance.
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The Institute of Medicine’s recent report “Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs” makes a series of recommendations based on the aforementioned findings to improve cancer care. This article focuses on the recommendations for the oncologists.
Barriers
There are several reasons why emotional, spiritual and some of the practical issues are not addressed during a patient-physician encounter. Although all oncologists are trained to inquire about and manage physical symptoms, few are trained to inquire and manage emotional and spiritual issues. There is also a practical concern about whether oncologists have the time or skills to handle psychological issues. If the oncologists do not think they can help the patient with their issues, they may be hesitant to discuss them.
Patients, on the other hand, are reluctant to volunteer their concerns for several reasons, including that they feel it is a normal part of cancer. There is stigma attached to emotional and spiritual concerns, patients may feel oncologists cannot help them with these issues or that their oncologists do not want to hear about these issues.
The IOM report suggests that failure to address psychosocial issues “compromises the effectiveness of health care and thereby adversely affect the health of cancer patients.” The IOM therefore proposes a new standard of care for integrating psychosocial care into routine care to overcome these barriers and improve care for the whole patient.
The new standard of care
To provide appropriate psychosocial health services for each cancer patient, the IOM report identifies the following standards for practitioners:
- Establish effective communication between patients and care providers.
- Identify each patient’s psychosocial health needs.
- Implement a plan of care that combines psychosocial services with biomedical services.
- Follow up, reevaluate and adjust the above plan of care as necessary.
Effective communication
An important aspect of appropriate overall health care, including psychosocial care, involves effective patient–physician communication. To overcome a patient’s stigma, oncologists and staff can normalize those concerns by preemptively addressing them. Use of one of the following sentences in a patient encounter can enhance patient–physician communication:
- Many patients in similar situations have significant distress because of various concerns.
- Some patients have specific concerns like transportation, insurance, feeling down or anxious, pain, fatigue and other physical symptoms.
Identifying patient health needs
To identify an individual patient’s needs, a screening tool such as a distress thermometer is helpful. Several organizations including the National Comprehensive Cancer Network have recognized this tool as an efficient and validated mechanism to screen patients for psychosocial issues. The term distress is used to overcome the stigma attached to the psychosocial issues.
Similar to pain assessment, a distress thermometer asks patients to report their distress level on a scale of zero to 10. In addition, there are 35 additional check boxes where patients can indicate what specific issues are of concerning them. The NCCN and other organizations recommend that the distress thermometer should be used at the first visit and then subsequently at routine intervals, depending on the disease status to screen for distress. The distress thermometer allows for an efficient use of the patient’s and physician’s time. Patients can complete the questionnaire while waiting for the physician or while getting chemotherapy. Oncologists can thus elicit patient concerns and a significant portion of the review of systems without asking a single question. When a patient has a distress level greater than four, interventions are advised.
Services and interventions
Depending on the causes of distress, the oncologist can address them in the office or refer patients to other health care professionals or community organizations. The table provides a summary of psychosocial needs and corresponding health services as identified in the IOM report.
For the practicing oncologist, these recommendations require they know their community resources. Providing links to reputable websites for disease and therapy information, providing information regarding local support groups or the local chapter of the American Cancer Society, and having information available for the indigent programs for each drug are efficient patient interventions. The oncologist does not need to solve the problems; it is often enough to know who to send the patient to who can help them. For example, knowing organizations that provide transportation for cancer patients or knowing psychotherapists or psychiatrists available for patients can help readily address various other patient concerns. Palliative care service providers may also be a good resource for the oncologist as well as the patient and family. If there are specific resources that are not available, oncologists should use their influence in the health care community as well as the community at large to help develop them.
Thus, the new standard of care for taking care of the whole patient can be and should be achieved with minimal burden on an oncology practice with potentially significant improvement in patient satisfaction and care. These recommendations should be implemented immediately in all oncology practices.
Biren Saraiya, MD, is a fellow in Hematology-Oncology at the Cancer Institute of New Jersey at UMDNJ-Robert Wood Johnson Medical School and is a member of the HemOnc Today Editorial Board.
Robert Arnold, MD, is the Leo H. Criep Chair in Patient Care, Professor of Medicine in the Division of General Internal Medicine and Chief of the Section of Palliative Care and Medical Ethics at the University of Pittsburgh.
For more information:
- Committee on Psychosocial Services to Cancer Patient/Families in a Community Setting. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, D.C.: Institute of Medicine; 2008. Available at www.nap.edu/catalog.php?record_id=11993.