Article of the Month
Assessment of palliative care cancer patients’ most important concerns
Baile WF, Palmer JL, Bruera E, Parker PA
Supportive Care Cancer 2011; 19: 475-481
Medical problems are only a part of the concerns of cancer patients that cause suffering. It is well known that the treatment of TOTAL PAIN is a major objective of palliative care but in order to personalize treatment it is important to assess on a regular basis all the issues confronting patients.
The aims of this study were:
- to assess the concerns of patients who attended a palliative care clinic and determine their association to the level of distress provoked,
- to examine the ratings of physicians regarding patient concerns, and
- to assess the concordance between patient and physician ratings
The authors assessed 137 patients attending the outpatient symptom control and palliative care clinic (mean age 60.9 years; 55% males - all patients had metastatic disease). Prior to being seen by a physician, the patients completed the Concerns Checklist (CCL), the Hospital Anxiety and Depression Scale (HADS), and the Cancer Behavior Inventory-Brief Form (CBI-B) and after the visit the physician completed a physician version of the CCL to identify which issues the physicians thought were important concerns of their patients.
The CCL is a 15-item instrument (11 items with an additional 4 lines for patients to add concerns). The patients rate the degree of worry on a 0 (not at all) to 3 (very much) scale. Each concern, or item, on the scale is given a value as to how troubling it was for the patient over the past week.
HADS is a 14-item questionnaire which assesses anxiety and depression.
CBI-B is a 14-item tool used to measure a patients’ self-efficacy for coping with their cancer.
The patients indicated that they were most concerned about:
- not being able to do their usual activities;
- the future;
- caring for themselves.
They were less concerned about
- not getting enough support from others and
- spiritual/religious issues
The mean HADS anxiety score was 6.9 while 42% scored 8 or higher which indicates a high level of anxiety. The mean HADS depression score was 7 and 44% scored 8 or above, which indicates potentially significant depressive symptomatology.
Evaluations by the physicians indicated that they thought patients were most concerned about:
- the future;
- not being able to do usual activities;
- treatment
The physicians believed that patients had fewest concerns about
- intimate/sexual relationships and
- spiritual/religious issues.
Interestingly, the physicians reported higher levels of concern in each area compared to the patients.
The study of concordance between patients’ and their physicians’ ratings showed no significant agreement between physician and patient ratings. The highest concordance was for the patients’ concerns about 1. the future and 2. caring for themselves.
It was found that the higher levels of patient concerns were associated with greater anxiety (r=0.52) and depressive symptoms (r=0.04) and lower self-efficacy. Patients with more concerns had more symptoms of anxiety(r = 0.52) and depression (r=0.40) and lower self-efficacy (r= -0.37).
Why I choose this article?
This article reminds to us that in addition to medical problems, patients may have concerns regarding various aspects of their life that are clearly related and affected by their disease. Moreover, they may suffer from depression and/or anxiety symptoms that are higher in patients with more concerns. Many problems may not be recognized or may be over or underestimated if they are not assessed on a regular basis. The evaluation of the total needs of patients as well as the causes of their suffering is the only way we can effectively provide the necessary elements of total care.
Reviewed by Dr. Carla Ripamonti (Italy). Dr. Ripamonti is a member of the IAHPC Board and her bio may be viewed at http://www.hospicecare.com/Bio/c_ripamonti.htm
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