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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
Emo$onalsupportduringChemo
PazFernández-Ortega.PhD,MSc,RN,BPsychChairofEduca9onMASCCSG
NursingResearchCoordinator.Ins4tuteCatalàd’OncologiaBarcelona-Spain.Mail:[email protected]
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
Emo$onalsupport
Mul$dimensionality
Inten$on&percep$on
Specialsitua$ons
Whoisatrisk
Toolsandbestinterven$ons
Takehomemessage…
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
MULTIDIMENSIONAL NEEDS
MULTIDISCIPLINARY APPROACH
SOCIAL WORK
ONCOLOGY
RESEARCH
PALLIATIVE CARE
NUTRITION
RADIOTHERAPY
PHARMACIST
CANCER NURSES
Psychological
BiologicalSocial-spiritual
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
Chemotherapy intention always is/ should be to bring benefit to patient
Effec$vity Subjec$ve-cogni$vepercep$onbenefit/nonbenefit
But,howpa$entsperceivethis?Signalscomingfromprofessionals,nurses&family-caregivers
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
Outcomes & benefit perceived for patients
Effec$vity Subjec$ve-cogni$vebenefit/nonbenefit
RigorEvidence-based
protocolsProfessionalcompetencies
-AKtudes-Empathy
Pa$entsgetsignalsfromProfessionals,nursesandteam
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
Whatisemo$onalsupport
• Emo$onsrefertofeelingsinpre-chemotherapy– Feelingsasfear,fustra$on,guilty…
Pa$entsneed:• Receivetreatmentinforma$on• Receiveinstrumentalinforma$onand..• Receiveaffec$veinforma$on
• Some$mesoneissubs$tu$ngtheotherBalancingall..
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
Majorityofpa$entsreceivingChemotherapy;AdjuvantorPallia$veand/orinclinicaltrialsPhaseI• Situa$onofsuffering• Threateningsitua$on• Lossofcontrol• Impactsitua$on• Feelingofdespair• Fear• Doubts• Difficul$esforcommunica$on• Difficul$estokeeptheaMen$on
Vulnerabilitysitua$on
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
Whoisourpa$ent?
ALL THEM ARE INCLUDED IN THE SITUATION!!!
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
Physical needs interrelation:• Symptoms more prevalent: asthenia, anorexia and
loss of weight…
• Refractory situation of distress also causing 41-55% of cases.
• Complex lesions: external lesions, hemorrhagic, infections, odor…
Consider high complexity if: • Low adherence in previous treatments • Difficulty in medications management • If using devices as pumps
Advancedoncologynursepa$entevalua$on
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
Physical needs, interrelation:
• High nº symptoms + high intensity
• High toxicity • Low adherence • Repetitive - hospitalization • Patient age • Emergencies situation • Ending active treatment
Symptoms more prevalent: asthenia, anorexia and loss of weight… Refractory situation of distress also causing 41-55% of cases. Complex lesions: external lesions, hemorrhagic, infections, odor… Consider as high complexity if: • Low adherence in previous treatments • Difficulty in medications management • Lack of supportive medications ++ • If using devices as pumps or
nasogastric or other
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
Psychological needs Emotional suffering is the result of adaptation to difficulties.
• It is a cognitive state • Prognosis predictor. * • with a sense of threat for the personal integrity • feeling of impotence -predestination • lack of personal and psychosocial resources to cope • feelings of loss of control • hopelessness • uncertainty.
Li L et al. (2017) Prognostic values of EORTC QLQ-C30 and QLQ-HCC18 index-scores in patients with hepatocellular carcinoma clinical application of health-related quality-of-life data. BMC Cancer.
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
Psychological needs
Somedata:• Psychologicalproblems(12–85%)• Informa$on(6–93%)• Socialproblems(1–89%)• Spiritual(14–51%)**• communica$on(2–57%)• Sexualityneeds(33–63%) * Harrison JD (2009) What are the unmet supportive care needs of people with cancer? A systematic review. Support Care Cancer 17:1117–1128
**Jimenez-FonsecaP.2018Themedia$ngroleofspirituality(meaning,peace,faith)betweenpsychologicaldistressandmentaladjustmentincancerpa$ents.SupportCareCancer.
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
High level of distress • High demand of attention • Low demand of attention Meaning of the treatment How patient use his coping strategies Emotional and spiritual resources Recent cases in same family Degree of threat perceived Higher risk personality disorders & history of psychiatric illness.
Psychological needs Emotional suffering is the result of adaptation to difficulties. Do professionals check adaptation??
Advancedoncologynursepa$entevalua$on
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
Social - Family needs • Living conditions and environmental. • Role, relationships, family dynamic, relations in family. • Self-care practices • Values, beliefs and practices • Resources and organization for care • Financial and economic impact of disease
COMPLEXITY CRITERIA: – caregiver claudication for caring – increase burden of care – not cover the caregiver needs – lack of support
Advancedoncologynursepa$entevalua$on
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
Which are patient ‘s expectation of chemo?
Mo$va$on&benefitexpectedforchemo.-Istheremanypossibili$es?-Isonlythe“lasthopeforpa$ent”??
Thereisdiscordancebetweenpa$entfamily
Solidaritywiththehumanbeing.Altruism
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
• Personalizedrela$onship• Informa$onreceived• Shareddecisionsontreatment• Proves&complementarytests• Experienceofinclusion/exclusion• Proximitytotheteam• Adjustedexpecta$ons• Side-effects• Accessibilityincaseofdoubts• Percep$onofmeaning(legacy)
What aspects can influence subjective perception patient/family during chemo or Clinical Trials?
Pa$ent-Family
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
• Sa$sfac$onwithemo$onalsupport– Defini$on:theextenttowhichpa$entsfeeltheyreceivehelptocopewithemo$onsandstress/distress– Stress-distressincreaseduringChemo
Whatpa$entstellusabout?:
Brandes K, et al. Understanding the interplay of cancer patients' instrumental concerns and emotions. Patient Educ Couns. 2017;100(5):839-845.
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
Exis$ngtools?:Sometoolsarepurelyinformingorprovidinginforma$on–sotheyareaMendingpa$ents’informa$onalneeds.
– Mostfocusinsymptoms,notalwayscoveremo$onalneeds..– Best:balancingtheinstrumentalissueswiththeemo$ons
Toolswithaholis$cperspec$ve:• CHEMOSUPPORT–2018OncologyNursingForum,Coolbrandtetal.• Short-FormSuppor$veCareNeedssurvey(SCNS-SFM)*• Effec$vefollow-uppostChemotherapy;Internet,video**,phone
calls,APP,pa$entsgroupseduca$on,expertpa$ent…
*BoyesA,(2009)Briefassessmentofadultcancerpa$ents’perceivedneeds:developmentandvalida$onofthe34-itemSuppor$veCareNeedsSurvey(SCNS-SF34).JEvalClinPract.
**KinnaneN.(2008)Evalua$onoftheaddi$onofvideo-basededuca$onforpa$entsreceivingstandardpre-chemotherapyeduca$on.EurJCancerCare.
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
Case:MaríaAndchemotherapy…
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
María...• Ms.Misan77year-oldwomanrecentlydiagnosiswithstageIVPancrea$cCancer.
• Shehadremainedingreathealthun$lherrecentdiagnosis,ajerwhichherenergyhadplummetedandshewasspendingover50%dayinsofa-bed.
• Overwhelmedwiththesightoftheirlovedonelosingherstrengthwitheachpassingday,herfamilyhadgoneintopanic.– “Couldn’tthedoctorssaveherfromthiscancer?”– “Chemotherapyhashelpedsomany,right?”– “Weneedtotrysomething,doctor!”
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
María...• Thepa$entherselfwasdetachedfromtheideaofbaMlingthedisease:– “Ihavelivedagoodlife,”shewouldsay,andtakeapassivedistanceinhertreatment/illness.
– Thisaotudefurtherdistressedthefamily:“itislikesheisgivingup.”
– Uponrequestofthecancernurse,oncologistevaluatedthepa$entandtookthe$metodiscusstreatmentop$ons.
• Theonlyremainingop$onwaschemotherapySurgerywasnolongeranop$on,andradiotherapywasnotgoingtobepar$cularlyuseful.
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
Maria...• Pa$entandfamilywerereluctantanddidnotknowwhatchemotherapyreallymeant.– Wouldbeusefulaninforma$vepamphletofthepoten$alchemotherapeu$cdrugs…...
– Pamphletexplains:“Nephrotoxicity,neurotoxicity,thrombosis,rash,edema,riskofbleeding…”
– Familylongdiscussions:- chemotherapyisgoingtomakehersuffermore!”- “sheisnotgoingtogiveuplikethis!”- “ifnotchemotherapythenwhat?!”
• AND….“whatifchemotherapysavesherlife?!”
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
NowChemoand….???
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
Someuseful$ps:• Sit,don’tstand:samelevelaspt.
• Makeeyecontact.Nottocomputer
• Listencarefully:compassionatepresence.
• Useplain,non-medical• Usethepa$ent’swords.• Slowdown:Speakclearlyandmoderatepace.
• Limitandrepeatcontent:3-5keypointsandrepeatthem.
• Askpa$entstorepeatajertheinforma$ongivenhislanguage
• Bespecificandconcrete:Don’tvague• Showgraphics:picturesorillustra$ons,• Includefamilymembersindiscussion.• Demonstratehowit’sdone.Demonstra$on• Invitepa$entpar$cipa$on:
− “Whatques$onsdoyouhave?”or“Wediscussedalotofinforma$on.Whatcanwereviewagain?”
− Don’t:“Doyouhaveanyques$ons?”− Elicitques$onsfrompa$entsseveral$mesduringanofficevisit.
• Showthatyouhavethe$me:• Helppa$entspriori$zeques$ons.longlist• Remindpa$entstobringques$onswiththemtoappointments.
Includefamilymembersindiscussion.Demonstratehowit’sdone.Whetherdoingexercisesortakingmedicine,ademonstra$onofhowtodosomethingmaybeclearerthanaverbalexplana$on.Invitepa$entpar$cipa$on:Encouragepa$entstoaskques$onsandbeinvolvedintheconversa$onduringvisitsandtobeproac$veintheirhealthcare.
Say“Whatques$onsdoyouhave?”or“Wediscussedalotofinforma$on.Whatcanwereviewagain?”(open-ended)
Donotaskpa$ents,“Doyouhaveanyques$ons?”(close-ended)
Elicitques$onsfrompa$entsseveral$mesduringanofficevisit.
Showthatyouhavethe$me:Beconsciousaboutpresen$ngyourselfashaving$meandwan$ngtolistentotheirques$ons.Helppa$entspriori$zeques$ons.Ifpa$entshavealonglistofques$ons,helpthemdecidewhichonesaremostimportanttoaddressatthisvisit.Havethemscheduleanothervisittoaddresstherestoftheirques$ons.Remindpa$entstobringques$onswiththemtoappointments.Encouragethemtoaskques$onsinotherhealthcareseongs.
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
hlp://www.helphurlool.com/
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
Takehomemessage…
• Chemotherapycontext+distress– Mul$dimensionality-mul$profesionals– Momentsthatincreasecomplexity-firstcycle– Personsmorevulnerable;older,migrants,pallia$ve,adolescents– Relapse;second-3rd-4thline.ClinicalTrial-Finishtreatment
• Baselineassessmentisagoodpredictorofpostsurvivalandmorbidity– Professionalsbeingalertonsignsfordistress– Beingalerttocomplexity– Cogni$vemeaningaMributedtoChemo– Toolsandreferraltoexpertprofessionals
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PazFernándezOrtegaPhD,MSc,RN.Educa9onSG
Thanks!
Ques$ons?Sugges$ons?Discussions…