Prevalence and management of chronic nonmalignant pain in palliative care populations: A systematic review.

OBJECTIVES: To investigate the prevalence and current approaches to clinical management of chronic nonmalignant pain in patients referred to palliative care services. METHODS: A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered with PROSPERO (CRD42021205432). Six databases were searched on 25 August 2020 and again on 11 July 2022: PubMed and Ovid MEDLINE, Elsevier Scopus, PsychINFO, the Cochrane Library, and CINAHL. Search included prevalence or intervention studies with patients who had chronic nonmalignant pain and were referred to palliative care services. Screening was undertaken independently by 2 reviewers. RESULTS: The searches returned 417 titles; subsequent screening identified 5 eligible studies, 4 from the USA and 1 from Hong Kong, including 2 cohort and 3 cross-sectional studies. Sample sizes ranged from 137 to 323, with a total of 1,056 patients. The prevalence of chronic nonmalignant pain ranged from 14% to 34% across different palliative care settings. There was significant crossover of pain types; 54% of patients with chronic no-malignant pain had additional cancer-related pain or cancer treatment-related pain. Opioids were used to manage stand-alone chronic nonmalignant pain for 39% of patients compared to 58% with mixed chronic nonmalignant pain and other pain diagnoses. SIGNIFICANCE OF RESULTS: Five studies have documented the prevalence of chronic nonmalignant pain of 14-34% in palliative care. Further research including prevalence and treatment studies would provide clearer evidence for best practice management of chronic nonmalignant pain in the palliative care setting.

Psycho-Existential Symptom Assessment Scale (PeSAS) Screening in Palliative Care.

CONTEXT: Psycho-existential symptoms are common yet often missed or neglected in palliative care. Screening can be an effective way to recognize and respond to this need. OBJECTIVES: We aimed to implement routine use of the Psycho-existential Symptom Assessment Scale (PeSAS) as a screening tool in Australian palliative care services and discern the symptom prevalence identified. METHODS: In a multi-site rolling design, we established implementation site committees and embarked on experiential workshops to train clinicians in the tool's efficient use. Patient symptom prevalence data were collected to compare uptake across sites. Descriptive statistics were applied. RESULTS: Over one year, we trained 216 clinicians across six palliative care services in the use of the PeSAS as a screening tool and collected data from 1405 patients. Clinicians reported significant growth in their sense of efficacy in assessing psycho-existential wellness. Services using electronic records implemented most easily. Psycho-existential symptoms with clinically significant prevalence (scores ≥ 4/10) included anxiety 41.1%, discouragement 37.6%, hopelessness 35.8%, pointlessness 26.9%, depression 30.3%, and the wish to die 17%. The precision of measurement within 3% was found for severe ratings (score ≥ 8/10) including anxiety 10.6%, depression 10.2%, the wish to die 7.6%, and confusion 3.6%. CONCLUSION: Clinicians can be trained to screen with the Psycho-existential Symptom Assessment Scale, which serves as a valuable measure to better recognize symptoms of psycho-existential distress among palliative care patients. Implementation barriers included the prior ethos of the service, confidence in talking about these themes, electronic data entry, and perceived time pressures.

Patient-caregiver communication concordance in cancer-refinement of the Cancer Communication Assessment Tool in an Australian sample.

PURPOSE: The objective of this study was to expand the international psychometric validation of the Cancer Communication Assessment Tool for Patients and Families (CCAT-PF) within a sample of Australian cancer patients. METHODS: Survey data from 181 cancer patient-caregiver dyads ≥ 18 years of age with solid or haematological cancers were analysed (85.4% response rate). Spearman's rho was used to examine the correlation between CCAT-P and CCAT-F scores and weighted kappa the agreement between them. Exploratory factor analysis using scree plot and Kaiser-Guttman criteria was conducted to evaluate the scale structure. Cronbach's α and Pearson correlation coefficients were used to measure internal consistency and concurrent validity respectively. RESULTS: Mean scores were the following: CCAT-P 46.2 (9.8), CCAT-F 45.7 (9.4), and CCAT-PF 24.1 (8.0). We confirmed the poor concordance between patient and caregiver reporting of items in the CCAT-PF, with all but two items having weighted kappa values < 0.20 and Spearman's rho < 0.19. We derived a three-factor solution, disclosure, limitation of treatment, and treatment decision making, with reliability ranging from Cronbach's α = 0.43-0.53. The CCAT-P and CCAT-F showed strong correlations with preparation for decision-making (CCAT-P: r = 0.0.92; CCATF: r = 0.0.93) but were weakly associated with patient/caregiver distress related with having difficult conversations on future care planning. CONCLUSION: Preliminary validation of the CCAT-PF in the Australian setting has shown some similar psychometric properties to previously published studies, further supporting its potential utility as a tool to assess patient-caregiver dyadic communication. TRIAL REGISTRATION: ACTRN12620001035910 12/10/2020 retrospectively registered.

The flourishing scholarship of psychosocial oncology viewed across 30 years through the lens of this journal, Psycho-Oncology.

OBJECTIVE: This issue celebrates the 30th anniversary of Psycho-Oncology as a journal, a home for scholarship integrating the psychological, social and behavioural dimensions of cancer. Psycho-oncology developed as an evidence-based discipline to offer an alternative to unproven therapies and to optimise coping and support for patients with cancer and their families. METHODS: A review of key articles was undertaken for this editorial. RESULTS: Empirical studies have defined the prevalence of morbidity arising from cancer and the acute, longer-term and late effects of its varied treatments. Interventions have been adapted to respond to existential challenges, death anxiety, fear of recurrence, disease progression, palliative care and have been continued into bereavement. Mixed modality treatments have combined psychotropic and psychotherapeutic interventions. Survivorship studies have examined rehabilitation, fertility, sexuality, body image and relational impacts of illness. CONCLUSION: This journal has helped the discipline to flourish by publishing the innovative outputs of its community of researchers.

Socio-Economic Deprivation and Symptom Burden in UK Hospice Patients with Advanced Cancer-Findings from a Longitudinal Study.

Socio-economic deprivation is known to impact on cancer diagnosis, treatment and access to services, but little is known of the impact of socio-economic deprivation on symptom burden in patients with advanced cancer. Patients with advanced cancer attending hospice day services were recruited into a 24 week longitudinal study. An area-based index of social deprivation was collected along with depression and symptom burden at baseline, 8, 16 and 24 weeks. Of the 595 patients included, with an age range of 33-89 years and a mean age of 68 years, 67% were female, and 37% were diagnosed with cancer in the last 12 months. Twenty nine percent lived in one of the most deprived 20% of neighbourhoods. Patients living in the most socio-economically deprived areas were significantly likely to report receiving insufficient information regarding their cancer at diagnosis (p = 0.007), greater pain (p = 0.02), moderate to severe depression (p = 0.04) and higher global symptom burden (p = 0.04). This study is the first to report that patients with advanced cancer attending hospice services, living in the most deprived neighbourhoods experience significantly greater symptom burden, notably depression and pain. We recommend using patient outcome measures in order to provide targeted support and thereby reduce the increased symptom burden that socio-economically disadvantaged patients experience at the end of life.

Is care really shared? A systematic review of collaborative care (shared care) interventions for adult cancer patients with depression.

BACKGROUND: Collaborative care involves active engagement of primary care and hospital physicians in shared care of patients beyond usual discharge summaries. This enhances community-based care and reduces dependence on specialists and hospitals. The model, successfully implemented in chronic care management, may have utility for treatment of depression in cancer. The aim of this systematic review was to identify components, delivery and roles and responsibilities within collaborative interventions for depression in the context of cancer. METHODS: Medline, PsycINFO, CINAHL, Embase, Cochrane Library and Central Register for Controlled Trials databases were searched to identify studies of randomised controlled trials comparing a treatment intervention that met the definition of collaborative model of depression care with usual care or other control condition. Studies of adult cancer patients with major depression or a non-bipolar depressive disorder published in English between 2005 and January 2018 were included. Cochrane checklist for risk of bias was completed (Study Prospero registration: CRD42018086515). RESULTS: Of 8 studies identified, none adhered to the definition of 'collaborative care'. Interventions delivered were multi-disciplinary, with care co-ordinated by nurses (n = 5) or social workers (n = 2) under the direction of psychiatrists (n = 7). Care was primarily delivered in cancer centres (n = 5). Care co-ordinators advised primary care physicians (GPs) of medication changes (n = 3) but few studies (n = 2) actively involved GPs in medication prescribing and management. CONCLUSIONS: This review highlighted joint participation of GPs and specialist care physicians in collaborative care depression management is promoted but not achieved in cancer care. Current models reflect hospital-based multi-disciplinary models of care. PROTOCOL REGISTRATION: The protocol for this systematic review has been registered with PROSPERO. The registration number is CRD42018086515.

The assessment of anxiety in aged care residents: a systematic review of the psychometric properties of commonly used measures.

ABSTRACTBackground:Assessing anxiety among residential aged care facility (RACF) residents is challenging, and it cannot be assumed that valid and reliable measures used within the community are also appropriate for this setting. This review systematically examined the literature to identify which anxiety measures were most commonly used with older adults in RACFs, and determine whether psychometric data support their use within this population. METHODS: Using the PRISMA guidelines, five electronic databases were searched using key terms and subject headings. The search was limited to literature published in English. Eligible studies utilized an anxiety measure to assess anxiety symptoms among RACF residents. Based on the findings of this search, a critical review of the research into the reliability, validity, and administrative and respondent burden of the most commonly used measures (i.e. used in four or more studies) was conducted. RESULTS: In total, 1,771 articles were identified, with 50 studies included in this review. Overall, 22 measures were used, with the majority of studies utilizing a clinician-administered or self-report measure. The RAID, HADS, STAI, and GAI were the most commonly used measures. While overall there is a lack of research and consensus into the psychometric properties of these measures within RACFs, strongest evidence of reliability and validity was found for the GAI. CONCLUSION: Commonly used measures of anxiety within aged care populations are not well validated for this complex subsample of older adults. Strengths and weaknesses of each measure with regards to their usefulness in aged care settings are discussed, with future research areas highlighted.

Identifying and addressing the support needs of family caregivers of people with motor neurone disease using the Carer Support Needs Assessment Tool.

OBJECTIVE: Family caregivers of people with motor neurone disease (MND) experience adverse health outcomes as a result of their caregiving experience. This may be alleviated if their support needs are identified and addressed in a systematic and timely manner. The objective of the present study was to assess the feasibility and relevance of the Carer Support Needs Assessment Tool (CSNAT) in home-based care during the period of caregiving from the perspectives of the family caregivers of people with MND and their service providers. METHOD: The study was conducted during 2014 in Western Australia. Some 30 family caregivers and 4 care advisors participated in trialing the CSNAT intervention, which involved two visits from care advisors (6-8 weeks apart) to identify and address support needs. The feedback from family caregivers was obtained via telephone interviews and that of care advisors via a self-administered questionnaire. RESULTS: A total of 24 caregivers completed the study (80% completion rate) and identified the highest support priorities as "knowing what to expect in the future," "knowing who to contact if concerned," and "equipment to help care." The majority found that this assessment process adequately addressed their needs and gave them a sense of validation, reassurance, and empowerment. Care advisors advocated the CSNAT approach as an improvement over standard practice, allowing them to more clearly assess needs, to offer a more structured follow-up, and to focus on the caregiver and family. SIGNIFICANCE OF RESULTS: The CSNAT approach for identifying and addressing family caregivers' support needs was found to be relevant and feasible by MND family caregivers and care advisors. The tool provided a formal structure to facilitate discussions with family caregivers and thus enable needs to be addressed. Such discussions can also inform an evidence base for the ongoing development of services, ensuring that new and improved services are designed to meet the explicit needs of the family caregivers of people with a motor neurone disease.

Pilot Evaluation of a Communication Skills Training Program for Psychiatry Residents Using Standardized Patient Assessment.

OBJECTIVE: Mental health clinicians can experience difficulties communicating diagnostic information to patients and their families/carers, especially about distressing psychiatric disorders such as schizophrenia. There is evidence for the effectiveness of communication skills training (CST) for improving diagnostic discussions, particularly in specialties such as oncology, but only limited evidence exists about CST for psychiatry. This study evaluated a CST program specifically developed for psychiatry residents called ComPsych that focuses on conveying diagnostic and prognostic information about schizophrenia. METHOD: The ComPsych program consists of an introductory lecture, module booklets for trainees, and exemplary skills videos, followed by small group role-plays with simulated patients (SPs) led by a trained facilitator. A standardized patient assessment (SPA) was digitally recorded pre- and post-training with a SP using a standardized scenario in a time-limited (15 min) period. Recorded SPAs were independently rated using a validated coding system (ComSkil) to identify frequency of skills used in five skills categories (agenda setting, checking, questioning, information organization, and empathic communication). RESULTS: Thirty trainees (15 males and 15 females; median age = 32) undertaking their vocational specialty training in psychiatry participated in ComPsych training and pre- and post-ComPsych SPAs. Skills increased post-training for agenda setting (d = -0.82), while questioning skills (d = 0.56) decreased. There were no significant differences in any other skills grouping, although checking, information organization, and empathic communication skills tended to increase post-training. A dose effect was observed for agenda setting, with trainees who attended more CST sessions outperforming those attending fewer. CONCLUSION: Findings support the generalization and translation of ComPsych CST to psychiatry.

A review of cognitive therapy in acute medical settings. Part I: therapy model and assessment.

INTRODUCTION: Although cognitive therapy (CT) has established outpatient utility, there is no integrative framework for using CT in acute medical settings where most psychosomatic medicine (P-M) clinicians practice. Biopsychosocial complexity challenges P-M clinicians who want to use CT as the a priori psychotherapeutic modality. For example, how should clinicians modify the data gathering and formulation process to support CT in acute settings? METHOD: Narrative review methodology is used to describe the framework for a CT informed interview, formulation, and assessment in acute medical settings. Because this review is aimed largely at P-M trainees and educators, exemplary dialogues model the approach (specific CT strategies for common P-M scenarios appear in the companion article.) RESULTS: Structured data gathering needs to be tailored by focusing on cognitive processes informed by the cognitive hypothesis. Agenda setting, Socratic questioning, and adaptations to the mental state examination are necessary. Specific attention is paid to the CT formulation, Folkman's Cognitive Coping Model, self-report measures, data-driven evaluations, and collaboration (e.g., sharing the formulation with the patient.) Integrative CT-psychopharmacological approaches and the importance of empathy are emphasized. SIGNIFICANCE OF RESULTS: The value of implementing psychotherapy in parallel with data gathering because of time urgency is advocated, but this is a significant departure from usual outpatient approaches in which psychotherapy follows evaluation. This conceptual approach offers a novel integrative framework for using CT in acute medical settings, but future challenges include demonstrating clinical outcomes and training P-M clinicians so as to demonstrate fidelity.

Cancer surgeons' distress and well-being, II: modifiable factors and the potential for organizational interventions.

PURPOSE: We showed in a companion paper that the prevalence of burnout among surgical oncologists at a comprehensive cancer center was 42% and psychiatric morbidity 27%, and high quality of life (QOL) was absent for 54% of surgeons. Here we examine modifiable workplace factors and other stressors associated with burnout, psychiatric morbidity, and low QOL, together with interest in interventions to reduce distress and improve wellness. METHODS: Study-specific questions important for morale, QOL, and stressors associated with burnout were included in an anonymous Internet-based survey distributed to the surgical faculty at Memorial Sloan-Kettering Cancer Center. RESULTS: Among the 72 surgeons who responded (response rate of 73%), surgeons identified high stress from medical lawsuits, pressure to succeed in research, financial worries, negative attitudes to gender, and ability to cope with patients' suffering and death. Workplace features requiring greatest change were the reimbursement system, administrative support, and schedule. Work-life balance and relationship issues with spouse or partner caused high stress. Strongest correlations with distress were a desire to change communication with patients and the tension between the time devoted to work versus time available to be with family. Surgeons' preferences for interventions favored a fitness program, nutrition consultation, and increased socialization with colleagues, with less interest in interventions conventionally used to address psychological distress. DISCUSSION: Several opportunities to intervene at the organizational level permit efforts to reduce burnout and improve QOL.

Cancer surgeons' distress and well-being, I: the tension between a culture of productivity and the need for self-care.

BACKGROUND: Burnout is a prevalent and important occupational hazard among surgical oncologists. The well-being or distress experienced can have a significant effect on clinicians and their families, the quality of care provided to patients, and the success of the health care organization. METHODS: We aimed to measure the prevalence of burnout, psychiatric morbidity, and quality of life using standardized measures; characterize associated features; and ascertain the surgical faculty's views on potential interventions and obstacles to change. Additional questions about service commitment to well-being, use of annual leave, and attitudes about weekend surgical practice were constructed to guide future targeted interventions. RESULTS: Among the 72 surgeons who responded (response rate of 73%), we found that 42% of surgeons reported burnout and 27% psychiatric levels of distress, while 30% used alcohol and 13% used sleep medications as a possible means to cope. Only one third of surgeons reported high quality of life across physical, emotional, spiritual, and intellectual domains. DISCUSSION: Compared to general surgical practices, cancer surgeons achieved more personal fulfillment and made less use of distancing methods to cope with their patients. Institutional culture contributes to the nonuse of available annual leave, attitudes about weekend operating schedules, and missed opportunities for the leadership to attend to surgeons' well-being.

Averting adverse events in communication skills training: a case series.

OBJECTIVE: To document cases of adverse or near adverse events in communication skills training (CST) and to identify risk factors and strategies to reduce the likelihood of their occurrence. METHODS: Six physician CST cases meeting criteria for an adverse or near adverse collected from experienced facilitators are analyzed and discussed. RESULTS: Three types of adverse CST events are described: traumatic personal experiences or losses evoked by training; perception that feedback is not empathic; and where trainees are referred for remedial CST as a risk management strategy. CONCLUSION: Early identification of risk factors and emotional cues of trainees is a key first step that facilitates implementation of remedial strategies to avert potential adverse events. Consideration of ways that physicians' personal experiences impact communication and good feedback techniques are vital. The implications of physicians sent to CST for risk management purposes is a new scenario that deserves special consideration. PRACTICE IMPLICATIONS: To make CST safer and to optimize learning, early recognition of potential adverse events is essential. Specific feedback techniques should be mastered by all CST facilitators.

The implementation and assessment of a comprehensive communication skills training curriculum for oncologists.

OBJECTIVE: The objective of this paper is to report the implementation and assessment of the Comskil Training Curriculum at Memorial Sloan-Kettering Cancer Center. METHOD: Twenty-eight attending physicians and surgeons participated in communication skills training modules as part of a train-the-trainer program. Doctors were video recorded in clinical consultations with patients two times before training and two times after training, resulting in 112 video recordings for analysis. Recordings were coded using the Comskil Coding System. RESULTS: Communication skills related to two of the six major skill sets, Establishing the Consultation Framework and Checking, increased following training. Limited changes emerged in three skill sets, while one skill set, Shared Decision Making, did not change. Doctors who attended more training modules had higher levels of change. Female participants demonstrated three skills more frequently than males post-training. CONCLUSIONS: The intervention produced significant communication skills uptake in a group of experienced attending clinicians, mediated by the amount of training. Future research should focus on the dose of training necessary to achieve skills uptake and the effect of skills training on patient outcomes.

The assessment and management of family distress during palliative care.

PURPOSE OF REVIEW: In the advanced stages of illness, families manage multiple caregiving demands while facing the emotional task of preparing for the loss of their loved one. Palliative care settings are well suited to identifying families at risk for elevated distress, and providing support as they navigate this process. This review summarizes current research in the assessment and management of family distress at the end of life. RECENT FINDINGS: The recent literature on families of terminally ill cancer patients has provided a more precise description of the relational and cultural factors that contribute to family distress. Studies eliciting the perspectives of family members on what is needed at the end of life affirm the importance of supportive communication and continuity of psychosocial care into bereavement. Other developments include efforts to establish guidelines for conducting family meetings in the palliative care setting, and to train palliative care practitioners in family-centered assessment techniques. Finally, there is a limited but growing evidence base for the utility of delivering family-focused psychosocial interventions during palliative care. SUMMARY: The knowledge gained from current research on what is most salient to family members during palliative care is critical for ensuring effective delivery of supportive services and collaborative engagement in those services.

Beyond the psychotherapy and survival debate: the challenge of social disparity, depression and treatment adherence in psychosocial cancer care.

The psychotherapy and cancer survival debate generated great interest in the psychoneuroimmunological and bio-behavioral mechanisms that might mediate any gain in survival. Recent methodologically-improved cognitive-existential, supportive-expressive and psycho-educational group interventions for patients with breast cancer and melanoma have not extended survival times. Shorter survival has been associated with social disparity and untreated clinical depression, potentially mediated by poorer adherence to anti-cancer treatments. Group therapy both prevents and treats depression. Future research could address these bio-behavioral mechanisms.

Supportive-expressive group therapy for women with metastatic breast cancer: survival and psychosocial outcome from a randomized controlled trial.

BACKGROUND: Mixed reports exist about the impact of supportive-expressive group therapy (SEGT) on survival. METHODS: From 485 women with advanced breast cancer recruited between 1996-2002, 227 (47%) consented and were randomized within an average 10 months of cancer recurrence in a 2:1 ratio to intervention with 1 year or more of weekly SEGT plus three classes of relaxation therapy (147 women) or to control receiving three classes of relaxation therapy (80 women). The primary outcome was survival; psychosocial well-being was appraised secondarily. Analysis was by intention-to-treat. RESULTS: SEGT did not prolong survival (median survival 24.0 months in SEGT and 18.3 in controls; univariate hazard ratio for death 0.92 [95% CI, 0.69-1.26]; multivariate hazard ratio, 1.06 [95% CI, 0.74-1.51]). Significant predictors of survival were treatment with chemotherapy and hormone therapy (p<0.001), visceral metastases (p<0.001) and advanced disease at first diagnosis (p<0.05). SEGT ameliorated and prevented new DSM-IV depressive disorders (p = 0.002), reduced hopeless-helplessness (p = 0.004), trauma symptoms (p = 0.04) and improved social functioning (p = 0.03). CONCLUSIONS: SEGT did not prolong survival. It improved quality of life, including treatment of and protection against depression.

Issues in pediatric palliative care: understanding families.

While family-centred care has always been part of the rhetoric of hospice and palliative care, few models have been developed that successfully integrate care of the caregivers into the overall schema. Systematic analyses of interventions have failed to produce any demonstrable benefit to families arising from the modern practice of palliative care. This alarming finding constitutes the greatest challenge for the 21st century. Pediatric palliative care may have much to teach in its approach to family care. Family-focused grief therapy is one model, used with both adolescent and adult families, that has promise for the field. The time has surely arrived for palliative medicine to focus on family-based research.