The Distressed Patient

MAY 01, 2009
Christina T. Loguidice
As you can well imagine, a cancer diagnosis can lead to an incredible amount of distress, which may be amplified once a patient starts to undergo treatment and experience its related side effects. In a session entitled “Distress in the Oncology Patient,” Joy Know, BSN, MSN, ARNP, Providence Comprehensive Breast Center, Everett, WA, reviewed the National Comprehensive Cancer Network (NCCN) guidelines regarding identification of distress, discussed the importance of assessing patients for distress, and reviewed distress assessment tools and interventions. Thereafter, Dawn Dickson, MSW, Providence Regional Cancer Partnership, Everett, WA, outlined the realities of implementing of distress tool into a regional cancer center.

Defining Distress
According to the NCCN, distress is a mix of anxiety and depressive symptoms, which may result in sleeplessness, loss of appetite, trouble focusing, and difficulty performing regular daily activities. While some distress is considered normal, up to one third of cancer patients experience significant distress, and only 5% of these individuals obtain psychological help. While distress won’t affect the cancer itself, it can affect a patient’s ability to cope with their cancer and to follow treatment recommendations, potentially resulting in poorer outcomes; thus, “distress, like pain, should be recognized, monitored, documented, and promptly treated at all states,” noted Know.

Patients at Risk Numerous factors can place a patient at increased risk, including a personal or family history of depression, significant morbidities, history of ethyl alcohol or drug abuse, poor prognosis, lower socioeconomic status, and lack of support or other life stressors. Populations at high risk include young patients, those older than 70 years, and female patients.

Distress Assessment and Intervention
A patient’s distress symptoms should be monitored throughout diagnosis and treatment. There are numerous methods for assessing distress, including asking informal questions, using an established anxiety or depression scale or a distress thermometer, and referring to the Diagnostic and Statistical Manual for Mental Disorder, which is, largely, used by psychiatric nurse practitioners and other mental health professionals.

Fortunately, when distress is identified, it often can be treated without pharmacotherapy. One of the most effective interventions is patient education, which can help alleviate anxiety. Reassurance also goes a long way, and nurses should let their patients know that distress is common. They can also recommend participation in activities that can help the patient replace their negative emotions with more positive ones, such as meditation or art therapy.

Distress Tool Implementation
Implementing a distress tool into practice can prove incredibly difficult. Dickson discussed the challenges she faced when incorporating such a tool into a regional cancer center. She struggled with three main barriers: resistance (clinical and ancillary staff and patients), limited time and resources, and insufficient information regarding the distress tool.

The pilot test had been conducted in her institution’s radiation oncology department first. Patients were given the distress tool by the receptionist at consult only, and a social worker followed up on any scores of 5 and higher; MDs and RNs did not review the results. The procedure changed when it was rolled out to the medical oncology department. The distress tool was given at every MD appointment, though not at consult. If a patient scored a 6 or above, a medical assistant would immediately page a social worker or a behavioral health psychologist, and the patient would receive a follow-up phone call from a behavioral health psychology intern within 48 hours. All data were recorded, and after 1 year, a total of 4,479 distress assessments were collected. The data revealed that 28.2% of patients self-scored a distress level of 5 or above, with 1.1% scoring a level of 10. A distress level of 2 was the most prevalent, marked by 11.1% of patients.

Dickson notes that implementation of a distress tool provides numerous opportunities to improve patient care and patient–provider communication. It also presents a great opportunity for data collection and research, as patients may be more likely to report distress in writing than verbally. Implementing a distress tool can be challenging; thus, it is important to keep expectations realistic and view the process as an evolving one.

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