International Workshop on Palliative Care to the Geriatric Oncology Patient, Muscat, Oman Feb 2013

1. Redesigning Psychosocial
Services to Accommodate the
Needs of Cancer Patients
International Workshop on Palliative Care
to the Geriatric Oncology Patient
Muscat, Sultanate of Oman,
February 10-13, 2013
James C. Coyne, Ph.D.
Abramson Cancer Center, University of Pennsylvania
Health Psychology Program, University of Groningen

2. We would all like cancer patients to have better
management of their symptoms and better
understanding of what is possible in their
personal circumstances.

3. We would all like cancer
patients to feel that they
can talk to a healthcare
professional about their
concerns without feeling
guilty about taking up the
professional’s time.

4. An aspiration: “All patients
with cancer and their families
should expect and receive
cancer care that ensures the
provision of appropriate
psychosocial health services.”

5. What is attainable and acceptable is conditioned
by patient and family expectations, the health
system, and cultural context.
Efforts to address the needs of cancer patients
can have unintended consequences, particularly
when they are undertaken in dysfunctional
systems with perverse incentives.

6. International standards are:
•often culture bound
•impractical for particular contexts
•may reflect most pressing needs of other
health systems.

7. Look before you leap!
 Evaluate
appropriateness
 Involve key
stakeholders
 Monitor
implementation

8. An American woman Susan Krantz, received
national news attention when she complained
about her physician charging her $50 for her
having asked questions during her annual physical.
Her insurance company
paid her physician for the
physical, but not for
answering her questions.
She had not been warned
of the extra charge ahead
of time.

9. Talking to patients as a (billable) procedure
Conversations with the meter running
“We’re not paid to solve
patients’ problems, we are
paid to do procedures.”

10. International and national organizations
increasingly mandate routine screening for
psychological distress as a condition for
accreditation.
Is routine screening for distress feasible in your
setting and will it improve patient outcomes?

12. The promise of screening
•Cheap, quick
•Identifies distress and depression that would
otherwise be undetected
•Uncovers unmet needs
•Gives voice to otherwise silent or unheard
patients in need

13. Challenges that come with screening for
distress
•What do scores mean?
•Requires follow up to resolve positive screens,
involving staff and patient time and resources
•Many needs that are identified will not have
standard or ready solutions

14. Does your culture have a translation of
“psychological distress” that patients will
understand?

15. Monitoring screening for distress with
quality of care indicators

16. Oncologists cannot close their medical records
without indicating whether they have asked a
patient about distress.
Oncologists must indicate what action was taken
if a patient report being distressed.
Oncologists can comply with quality indicators by
asking simply “you feeling depressed?” and
prescribing antidepressants to patients who
answer “yes” without formal diagnosis, patient
education, or follow-up.

17. A significant proportion of breast cancer patients
in the United States are prescribed an
antidepressant without ever having a two weeks
mood disturbance in their life.

18. Raffle, A and Gray, M. (2007). Screening:
Evidence and Practice. Oxford Press.
Screening must be delivered in a well functioning
total system if it is to achieve the best chance of
maximum benefit and minimum harm. The
system needs to include everything from the
identification of those to be invited right through
to follow-up after intervention for those found to
have a problem.

19. Alternative to screening:
•Give patients time to talk and listen to them,
don't let screening for distress get in the way.
•Don't require cancer patients to interact through
computer touch screen assessments.
•Do give them the opportunity to talk about their
experiences, their needs, their concerns, and
their preferences regardless of their level of
distress.

20. Alternative to screening:
• Enhanced support, access to services, and
follow up for patients already known to be
distressed or socially disadvantaged.
• Provide ready access for patients to discuss
unmet needs with professional and peer
counselors regardless of level of distress.
• Increase resources for addressing health
disparities in access to psychosocial services.

21. Current Dutch practices do not comply with
proposed international guidelines for mandated
screening.
All cancer patients, not only those who screen
positive for distress, are offered opportunity to
talk to a professional about their needs and
concerns, unless they explicitly indicate they do
not want to do so.

22. What are goals for psychosocial care to strive
for in any culture?
•Better pain management and symptom control
•Ready access to support and information,
informal services
•More specialized, intensive services for high risk
patients and conspicuous problems

23. Hospice is not a
battlefield in the "war on
drugs," but it may be
unfairly considered as
such.

24. "Nothing would have a more
immediate effect on quality of
life and relief from suffering,
not only for the cancer
patients but also for their
families, than implementing
the knowledge accumulated
in the field of palliative care."
-Cancer and Palliative Care Unit of the
World Health Organization

25. Many patient concerns can be addressed with
information, support and attention, and follow up.
Fewer patients need more specialized services,
but they should have access to them, and the
services should be evidence based.

26. Smoking cessation for cancer patients and
caregivers
Smoking not only causes
cancer, but can lead to
significant morbidity
during treatment and
even cause treatment
interruption.

27. Don’t neglect needs and resources of
family members
•Wives vs. husbands
•Monitoring wound healing, side effects
•Enlist their support for better pain control and
symptom control
•Provide ready access to support and
information, informal services

28. To overcome limitations in the availability of
psychosocial services, is there a place in your
culture for
Mobilizing existing community resources?
Volunteerism?
Public education to make better psychosocial
care for cancer patients a shared vision?
Identification of cancer champions and targeted
philanthropy?

29. In designing psychosocial
services, how can we engage
cancer patients, and family
caregivers in specifying their
priorities for the most needed
services?

30. Thank you!
jcoynester@gmail.com
Follow me on Twitter
@CoyneoftheRealm