Improving Palliative Care for Cancer (2001) / Chapter Skim
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7 Clinical Practice Guidelines for the Management of Psychosocial and Physical Symptoms of Cancer
7 Clinical Practice Guidelines for the Management of Psychosocial and Physical Symptoms of Cancer
Pages 199-232
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From page 199... ...
Although pain management guidelines have been the most widely disseminated, we know that many patients continue to suffer not only from pain, but from other troubling symptoms in their final days (Ahme~zai, 1998; American Academy of Neurology, 1996; American Board of Internal Medicine, 1996; American Nursing Association, 1991; American Pain Society, 1995; Carr et al, 19941. Despite clear advances in the identification and 199
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From page 200... ...
noted in Ensuring Quality Cancer Care that the use of systematically developed clinical practice guidelines, based on best available evidence, improved the quality of care delivered (IOM, 1999~. Smith and Hiliner (1998)
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From page 201... ...
Development and evaluation of clinical practice guidelines for end-of-life care must take into account the unique aspects of treatment during this period. The task becomes daunting, given the recognized problems with implementation of clinical practice guidelines for pain management and the complexity of developing guidelines that direct both medical and psychological care.
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From page 202... ...
. nt~emet~cs Surveillance of breast and colorectal cancer patients Path or algorithm guidelines for specific diseases Management of non-small cell lung cancer Metastatic prostate cancer compliance or outcomes Likely that all future guidelines will be boundary guidelines for new technologies, with overlap of ASCO and NCCN methods and topics Society for Surgical Path guidelines for Consensus panels Oncology management of common surgical problems American Urology Path guidelines for common Consensus based on evidence Association urology problems University of Path guidelines for most PONA did systematic reviews, California (UC)
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From page 203... ...
Development of algorithm-based clinical practice guidelines relating to psychiatric, psychosocial, and spiritual domains has the potential to enhance end-of-life care in a major way by defining a gold standard for clinicians in an area not previously subjected to this level of scrutiny. This chapter outlines the status of clinical practice guidelines that relate to end-of-life care and suggests next steps for policy development.
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From page 204... ...
(NCCN, 2001) consensus, or combination Pilot testing; modify for endof-life care Doctor-patient NCCN Practice Guidelines: Evidence, Pilot testing; communication breaking bad news consensus, or modify for end (pending)
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From page 205... ...
pilot test NOTE: APA = American Psychiatric Association; APS = American Pain Society; AHCPR = Agency for Health Care Policy and Research; NCCN = National Comprehensive Cancer Network
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From page 206... ...
These tenets should include attention to the needs of traditionally medically underserved patients: those with little or no English proficiency, for whom care at the end of life is particularly difficult because communication is limited, and patients with chronic mental illness or limited education. The need for communication guidelines and standards is accentuated because of the awkwardness that many professionals fee!
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From page 207... ...
Given this cultural environment in which the meaning of death is denied and the fact that, in recent decades, oncology research has focused primarily on finding cures as opposed to improving palliative care, it is no
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From page 208... ...
Many institutions regard this human aspect of care as expendable, expensive, and unnecessary. As a consequence, too few social workers, mental health professionals, and pastoral counselors are available to provide the consultation and treatment that would benefit patients and their families when the severity of distress exceeds that readily managed by the primary team.
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3. Mental health professionals (psychiatrists, psychologists, psychiatric social workers, and nurses)
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210 c' oh .
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From page 212... ...
The panel, over two years' time, developed standards of care and an algorithm that triggers referral of a significant level of distress to mental health, social work, or clergy services (Holland, 1999~. It also developed clinical practice guidelines for these supportive care disciplines to guide their management of cases.
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From page 213... ...
· Standard 3. When ~ patient indicates ~ distress level of 5 or above, this is the algorithm that triggers referral to one of the specialized supportive services, depending on the problem: mental health, social work, or pastoral counseling.
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From page 214... ...
Evaluation of the quality of end-of-life care must include attention to the management of distress (Kornblith and Holland, 1996~. Clinical Practice Guidelines for Mental Health Social Work, and Pastoral Services The multidisciplinary NCCN panel addressed the need for an integration of psychosocial supportive services and the need for practice guidelines for the professionals who provide these services.
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From page 215... ...
Clinical Practice Guidelines are useful for modification for end-of-life care, as are the NCCN guidelines for the management of these disorders specifically in cancer patients (APA, 2000; Holland, 1997; Holland and Almanza, 1999~. Delirium Delirium is a common psychiatric disorder toward the end of life, estimated to affect as many as 85 percent of patients in their final days (Massie and Holland, 1983~.
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From page 216... ...
Reactive anxiety symptoms alone, or mixed with depressive symptoms, constitute the mildest DSM-IV psychiatric disorder, adjustment disorder (APA,2000~. The patient requires
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From page 217... ...
Both the APA Clinical Practice Guidelines for management of personality disorders in physically healthy individuals and the NCCN guidelines for management of distress in ambulatory cancer patients should be revised to provide guidelines for their management in palliative care (see Table 7-2~.
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From page 218... ...
IMPROVING MANAGEMENT OF DISTRESS: FUTURE DIRECTIONS TRAINING OF TEAM The team giving end-of-life care must be trained in how to recognize, diagnose, and treat distress and in using an algorithm for referrals to mental health, special social work services, or pastoral counseling. A brief curriculum is needed that can be given to staff easily, similar to the curricula in palliative care.
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From page 219... ...
PROFESSIONAL STANDARDS FOR MENTAL HEALTH AND PASTORAL SERVICES It is essential to have standards for training mental health professionals and pastoral counselors in palliative and end-of-life care, as has been done for physicians and nurses. This is particularly true of pastoral services where cost cutting may lead to use of clergy untrained in counseling techniques.
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From page 220... ...
should take existing standards of care and clinical practice guidelines developed by NCCN for use with ambulatory cancer patients and modify them for use at end of life. These should be disseminated and tested for feasibility.
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· Educational standards must teach mental health professionals how to modify their concepts to include end-of-life care (psychologists, psychiatrists, psychiatric social workers, and nurses) and clergy who are qualified as pastoral counselors)
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From page 222... ...
giving supportive services. In view of the acknowledged difficulties in implementation of clinical practice guidelines to manage distress and the unique stigma around psychosocial and spiritual services, it is essential that research be undertaken to address these barriers.
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From page 223... ...
Patient education is an essential component of care to ensure a collaborative approach to symptom management. Clinical practice guidelines usually consider a single symptom in isolation; thus, a guideline addressing a single symptom may apply less well because it fails to take into account many coexisting symptoms.
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From page 224... ...
Given the high incidence of terminal delirium and the frequent progressive impairment of cognitive functioning in the final stages of life, palliative care guidelines must address the needs of those patients who cannot speak for themselves to express troubling symptoms. Pain Achieving effective pain management has been a priority over the past decade.
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From page 225... ...
Despite all efforts, fatigue is often an intractable symptom in the final days of life. Clinical practice guidelines for this important symptom must build on recent studies documenting the high incidence of fatigue in chronic and terminal illness and its impact on quality of life.
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From page 226... ...
Nausea and Vomiting Clinical practice guidelines for management of nausea and vomiting have been widely promulgated in the care of cancer patients as advances in antiemetic therapy have vastly reduced the distress associated with chemotherapy. Nausea may be centrally mediated or caused by local factors such as decreased motility, medication effects, or gastrointestinal lesions (Reuben and Mor, 1986~.
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From page 227... ...
Further research on symptom management in the end of life will support evidence-based clinical interventions for terminal dyspnea. Control of Physical Symptoms: Next Steps Clinical practice guidelines for control of the common symptoms have, at present, been developed largely for the care of ambulatory and hospitalized patients.
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From page 228... ...
2000. APA Clinical Practice Guidelines for Psychiatric Disorders Compendium 2000.
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1990. Clinical Practice Guidelines: Directions for a New Program.
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From page 230... ...
The role of octreotide in palliative care. J Pain Symptom Manage 1994;9:406411.
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From page 231... ...
Heaven C The development of a training model to improve health professionals' skills, self-efficacy and outcome expectations when communicating with cancer patients.
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From page 232... ...
1998. Ensuring quality cancer care: Clinical practice guidelines, critical pathways, and care maps.
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