Oncology nurse navigators can improve outcomes, quality of care, and patient experience by recognizing and addressing the emotional toll that a cancer diagnosis can take on a patient, the family, and the social network. This message was made clear at the recent East Coast Regional Meeting of the Academy of Oncology Nurse & Patient Navigators.
Oncology nurses can help to guide patients to survival as they pilot the course of cancer’s emotional challenges—depression, anxiety, delirium, and other psychological sequelae, explained Carole F. Seddon, LCSW-C, BCD, OSW-C, and Laura Herald Hoofring, MSN, APRN-PMH, BC.
Both have been on the frontlines of cancer treatment and have witnessed the emotional distress experienced by cancer patients, and Ms Seddon herself is a cancer survivor.
Depression in Cancer Patients
Depression in cancer patients has many facets, causes, and effects on patient experience and outcome. The cancer diagnosis itself often induces a spectrum of difficult emotional experiences in patients that can influence outcomes.
Depression must be taken seriously as a comorbidity, explained Ms Seddon, Director of the Cancer Counseling Center, Duffey Family Patient and Family Services Program, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Hospital, Baltimore, MD. For instance, between 1973 and 2002, patients with cancer in the United States had nearly twice the incidence of suicide as the general population. If the symptoms of depression are severe, the nurse navigator can take the following steps, among others:
- Instruct the family and patient to go to the nearest emergency department, call 911, or contact a local mobile crisis service
- Assist the patient in obtaining a referral and identify outpatient mental health services including:
- Social work, psychiatry/psychiatric liaison nurse/primary care physician
- Assist the patient in contacting his or her insurance company to locate a mental health clinic
- Pain, palliative, and hospice services; a social worker, or a chaplain
- Assist the patient in managing physical symptoms and social and spiritual distress
- Encourage patients to engage in positive self-care, including activities of daily living, social activities, and exercise
- Help identify and encourage the use of complimentary activities
Most cancer patients do not experience a major depressive disorder as a result of a cancer diagnosis. Depression in cancer patients, particularly those with oropharyngeal, breast, pancreatic, or lung disease, is common, but it is not necessarily a psychiatric disorder. It is part of grief and can be a normal response to a cancer diagnosis, Ms Seddon noted.
Nurse Navigator Intervention
For patients who experience depression, nurse navigators have several tools at their disposal to help. Both psychological and medical therapies can be effective in treating depression and its causes in cancer patients. The goals of treatment, said Ms Seddon, are to improve patients’ abilities to adapt and to cope. To this end, assess the patient’s support system and determine if any red flag issues exist that indicate a lack of adaptation or coping, she said.
Adaptation is considered in terms of emotional distress, subjective quality of life, and social functioning at work and with friends and family. Psychological strategies are oriented within the framework of a self-regulation model of coping.
Coping constitutes behavior and cognitive activity, which can help the patient respond to and overcome adversity. The key ingredients in coping are optimism, practicality, flexibility, and resourcefulness. Nurse navigators can help to instill and strengthen these qualities in patients.
According to the National Comprehensive Cancer Network (NCCN), the following case characteristics put patients at greatest risk of significant depression:
- A history of a psychiatric disorder or substance abuse
- A history of depression or an attempted suicide
- Cognitive impairment
- Communication barriers
- Severe comorbid illnesses
- Social issues
- Spiritual/religious concerns
- Uncontrolled symptoms
And, according to the NCCN, the following are the points in the course of the disease at which nurse navigators can most effectively intervene:
- The patient identifies a suspicious symptom
- During diagnostic workup and diagnosis
- Awaiting treatment
- A change in treatment modality or end of treatment
- Discharge from hospital following treatment
- Transition to survivorship
- Medical follow-up and surveillance
- Treatment failure, recurrence, or progression
- Advanced disease
- Approaching the end of life
The Diagnosis and Its Challenges for Patients
Nurse navigators know that cancer is a frightening diagnosis for patients and families. Emotional distress is the norm. “The diagnosis of cancer induces stress caused by the patient’s perception of the disease,” Ms Seddon said. “Though there are other illnesses that are more difficult, cancer is perceived as a death sentence, and that’s what people think as soon as they’re diagnosed.”
Changes in Personal and Social Life
In many cases, the patient’s family life and social network are immediately disrupted. Patients watch close friends disappear just when support would be helpful. “I have found, through the 33 years that I’ve worked in oncology at Hopkins, that people would say, over and over again, the friends that they thought would be there for them were not, and those that they thought wouldn’t be, were,” she said.
“It’s not something that’s awful about your friends, it’s just what happens. They’re the same age as you. They’re going to be afraid. I even had someone say to me, ‘I know it’s not catching, but I get scared that it might be.’”
Many friends simply do not understand the cancer patient’s experience. Some simply do not know how to act, and this fact makes them uncomfortable enough to avoid the patient altogether. Should friends talk about cancer with the patient? Should they sympathize? Act as if nothing is wrong? Tell stories of other friends with cancer? Some friends simply do not know what to do, so they flee.
Nurse navigators can counsel patients on how to deal with these important changes in personal and social life. “It’s really, really important for people to be able to adjust,” Ms Seddon said. “If they don’t know how to do that, they need help.”
Medication and Other Treatment Modalities
Patients with cancer suffer with a major depressive disorder in about 20% of cases and are frequently quite anxious, and there are obvious medical choices to reduce the severity of symptoms. Antidepressants can be used for depression and anxiety, noted Ms Hoofring, Oncology Psychiatric Liaison Nurse, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Hospital, Baltimore, MD. Medical therapies, however, are fully effective in only about 30% of cases, and partially effective in about 30% of cases. Many patients will not respond at all to the use of antidepressants, she said.
Anxiolytics, such as benzodiazepines, can be very effective for acute anxiety, but they can be associated with unacceptable side effects. Starting with the lowest effective dose is always wise. Be aware that some patients will respond to anxiolytics with impaired memory, fatigue, intoxication, and disassociation. For some patients, these will be unacceptable side effects. Many patients also simply object to medical treatment of anxiety or depression.
Nonmedical therapy can also be effective in patients with depression and anxiety, as can education. One of these is cognitive-behavioral therapy. However, cognitive-behavioral therapy and other types of talk therapy, when effective, can take 6 to 8 weeks to produce results.
Depression and Delirium
The diagnosis of cancer, as well as the treatments, can cause some patients to descend into a type of acute delirium, said Ms Hoofring. Nurse navigators can detect this by asking the right questions of the patient, she explained.
“When your patient tells you that their thinking is not right, that they’re cloudy, that they can’t remember things and stuff, you should suspect delirium also, because hypoactive (or quiet) delirium looks like depression. Remember, that is brain failure. People’s brains are not working, and that is not normal," Ms Hoofring said.
“Again, it’s an acute syndrome. Somebody’s fine, and then they’re not. For example, my patients will say they’re at Johns Hopkins at 8:30 in the morning, and then later on, they’ll tell me that they’re at a different hospital that afternoon. It can happen very quickly, and it’s usually caused by some aspect of treatment. We do a lot to cancer patients to make their brains not work. Often, there is more than 1 cause, and it affects every aspect of patients’ cognition. They don’t have orientation. They’ll lose time first, and place, and person. They can’t concentrate. They can’t remember," she said.
Delirium can lead to other profoundly distressing emotional sequelae such as hallucinations, posttraumatic stress disorder (PTSD), depression, and anxiety disorders. Ms Hoofring referred to an unpublished study conducted by a colleague at The Johns Hopkins School of Medicine, Department of Oncology. This study revealed that patients who suffer delirium have a 10% to 15% greater risk of developing PTSD, depression, and anxiety disorders following a stay in the intensive care unit.
Managing delirium, anxiety, and depression, and helping patients navigate these conditions, are vital services that nurse navigators can perform for patients. Depression in particular is associated with suboptimal outcomes. Guiding patients to treatments and services that can relieve depression can be a significantly positive intervention.
