Panate Pukrittayakamee Psychological Distress in Palliative Care Early Detection and Management Panate Pukrittayakamee

Outline Psychological suffering Depression Management for psychological distress Spirituality

A 49-year-old women was diagnosed with breast cancer. She was treated by surgery, chemotherapy and radiation. Her condition had been stable for 3 years. She developed shoulder pain and paralysis because of spinal cord metastasis. When a researcher performed the Thai greeting, she burst into tears. (Nilmanat et al., 2010)

Why did she burst into tears? She had severe pain at her shoulder. She was paralyzed. She did not want to talk to a researcher. She felt worthless. She felt hopeless.

“There is nothing left for me to live for “There is nothing left for me to live for. I lost the dignity as a human being. I cannot even perform the greeting; arms and legs are completely weak. The disease has eaten my body up nothing is left. Nowadays, my life is worth nothing. I cannot do anything.” (Nilmanat et al., 2010)

“I have lost the value of being a mother, I feel sorry for my son “I have lost the value of being a mother, I feel sorry for my son. Last night, I woke my son up because I was in pain, asking him to massage my legs. When he woke up to massage me, his eyes remained closed … that really made me feel deep pain. He is so young … only 17 years old, still in the process of growing up, so he needs longer rest. I feel worthless.” (Nilmanat et al., 2010)

Why did she burst into tears? She had severe pain at her shoulder. She was paralyzed. She did not want to talk to a researcher. She felt worthless. She felt hopeless.

Total Pain Physical Psychological Social Spiritual Pain Depression Worthlessness Fear Loss Social Isolation Stigma Poverty Spiritual Loss of purpose Loss of hope (Saunders, 1967, Mehta and Chan, 2008)

Questions asking about suffering I know you have pain but are there things even worse than just the pain you want to talk about? What is the worst thing about this? How does this symptom affect you?

Personal Meaning of Illness Threat Loss Punishment Gain Challenge (Lipowski, 1982)

Major depressive disorder Negative view of self, world, and future Emotion Depressed mood Diminished interest or pleasure in activities Feeling of worthlessness or excessive guilt Recurrent thought of death Somatic symptoms Significant weight loss Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Cognitive function Diminished ability to think or concentrate (Sadock et al. 2015)

Screening questions 1) “คุณเคยรู้สึกเศร้าเสียใจ รู้สึกแย่หดหู่ไม่แจ่มใส ตลอดทั้งวันหรือเกือบทั้งวันแทบทุกวันเป็นเวลาอย่างน้อย 1 สัปดาห์หรือไม่” 2) “คุณเคยรู้สึกไม่สนุกหรือไม่เพลิดเพลินในเรื่องต่างๆที่คุณเคยสนุกหรือเคยชอบเป็นเวลาอย่างน้อย 1 สัปดาห์หรือไม่” For MDD Sensitivity 81%, Specificity 85% For all types of depressive disorder Sensitivity 73%, Specificity 90% (Chantakarn et al., 2014)

Elisabeth Kübler-Ross: 5 stages Shock and denial Reassure that they will not be abandoned Stage 2 Anger Empathic, nondefensive response Stage 3 Bargaining Encourage them to participate as partners in treatment Stage 4 Depression Evaluation and management Stage 5 Acceptance (Sadock et al., 2015)

Active listening Show that you are listening Sit down and good eye contact Paraphrasing and summarizing Listen to the real meaning and emotion Assess patient’s verbal, non-verbal reaction Ask questions to clarify certain points Responding to their concerns and emotions Non-verbal response Verbal response (NURSE)

Empathy and emotional support NURSE Name ‘I imagine this must be upsetting’ (naming the emotion) Understand ‘I expect most people would feel that way in a situation like this’ Respect ‘I’m impressed with how well you’ve handled such a tough situation’ Support ‘I’ll be here to help you through this’ Explore ‘Tell me more about how you’re feeling, and what this means for you’ (LeBlanc and Tulsky, 2015)

Balance between honesty and not being discouraging Not disputing patient claims of miracles Wish statements ‘Does this mean my cancer is back?’ ‘I wish things had turned out differently’ Hope for the best ‘Let’s hope for the best, while we also prepare for other possible outcomes’ Exploring realistic goals Emphasizing what can be done

Asking about patient's life outside of their illness Love of family and friends Humor Uplifting memories Religious faith and belief (LeBlanc and Tulsky, 2015, Koffman et al., 2013, Buckley and Herth, 2004)

Spirituality Personal beliefs about life, death and illness in terms of Meaning Value Purpose Hope Sense of connection to a greater power or God These beliefs are based on religious concept or personal attitude. (Ellis and Lloyd-Williams, 2012, Swinton, 2012)

Spirituality The meaning and purpose of life are threatened by a dying process. Spirituality should be discussed with patients in order to Understand their meaning of life Searching for a new role and purpose of life Help them find their hope (Ellis and Lloyd-Williams, 2012, Swinton, 2012, McClement, 2015)

Spiritual intervention Buddhism Death is a natural process Impermanence Focus on the present Focus on mind rather than physical symptoms At the end of life, the body cannot be controlled It is possible for the mind to remain clear until the end Meditation (Masel et al., 2012)

Case A 49-year-old women was diagnosed with breast cancer. She developed shoulder pain and paralysis because of spinal metastasis. She has been depressed.

What is the proper management? Ask whether she has suicidal ideation Start antidepressant Consult psychiatrist Ask patient about her suffering Provide spiritual intervention

Which one of the followings is the most appropriate conversation? ไม่ต้องกังวลครับ หมอยืนยันว่าโรคนี้รักษาให้หายขาดได้ หมอเข้าใจครับว่าคุณรู้สึกเสียใจที่คุณไม่สามารถดูแลลูกได้อย่างที่ตั้งใจไว้ คุณอยากใช้เวลาที่เหลืออยู่กับครอบครัวที่บ้านหรือไม่ครับ ถ้าโรคดำเนินถึงระยะสุดท้าย คุณอยากให้หมอปั๊มหัวใจหรือไม่ครับ ทำใจให้สบายครับ เดี๋ยวปัญหาต่างๆจะค่อยๆดีขึ้น

Which one of the followings is included in the screening questions for depression? คุณเคยรู้สึกไม่สนุกหรือไม่เพลิดเพลินในเรื่องต่างๆที่คุณเคยสนุกหรือเคยชอบเป็นเวลาอย่างน้อย 1 สัปดาห์หรือไม่ คุณเคยรู้สึกไม่อยากมีชีวิตอยู่เป็นเวลาอย่างน้อย 1 สัปดาห์หรือไม่ คุณเคยรู้สึกเศร้าเสียใจ รู้สึกแย่หดหู่ไม่แจ่มใส ตลอดทั้งวันหรือเกือบทั้งวันแทบทุกวันเป็นเวลาอย่างน้อย 1 เดือนหรือไม่ คุณเคยรู้สึกว่าคุณเป็นภาระให้ครอบครัวเป็นเวลาอย่างน้อย 1 สัปดาห์หรือไม่ คุณเคยรู้สึกท้อแท้สิ้นหวังเป็นเวลาอย่างน้อย 1 เดือนหรือไม่

References BUCKLEY, J. & HERTH, K. 2004. Fostering hope in terminally ill patients. Nurs Stand, 19, 33-41. CHANTAKARN, S., PUKRITTAYAKAMEE, P. & SAISAVOEY, N. 2014. Accuracy of the two-question screening for depression in psychiatric patients at the consultation liaison unit, Faculty of Medicine Siriraj Hospital, Mahidol University. J Psychiatr Assoc Thailand 59, 51-61. ELLIS, J. & LLOYD-WILLIAMS, M. 2012. Palliative care. In: COBB, M., PUCHALSKI, C. M. & RUMBOLD, B. D. (eds.) Oxford textbook of spirituality in healthcare. Oxford: Oxford University Press. KOFFMAN, J., MORGAN, M., EDMONDS, P., SPECK, P., SIEGERT, R. & HIGGINSON, I. J. 2013. Meanings of happiness among two ethnic groups living with advanced cancer in south London: a qualitative study. Psychooncology, 22, 1096-103.

References LeBlanc, T.W. and Tulsky, J.A. 2015. Communication with the patient and family. In: CHERNY, N. I., FALLON, M., KAASA, S., PORTENOY, R. K. & CURROW, D. (eds.) Oxford textbook of palliative medicine. Fifth edition. ed. Oxford: Oxford University Press. LIPOWSKI, Z. J. 1982. Psychological reactions to physical illness. CAN MED ASSOC J, 128, 1069-1072. MASEL, E. K., SCHUR, S. & WATZKE, H. H. 2012. Life is uncertain. death is certain. Buddhism and palliative care. J Pain Symptom Manage, 44, 307-12. MCCLEMENT, S. E. 2015. Spiritual issues in palliative medicine. In: CHERNY, N. I., FALLON, M. T., KAASA, S., PORTENOY, R. K. & CURROW, D. C. (eds.) Oxford textbook of palliative medicine. 5th ed. New York, NY: Oxford University Press.

References MEHTA, A. & CHAN, L. 2008. Understanding of the Concept of ‘‘Total Pain’’ A Prerequisite for Pain Control. Journal of hospice and palliative nursing, 10, 26-32. NILMANAT, K., CHAILUNGKA, P., TEMSAK, P., PROMNOI, C., TULATHAMKIT, K., NOO-URAI, P. & PHATTARANAVIG, S. 2010. Living with suffering as voiced by Thai patients with terminal advanced cancer. Int J Palliat Nurs, 16, 393-9. SADOCK, B. J., SADOCK, V. A. & RUIZ, P. 2015. KAPLAN & SADOCK’S Synopsis of Psychiatry Behavioral Sciences/Clinical Psychiatry, Philadelphia, Wolters Kluwer. SAUNDERS, C. M. 1967. The Management of Terminal Illness, London, Hospital Medicine Publications. SWINTON, J. 2012. Healthcare spirituality: a question of knowledge. In: COBB, M., PUCHALSKI, C. M. & RUMBOLD, B. D. (eds.) Oxford textbook of spirituality in healthcare. Oxford: Oxford University Press.