Psychosocial Oncology and Palliative Communication

Cancer is a multi-system disorder that influences all aspects of the life of affected individuals and their caregivers. Aside from the magnitude of the physical aspect of the disease and treatment there are complex sequalea that must be dealt with. This may include social interactions, family relations, peer interaction, intimate relationships, education, employment, spiritual attitudes and navigating the complexities of the health care system, providers and their ancillary functions. As the disease progresses there is a need for acceptance and adaptation to end of life issues and symptom management. The integration of palliative care within the context of psychosocial oncology is a integral part of the Comprehensive Care of cancer patients and their families.


Introduction
Cancer is a multi-system disorder that influences all aspects of the life of affected individuals and their caregivers. Aside from the magnitude of the physical aspect of the disease and treatment there are complex sequalea that must be dealt with. This may include social interactions, family relations, peer interaction, intimate relationships, education, employment, spiritual attitudes and navigating the complexities of the health care system, providers and their ancillary functions. As the disease progresses there is a need for acceptance and adaptation to end of life issues and symptom management. The integration of palliative care within the context of psychosocial oncology is a integral part of the Comprehensive Care of cancer patients and their families. Implicit in the training of physicians and other health care workers is a need to effectively communicate the reality of diagnosis, disease status and prognosis. This includes being able to accurately describe diagnostic procedures and treatment goals and what benefit and/or risk is involved. Helping patients and families make decisions about what constitutes good quality of life and when to discontinue aggressive treatment is one of a physician's most difficult tasks [1]. Despite diagnostic and therapeutic advances in oncology, many patients ultimately die of their disease, which is often stressful and emotional for the treatment team. Additionally practitioners currently get little to no formal training on the subject and very little is written in regards to how to say goodbye to a patient or the negative impact miscommunication has on that last interaction.
Unfortunately, many patients may have difficulty in accepting the gravity and import of a life limiting diagnosis. This can result in a lack of focus and, more critically, the inability to achieve appropriate goals.
Coping with a life limiting disease is never simple or easy; the clinician must have a multitude of strategies to deliver information about the disease process, treatments, and prognosis. Often using traditional communication strategies and methods will be insufficient. Unless approached appropriately previous coping strategies such as minimizing, deflecting or rationalizing can become so deeply entrenched that patients and their loved ones can lose the opportunity to complete necessary end of life communications.
The main goal of Psycho-Social Oncology is to provide an infrastructure to deliver better emotional care to patients and their families who are dealing with cancer. This PSO model presents a continuum of care beginning with the cancer diagnosis and following through to grief and bereavement services for survivors. Methods of coping with the treatment process are offered and implemented in multiple milieus. The process of dealing with palliative care and end of life should be offered in context of the continuum of care. This PSO model also addresses the issue of caregiver burden treating the entirety of the family as a holistic unit. Being able communicate effectively means being able effectively elicit concerns, fears and hopes from the patient and all 'stakeholders' in the patient's life.
Psychosocial oncology/palliative care is the provision of specific empirically validated treatments to those patients diagnosed with life limiting oncological disorders. Palliative care including symptom management, psychosocial counselling, and discussion about treatment goals and expectations should be incorporated into oncology care beginning at the time of diagnosis, particularly for patients with aggressive disease or high symptom burden.
The concept of palliation of symptoms and quality of life has continued to evolve since Dame Cicely Saunders founded the hospice movement. With the growth and advent of psychosocial oncology the nature and implementation of the continuum of oncology services and ultimately palliative services has changed. With advanced disease the patient's experience will change and vacillate in response to symptom burden, medication effectiveness, familial response (or lack of response) and myriad of other variables.
Comprehensive care of the patient with a life limiting condition necessitates the integration of psychosocial aspects of care into the overall assessment and management plan. A growing body of scientific evidence demonstrates that the psychological and social ("psychosocial") problems created or exacerbated by cancer (e.g., depression, other emotional problems, or a lack of information or skills needed to manage illness) can be effectively addressed by a number of services and interventions [2][3][4][5][6]. Data is unequivocal that psychosocial interventions can improve the quality of life in cancer patients [7][8][9][10][11][12][13][14][15][16][17][18]. The intensity of intervention mimics the paradigm presented in the world health organization's pain ladder [19][20][21][22].
Communication is the cornerstone of good multidisciplinary medical care. There can be many communication challenges regardless whether the clinician is a General Practitioner, Oncologist, or a Palliative consultant. In this regard, the title of psychosocial oncology is not limiting but rather inclusive by nature. Communication challenges can include strong demands from patients' relatives, strong emotions, troublesome doctor-patient relationships, insufficient clarification of patients' problems promises that could not be kept, helplessness; too close involvement, and insufficient anticipation of various scenarios [23]. Without clear, goal directed communication, care losses it purpose. When the purpose of care (whether it be aggressive treatment or preservation of quality of life), becomes muddied or even lost in an unfortunate battle of wills distress is certain to occur in the patient, family, and care givers.
The ideal bio-psycho-social approach requires a fully multidisciplinary, multidimensional approach. From a psychosocial perspective, distress and symptom management are a cornerstone of comprehensive palliative cancer care. A cornerstone of quality care is a solid grounding in a comprehensive theoretical orientation. This grounding should transverse disciplines. Sound communication fundamentals help a psychosocial oncologist navigate difficult transitional milestones in the trajectory from diagnosis to death.