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K. Kubota
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ES 06 - Communication Skills in the End of Life/ Symptom Management in Lung Cancer (ID 515)
- Event: WCLC 2017
- Type: Educational Session
- Track: Nursing/Palliative Care/Ethics
- Presentations: 6
- Moderators:K. Kubota, Jin -Ji Yang
- Coordinates: 10/17/2017, 15:45 - 17:30, F201 + F202 (Annex Hall)
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ES 06.01 - Advanced Directives - Are They Useful? (ID 7605)
15:45 - 17:30 | Presenting Author(s): Maiko Fujimori
- Abstract
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It is required to improve patient-physician communication and that patients be offered participation in informed decisions regarding their care ethically in the context of serious and life-limiting illnesses, citing effects of good communication on quality of care and life. Many patients with advanced cancer and caregivers seek empathetic communication from physicians. Inadequate communication about prognosis and treatment choices is common and is associated with unrealistic patient expectations regarding curability, provision of aggressive treatment that is not concordant with patients’ wishes and enrollment in hospice too late to deliver discernable benefit. Conversations related advance directive and advance care planning typically do not happen, or happen in hospital shortly before a patient’s death. In order to complete advance directives and prepare an appropriate advance planning, it is necessary to promote physicians’ empathic communication. Therefore, we developed the 2-day communication skills training (CST) for physicians based on patient preferences and confirmed the effectiveness for both patients’ psychological distress and physicians’ empathetic communication behaviors through a randomized controlled trial. After confirming the effectiveness at RCT, CST was conducted for doctors nationwide as a clinical implementation as a consignment project by the Ministry of Health, Labor and Welfare. Meanwhile, we developed question asking prompt list (QPL) for patients who were newly advanced lung and gastrointestinal cancer use in consultations and confirmed the usefulness through a randomized controlled trial. However, the QPL did not affect the number of actual question from the patient to the physician. It was needed to develop apamphletn intervention with QPL. Furthermore, the evaluation of caregivers is also needed. This presentation aims to determine the effectiveness of an integrated communication support program for promoting empathetic communication between rapidly progressive cancer patients, families and doctors, and to estimate the intervention effects on distress and QOL of patients and caregivers, faith in their physicians. These evidence of an effective intervention to promote communication and decision-making process based patients’ values and preferences between patients, caregivers and physicians with reducing physicians’ burden will be created. Based on the results, we will reflect clinical guideline regarding communication between patients and physicians in cancer care and develop a train-the-trainer workshop program with related academic society. It is also expected that providing supportive therapy at cancer hospitals will be standardized and subsequently the quality of life of cancer patients will be improved.
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ES 06.02 - Discussing Advance Care Plans - What Do You Say? (ID 7606)
15:45 - 17:30 | Presenting Author(s): Florian Strasser
- Abstract
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Patients with advanced, incurable cancer, and also their family members, typically struggle between hopes to have long lives or even get cured and the concious, unconcious or denied reality of limited life time due to cancer. This struggle becomes more pronounced in modern oncology, making predictions of response to anticancer treatments or survival increasingly difficult. Adressing existential issues and uncertainties is an often feared theme for cancer clinicians (doctors, nurses, other professionals) in clinical practice: concerns about destroying hope, hesitation about own professional role (e.g., authentic, paternalistic, servant for patients autonomy), doubts about involvement of family members, incertitude about decisional processes on anticancer treatments, or prudence on patients emotional condition (e.g., stress, trauma, anxiety, depression, anger) may constitute real challenges. Adequate communication skills including empathetic communication and concepts of shared decision making are necessary, but often not suffcient to perform as an accountable, understanding, educating, empowering, self-reflective, and competent clinician guiding patients and families to address the reality of limited live time, death, dying and bereavement. Preparation for illness-deterioration and end-of-life encompasses continuous engagement in a) patients illness understanding (e.g., causes and impact of pain, fatigue, or cachexia); b) decisional processes for or against anticancer treatments (e.g., concrete goals, significance of burdens, characterization of patients values and expressed definition of own quality-of-life); c) worst and best time range scenarios of life expectancy (never say a concrete mean estimate !) These communicative, educational and counselling interventions are part of early integrated palliative care, supported by high quality evidence to improve patients quality-of-life and symptoms. To integrate palliative care early services may adapt the name (supportive) but not the content. Advanced care plans (ACP) shall include most relevant elements to prepare for the end-of-life period, but often they are limited to power of attorney and life-sustaining treatment choices (e.g., POLST, Advanced Directives); evidence suggests that such limited processes may not alleviate existential distress, but still are important. ACP shall encompass a structured process delivered in several encounters of patient and family members with cancer clinicians, built on a trustful relationship invigorated in good decisions, patients values and life concept including spiritual aspects and patients and families’ adequate illness- and prognosis understanding. Evidence supports that ACP do not deteriorate hope and that even in cultures not used to ACP patients welcome them. Key elements of ACP encompass patients’ life values, expressed understanding and preferences of management of typical complications and disease deteriorations, concrete professional support (nurses, specialized palliative care nurses, physicians, other professionals, 24/7), timeschedule of family members offering support, preferred place of death, adressing premortal grief with important people, adressing premortal preparation for postmortal roles, preferences for funeral arrangments, legacy work, finish business including legal & financial issues and words of love, excuse, forgiveness and love, use time left conciously, prepare for prolonged live and lazarus effects. To engage in ACP clinicians may self-reflect about own accountability to have an opinion, offered in a humble, reliable, and attentive way. Also clinicians may embrace concepts of healthy denial and the power of the double way: the reality of death and dying together with promises of modern oncology. In summary it is less the issue of what to say, but how to support the process, offer advice and continuous, accountable support.
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ES 06.03 - Palliative Management of Dyspnea (ID 7607)
15:45 - 17:30 | Presenting Author(s): Keiko Tanaka
- Abstract
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[Introduction] Dyspnea is one of the most frequent, refractory and distressing symptoms in lung cancer patients. It is reported that dyspnea interferes will to live in terminally ill cancer patients. Palliation of respiratory symptoms is important to improve quality of life (QOL) of cancer patients and their families. [Definition of dyspnea] 'Dyspnea' is defined as 'a subjective experience of breathing discomfort', while 'respiratory failure' is defined objectively as 'pulmonary dysfunction with hypoxia and/or hypercapnia'. Dyspnea and respiratory failure are different entities, and it is shown that the severity of those do not always correlate with each other. [Impact of dyspnea] Dyspnea experience is derived from interactions among physiological, psychological, social, and environmental factors, and may include secondary physiological and behavioral responses. Dyspnea often triggers panic, fear, anxiety, depression, hopelessness, sense of loss of control to patients. Dyspnea is closely associated with fatigue, pain, and depression, and interfering with general activities, mood and enjoyment of life. Dyspnea at rest is also known to correlate with survival, identified as a predictor of poor prognosis in cancer patients. [Clinical Assessment of Dyspnea] As for the assessment of dyspnea, multi-disciplinary team approach and paying attention to patients' own words are important. The assessment should focused on the following three dimensions; 1) quantities (intensity), 2) qualities, 3) symptom impact or burden. Several appropriate scales in each dimensions will be shown in this session. [Management of Dyspnea] Objectives of dyspnea management are to reduce its frequency and severity, minimize its physical, psychological and spiritual distress, and maximize patients' function and QOL. To achieve these goals, the first step is to identify all the underlying causes, and when they are reversible and modifiable, to treat them with specific modalities accordingly. It is, therefore, important for oncologists to judge treatability, including adverse effects, and to estimate patients' prognosis accurately. This session will provide the outline of palliative management of dyspnea with focus on pharmacological and non-pharmacological means. [Pharmacological interventions] The Japanese Society for Palliative Medicine (JSPM) published 'Clinical guidelines for respiratory symptoms in cancer patients' in 2016. These guidelines are unique because they are more directly focused on 'dyspnea' management specifically, based on the formal development process for clinical guidelines. Some of the important recommendations will be introduced in this session. *Note: Strength of recommendation: 1 (strong) = recommended, 2 (weak) = suggested. Level of evidence: A (High), B (Moderate), C (Low), D (Very low) 1) Opioids Systemic morphine is recommended to be used (1B). Systemic oxycodone is suggested to be used, as alternative to morphine (2C), while systemic fentanyl is suggested not to be used (2C). Systemic codeine/dihydrocodeine is suggested to be used (2C). 2) Benzodiazepine anti-anxiety Benzodiazepine is suggested to be used in combination with opioid (2C), while it is suggested not to be used alone (2C). 3) Corticosteroid Systemic corticosteroid is suggested to be used in patients with lymphangitis carcinomatosa, superior vena cava syndrome and major airway obstruction (2D). It is, however, suggested not to be used routinely without consideration of dyspnea etiology (2D). [Non-Pharmacological interventions] The effectiveness of non-pharmacological interventions for dyspnea in advanced cancer and non-cancer (mostly chronic obstructive pulmonary disease) has been reported in Cochrane reviews. Interventions supported by good evidence include breathing training, walking aids, and exercise. Those with some evidence include handheld fan, follow-up programs by nurses and acupuncture/ acupressure. [Conclusion] It is difficult to conduct high-quality clinical research on symptom control in advanced cancer patients because of patients' vulnerability as well as the ethical conflict. More clinical researches of good designs need to be conducted in this field, so that standard palliative care may be delivered to all the cancer patients anytime and anywhere, helping them live their own lives with dignity. [References] 1) Chan K, Tse DMW and Sham MMK. Dyspnoea and other respiratory symptoms in palliative care. In: Cherny NI, Fallon MT, Kaasa S, Portenoy RK, Currow DC. Oxford Textbook of Palliative Medicine (5[th] ed). Oxford University Press, 421-434, 2015 2) Yamaguchi T, Goya S, Kohara H. et al. Treatment Recommendations for Respiratory Symptoms in Cancer Patients; Clinical Guideline from the Japanese Society for Palliative Medicine. J Palliat Medicine. 2016, 19(9): 925-935 3) Bausewein C, Booth S, Gysels M, and Higginson I. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database of Syst Rev. CD005623, 2008 4) Non-invasive interventions for improving well-being and quality of life in patients with lung cancer. Cochrane Database of Syst Rev. CD004282, 2011
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ES 06.04 - The Lung Cancer Patient, the Nurse and the Rehabilitation Opportunities in Denmark (ID 7608)
15:45 - 17:30 | Presenting Author(s): Marianne Cumberland
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Lung cancer is the most deadly cancer disease in Denmark, one out of four cancer deaths, is due to lung cancer. 4656 Danes are living with a lung cancer diagnosis in late 2015. There are 4700 new cases each year. This means that lung cancer is responsible for 7,8 % of all deaths in Denmark and 24 % of all cancer deaths.[1]Getting lung cancer has major personal consequences - and major consequences for society. There are rehabilitation services for Danish lung cancer patients, and it has a great potential for improvement. The purpose of lung cancer rehabilitation is to support and assist lung cancer sufferers and their relatives, dealing with the changes in everyday life – including at work – that the disease causes. A lung cancer patient in Denmark meets a nurse in many contexts. Nurses are a necessity for the lung cancer patient and rehabilitation in Denmark. I will present a small sample of the rehabilitation possibilities a lung cancer patient meets in Denmark. My focus is, nurse involvement and whether they have sufficient education for the task. Copenhagen Centre for Cancer and Health provides rehabilitation programs including physical activities, education, and discussion groups or sessions. The rehabilitation programs are for cancer patients living in the City of Copenhagen. A referral from the patient´s GP or hospital department is required in order to participate. There are similar centers in many other cities in Denmark. These centers provide good opportunities for lung cancer patients and rehabilitation. At the Health Care Centre, the lung cancer patient meets nurses.[2] “Well, you know – you have symptoms of something and you come here and tell the others about it and they say “I know just what you are talking about, that is how I´m feeling” – it´s a nice experience and makes me feel that I am all right” - Statement from a man with lung cancer, Copenhagen Centre for Cancer and Health The Danish Cancer Society is the largest disease-fighting organization in Denmark. The organization has more than 430,000 members. They have 3 main work areas in the fight against cancer: #prevention of cancer #giving advice to and supporting cancer patient and their relatives #cancer research. Via this organization, the lung cancer patient can talk to nurses and gets the opportunity to receive information, counseling, social networking and you can be anonymous – if you want to.[3] A Danish lung cancer patient can become a member of the Patient Association for Lung Cancer. It is a nationwide independent association for people with lung cancer and mesothelioma, and their families. You can stay up-to-date on lung cancer treatment, health policy, networking and you can also be a part of a community. You can also help put lung cancer on the agenda. There are 500 members in Denmark.[4] In order for the lung cancer patient's possibilities / conditions to improve, there are many projects in Denmark. The Vision Project - a multidisciplinary working group with professionals across the country and dealing with all aspects of the disease, from surgery to palliative care. Action areas are formulated and concrete initiatives made. In this context, there will be a particular focus on rehabilitation that can improve the life quality of lung cancer patients during and after treatment.[5] Social inequality in cancer rehabilitation - The University Hospital in Copenhagen and the Health Care Center in Copenhagen are developing a concept for motivational conversations offered to vulnerable patients. The hospital assesses the need for cancer rehabilitation to those expected to be at risk of saying no to a rehabilitations process. It is a nurse who coordinates the project.[6] Proluca (the value of Postoperative Rehabilitation of Operation for cancer) is a research project in which the effect of early training after surgery for lung cancer is evaluated. The project aims to investigate whether training shortly after surgery for lung cancer can lead to an improved performance in the post-operation phase. It is as a nurse who coordinates the project in the health care center in Copenhagen.[7] Good lung cancer care is related to nurse education. In Denmark the Bachelore’s degree programme in Nursing has a duration of 3 and a half years; you can also get an Advanced Cancer Nurse Education – this requires 1 and a half year of training.[8] Taking care of a lung cancer patient can often be complicated and requires nursing care at a high level. On a global scale, Denmark has a lot to offer lung cancer patients, but there is obviously still room for improvement, since this group of patients faces so many different challenges in their everyday life. And it takes well-educated nurses to meet the complex demands of lung cancer patients. [1] www.lungecancer.dk/ [2] www.kraeftcenter-kbh.dk/ [3] www.cancer.dk/international/ [4] www.lungekraeft.com/ [5] lungecancer.dk/documents/F1BFDA1D-EBFD-409A-A26A-15FF5385F00A.pdf [6] www.kraeftcenter-kbh.dk/projekter/social-ulighed [7] www.kraeftcenter-kbh.dk/projekter/proluca [8] www.dsr.dk/
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ES 06.05 - Approach to Malignant Pleural Effusions (ID 7867)
15:45 - 17:30 | Presenting Author(s): Peter Goldstraw
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The onset of an MPE usually indicates a significant reduction in prognosis, with a median life expectancy of 3 to 12 months from onset. MPE associated with breast cancer is usually associated with a better than average prognosis whilst lung cancer has the worst prognosis. Confirmation of malignancy and determination of the cell type may be established by increasingly invasive techniques; pleural aspiration cytology, facilitated by ultrasound guidance if the effusion is small or loculated, pleural biopsy, blind or image guided, thoracoscopy (usually now video-assisted) under local or general anaesthesia. Whilst it is reasonable to start with the least invasive procedure suitable in the circumstances, in patients who are reasonably fit it is important to avoid an escalating cascade of failed procedures, each with the risk of causing pleural adhesions and clot formation, making effective palliation more difficult. There is much to commend early acceptance of an approach which combines the best chance of a tissue diagnosis with the best chance of effective palliation. This decision will be influenced by an assessment of prognosis. Prognosis once an MPE has been confirmed is dependent upon the extent of metastatic disease and associated co-morbidity. In a surgically palliated population in-hospital and 30-day mortality was statistically related to blood albumen levels, being 0% and 0.98% in those with normal albumen levels and 6.8% and 19% in those with hypoalbumenaemia (p=0.001) (1). In a series of 278 patients referred to the Department of Thoracic Surgery at the Royal Brompton Hospital over a 72 month period 195 underwent thoracoscopic talc pleurodesis, 39 had a pleuro-peritoneal shunt inserted, 38 had pleurodesis through an intercostal drain, 29 had pleural biopsy alone and 9 were treated with long-term pleural drainage, a total of 310 surgical procedures. Overall median survival was 211 days post operatively. Survival was not significantly different for tumour type or method of palliation but was related to leucocytosis (p<0.0001), hypoxaemia (p=0.014) and hypoalbumenaemia (p0.0001) (2). The summative effect of these factors is shown in the table below. Table 1
How might this information be used to personalise treatment options in patients for whom effective systemic therapy does not exist. Those whose prognosis is judged to be less than 2 months (having all 3 adverse prognostic factors) palliation may be achieved by repeated pleural aspiration. If prognosis is judged to be greater than 2 months, and especially if the patient is in a poor general condition, adequate palliation could be achieved by the insertion of an indwelling pleural catheter under local anaesthesia. In fitter patients with an estimated survival greater than 6 months VATS insufflation of talc or the insertion of a pleuro-peritoneal shunt should be considered. The choice of talc or shunt will be dictated by the adequacy of lung expansion during positive pressure ventilation. In many respects these 2 techniques are complementary but having both of these techniques available at thoracoscopy allows affective long-term palliation to be achieved in 95% of patients (3). However pleuro-peritoneal shunts can be complicated by occlusion within 4 months in 15% of cases but spontaneous pleurodesis has usually been achieved by this time (4). Pleurectomy is rarely indicated in the palliation of MPE. Reference List (1) Pilling JE, Dusmet M, Ladas G, Goldstraw P. Predictors of early mortality and morbidity follwoing surgical palliation of malignant pleural effusion. Journal of Thoracic Oncology 2[8], s430. 2007. (2) Pilling JE, Dusmet ME, Ladas G, Goldstraw P. Prognostic Factors for Survival after Surgical Palliation of malignant Pleural Effusion. J Thorac Oncol 5, 1544-1550. 2010. (3) Petrou M, Kaplan D, Goldstraw P. The management of recurrent malignant pleural effusions: The complementary role of talc pleurodesis and pleuroperitoneal shunting. Cancer 75, 801-805. 1995. (4) Genc O, Petrou M, Ladas G, Goldstraw P. The long-term morbidity of pleuroperitoneal shunts in the management of recurrent malignant effusions. European Journal of Cardio-thoracic Surgery 18, 143-146. 2000.No of factors n Median survival (days) 95% CI p None 39 702 473-931 .00001 One or two 74 200 111-289 Three 23 42 23-61
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ES 06.06 - Dignity Conserving Therapy (ID 7609)
15:45 - 17:30 | Presenting Author(s): Natasha B Leighl
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Dignity has been defined as the “quality or state of being worthy, honored or esteemed”[1]. While dignity-conserving therapy is popularly defined as assisted suicide in the setting of terminal illness, it may also be considered as a larger goal of palliation and achieving a “good death”. Chochinov has defined 8 subthemes in the conservation of dignity at the end of life, including continuity of self, role preservation, maintenance of pride, hopefulness, autonomy/control, generativity/legacy, acceptance and resilience or fighting spirit [1]. Based on how patients and their caregivers define dignity, different interventions may be used to target or support physical and/or psychological distress, a patient’s level of independence, patient perspectives and interactions with others. Dignity Therapy as developed by Chochinov involves a brief therapy session, which may be delivered at the bedside, transcribed and shared with friends and/or family, to support the patient in his or her desire to live in the moment, maintain normalcy as best as possible and to seek spiritual comfort. More commonly, however, dignity conserving therapy refers to physician-assisted death. This has been legalized in at least 8 countries, including the Netherlands, Belgium, Switzerland, Germany, Luxembourg, Columbia, Canada and 6 states in the USA [2]. In Canada, recent legislation decriminalized medically assisted death. Li et al have reported the University Health Network (UHN, Toronto, Canada) experience of establishing a hospital-based physician-assisted program of medical assistance in dying (MAiD) [2]. Three teams were developed including a clinical team, an assessment team and an intervention team. The clinical team is involved in the usual care of the patient, including nurses, allied health professionals, consulting physicians and the physician most responsible for the patient’s care. Upon patient request, the most responsible physician refers the patient to the hospital MAiD program. At this point, full palliative consultation and support is offered if not already in place. An assessment team of two physicians, with expertise in the assessment of prognosis, patient suffering and capacity or ability to provide informed consent, evaluate the patient (MAiD medical specialist, palliative care physician, psychiatrist). To be eligible for MAiD through the UHN program, a person is required to have health care services covered through the Canadian public healthcare system, to be at least 18 years old and capable of making his or her own health care decisions, and to have a grievous and irremediable medical condition. This includes a serious and incurable illness, disease or disability, to be in an advanced state of irreversible decline in capability, such that the illness or state of decline causes enduring physical or psychological suffering that is intolerable to the person and cannot be relieved by means that the person considers acceptable. Natural death must be reasonably foreseeable based on medical circumstances, the request for medical assistance in dying must be voluntary and the person is required to voluntarily provide informed consent after being informed of alternative means to relieve suffering including palliative care. Disagreements between assessors are resolved through discussion involving leaders of the MAiD program. Once deemed eligible for MAiD, the patient completes a request form for the procedures, followed by a mandatory reflection period of at least 10 days unless death or loss of capacity is imminent. The intervention team, comprised of physicians and/or a nurse practitioner, conducts a final evaluation of the person and ensures they retain capacity before obtaining final informed consent and providing the intervention. Psychosocial professionals are available to provide support to family as needed and to conduct debriefing sessions for staff before and after the intervention. A multidisciplinary quality committee provides oversite and reports to the hospital Medical Advisory Committee. Since the program’s inception in March 2016, 111 inquiries have been received, 39% information-seeking only [Dr. Madeline Li, personal communication]. Of these, 71% have a cancer diagnosis, commonly lung cancer. Other diagnoses include neurologic disorders such as ALS (14%), cardio-respiratory chronic disease including CHF, COPD, and interstitial lung disease (9%). Assessments have been conducted for 41 individuals, 7 were found ineligible, 35 have been approved and 24 have completed interventions. Many of these were already receiving specialty palliative care services. The most common reason for not proceeding with the intervention was clinical decline or loss of capacity. Those that received MAiD cited loss of autonomy as the main reason behind their request [2]. Preserving dignity in the face of incurable lung cancer remains a challenge for patients, families and their health care providers. An individualized approach and involving a multidisciplinary support team including palliative care remains key. References: 1. Chochinov HM. Dignity-conserving care – a new model for palliative care. JAMA 2002;282:2253-60. 2. Li M, Watt S, Escaf M, Garedam M, Heesters A, O’Leary G, Rodin G. Medical assistance in dying – implementing a hospital-based program in Canada. New Engl J Med 2017;376:2082-8.
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MS 21 - Being Mortal: Learning from ZEN (ID 543)
- Event: WCLC 2017
- Type: Mini Symposium
- Track: Nursing/Palliative Care/Ethics
- Presentations: 3
- Moderators:M. Cummins, K. Kubota
- Coordinates: 10/18/2017, 11:00 - 12:30, Room 316
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MS 21.01 - Spirituality in Asia (ID 7742)
11:00 - 12:30 | Presenting Author(s): Nanrei Yokota
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Human being is mortal. However, people don’t want to think about death and prefer to live without considering it. Death has actually been hated in society. In general, death is thought as LOSS. Indeed, healthy body, time as a gift of life, society meaning, several experience, all achievements including money, house, family, friends, status and honor are LOST at death. In medicine which prolongation of life has been a primary purpose, death is considered as defeat. However, if we consider death as loss or defeat, theoretically goal of life itself would be futile definitely toward loss and defeat. “Human beings, who are all mortal and their own deaths are inevitable, seriously think, worry, are embarrassed and hate when they encounter death of other person. They think that death is not appropriate for them.” Gautama Buddha who was born in India 5[th] century BC thought as above, tried to find the cause of death throes and search for how to deal with terror of death throes. Teaching of Buddha from India was introduced to China in where that was developed as ZEN. Teaching of ZEN has been growing calls in the world. ZEN stresses the importance of staring DEATH. In other words, that is to learn how to live responding enough to DEATH as inquiry. It is never to pursue a world after death, just to actively find meaning of life through staring death. We would like to learn how to live while reacting DEATH that tends to evade in modern society, through historical teaching of ZEN. アジアにおける精神性 ー死から勉強するー 人は誰しも死を逃れることはできない。それにも拘わらず、人は死を見つめようとはしていない。できれば死を忘れて暮らしたいと思っている。実に死は、現代社会においても忌み嫌われていると言えよう。 一般に、死は「喪失」であると思われている。たしかに健康な肉体も、人生において与えられた時間も、社会における存在意義も、さまざまな体験も、手に入れたものすべて、貯めたお金や家、家族、友人や恋人、地位名誉などを「喪失」してしまう。 また生命を一日でも長く生かすことを考える医療において、死は「敗北」と認識されている。しかし、もしも死が「喪失」や「敗北」でしかないとしたならば、人生は「喪失」と「敗北」に向かって確実に進んでゆく空しいものとなるであろう。 「愚かな人間は、自分が死ぬものであって、また死を免れないのに、他人が死んだのを見ると、考え込んでしまい、悩み、恥じ、嫌悪している。じつは自分もまた死ぬものであって、死を免れないのに、他人が死んだのを見ては、考えこんで、悩み、恥じ、嫌悪する。このようなことは自分にはふさわしくないであろう」。 このように考えて、死の苦しみの原因を求め、死の恐怖や苦しみから如何に逃れることができるか、その道を求めたのが、紀元前五世紀にインドに生まれた、ゴータマ・ブッダであった。 ブッダの教えは、インドから中国に伝わり、中国においては「禅」という道に発展していった。「禅」の教えは、今日においても広く世界で求められている。 「禅」においては、「死」を見つめることを大切に説いている。死を問いとして、それに応えるに足る生き方を学んでいると言ってよい。それは決して死後の世界の探求ではない。あくまでも死を見つめて、積極的に生の意味を見いだすことを目指している。 現代においても、ともすれば忌避されがちな「死」について、古来の「禅」の教えを参照しつつ、「死」をどう受け止めて生きるかを学んでみたい。
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MS 21.02 - Meditation: From the Temples to the Clinic (ID 7743)
11:00 - 12:30 | Presenting Author(s): Alejandro Chaoul
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The Buddhist traditions are rich in meditation practices, utilizing them for their spiritual development as a tool towards enlightenment, and also for physical, emotional and mental wellbeing. For centuries, these practices were only for a select group of yogis in caves or nuns and monks in monasteries, but globalization and other movements of the Twentieth century helped bring these practices to a wider population, including people with illnesses such as cancer. This presentation will focus on how some of the philosophical Buddhist concepts, like the understanding of our own mortality or impermanence, and some of the meditation practices had been applied in a non-religious way as part of the offerings for cancer patients and their caregivers within contemporary western clinical settings in our Integrative Medicine Center at MD Anderson Cancer Center in Houston. George Engel’s seminal 1977 paper in Science provides the background for a bio-psycho-social approach at our Integrative Medicine Center that is now part of the Department of Palliative, Rehabilitation and Integrative Medicine at MD Anderson. In other words, a healing focused not just on the physical (i.e., bio) but also on the psycho-social-spiritual aspects of the person, which sometimes seems to be forgotten in conventional allopathic medicine. The bio-psycho-social approach is very much in accordance to the Buddhist approach, and palliative care and integrative medicine are optimal settings. I will share how we bring these into our group classes as well as individual clinic sessions, where people with different kinds of cancers, including lung cancer, participate. In particular I will address cases of people with lung cancer, and issues of stigma, of facing one’s own mortality, and how the concepts and practices that stem from a Buddhist perspective can have positive impact in their quality of life, overall survival, and better relationship to others, in particular their family members and caregivers. In addition I will share the results of a single arm clinical study of Tibetan Yoga (meditation and simple movements) for people with lung cancer and their caregivers that was held at MD Anderson Cancer Center in collaboration with the Ligmincha Texas Center for the Tibetan Meditative and Healing Arts. The purpose of this study was to establish feasibility and preliminary efficacy of a mind-body intervention in lung cancer patients and caregivers. Patients with stage I-III non-small cell lung cancer undergoing radiotherapy and their family caregiver participated in a 15-session Tibetan Yoga (TY) program that included breathing exercises, guided visualizations, and gentle movements. This single-arm trial assessed pre/post intervention levels of mental health (CESD; BSI), fatigue (BFI), sleep disturbances (PSQI), spiritual well-being (FACT-SP) and overall QOL (SF-36). Patients (mean age: 73 yrs., 62% male, 85% stage III) and caregivers (mean age: 65 yrs., 73% female, 85% spouses) completed a mean of 12 TY sessions (range: 6-15) and 95.5% of them rated the program as useful or very useful. Paired t-tests revealed a significant increase in spiritual well-being (P=.03; d=1.12) for patients and decrease in fatigue (P=.03; d=.87) and anxiety (P=.04; d=.91) for caregivers. This first couple-based Tibetan yoga program appears to be a safe, feasible, acceptable and subjectively useful supportive care strategy for patients and their caregivers. Based on these promising preliminary findings regarding treatment gains, the next step is to conduct a randomized controlled pilot trial. Furthermore, based on this and other Tibetan meditation and Tibetan yoga studies with other cancer populations (namely, lymphoma and women with breast cancer), we have incorporated this as a new class of Tibetan meditation and movement as part of our free offerings for people with cancer and their caregivers in our Integrative Medicine Center.
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MS 21.03 - Self-Care: "Provider, Heal Thyself" (ID 7744)
11:00 - 12:30 | Presenting Author(s): Maria Ftanou
- Abstract
- Presentation
Abstract:
This paper discusses the prevalence of burnout in oncology settings and strategies that can be implemented at both an individual and organizational level to maintain and create a healthy workforce. Background Lung cancer is the leading cause of death by cancer for both men and women worldwide. Most lung cancers are diagnosed at advanced stage and approximately 16% of lung cancer patients will be alive five years post-diagnosis [1]. Working in lung cancer can be gratifying and very rewarding; however it requires high levels of emotional engagement. Oncology professionals work intensively with patients, they provide sophisticated treatments, emotional support, and comfort to patients and their family across the cancer trajectory [2]. Burnout, which refers to feeling emotionally and physically exhausted is common in oncology settings. In a random sample of 1000 US oncologists, 56% experienced burnout at some point in their career [3]. In an Australian sample, 33% of staff with direct patient contact and 27% of staff with non-direct patient contact displayed high levels of emotional exhaustion [4]. Oncology staff who are younger, female, isolated and who work longer hours are more likely to experience burnout [5]. Predictors of stress and burnout include increased work demands, staff shortages, lack of communication training, lack of control or autonomy and dissatisfaction with leave arrangements [6]. Burnout has serious consequences for oncology professionals including elevated rates of mental and physical health concerns, suicidal ideation, difficulties sleeping, frequent bouts of illness, and addiction, intimacy and relationships problems. As a result, patient care is often compromised due to increased errors, turnover and absenteeism and reduced empathetic care. Assessment and strategies to combat burnout A number of tools can assist in better understanding levels of burnout in oncology staff. The most frequently used tool to determine rates of burnout is the Maslach Burnout Inventory (MBI-HSS). The MBI-HSS is a 22-item self-report questionnaire. It measures three distinct dimensions of burnout: (1) emotional exhaustion (EE) characterised by feeling emotionally overextended; (2) depersonalisation, which includes feeling disconnected, detached; and (3) personal accomplishment, the negative judgements one makes about their career and levels of success [7]. Assessing burnout can lead to early identification and interventions for stress management. To reduce burnout, both individual and organisational factors need to be implemented. Developing personal resilience is essential for combating stress and burnout. A number of individual strategies that can assist in developing and maintaining resilience, include creating a work-life balance and adopting self-care and relaxation routines [8]. At an organisational level, coping can be enhanced by the provision of supports such as supervision, professional development opportunities, and the development of work schedules that promote team engagement and address staff shortages and adequate leave arrangements. Furthermore, formal education on how to better manage stress, including mindfulness-based stress reduction, cognitive behaviour therapy and communication training interventions can improve stress management and staff wellbeing [8]. Conclusion Working in oncology can be very rewarding, but can also be emotionally and physically exhausting. The workforce is the most important resource in any organization and burnout needs to be addressed both at the individual and organisational level. At an individual level, oncology professionals need to acknowledge stress, create a work-life balance and adopt self-care and relaxation practices. To maintain a healthy workforce, organizations need to ensure adequate staffing, leave arrangements and provide access to appropriate training, professional and emotional supports. References 1. Cancer Australia. Lung cancer statistics: Australian Govenrment; 2017 2. Diggens J, Chesson T. Do factors of emotion-focussed patient care and communication impact job stress, satisfaction and burnout in radiation therapists? Journal of Radiotherapy in Practice 2014;13(1):4-17. doi: 10.1017/S146039691300006X 3. Whippen DA, Canellos GP. Burnout syndrome in the practice of oncology: results of a random survey of 1,000 oncologists. Journal Of Clinical Oncology: Official Journal Of The American Society Of Clinical Oncology 1991;9(10):1916-20. 4. Girgis A, Hansen V, Goldstein D. Are Australian oncology health professionals burning out? A view from the trenches. European Journal Of Cancer (Oxford, England: 1990) 2009;45(3):393-99. doi: 10.1016/j.ejca.2008.09.029 5. Kamal AH, Bull JH, Wolf SP, et al. Prevalence and Predictors of Burnout Among Hospice and Palliative Care Clinicians in the U.S. Journal Of Pain And Symptom Management 2016;51(4):690-96. doi: 10.1016/j.jpainsymman.2015.10.020 6. Isikhan V, Comez T, Danis MZ. Job stress and coping strategies in health care professionals working with cancer patients. European Journal Of Oncology Nursing: The Official Journal Of European Oncology Nursing Society 2004;8(3):234-44. 7. Maslach C, Jackson S E, P. LM. Maslach Burnout Inventory Manual, 3rd edition. Mountain View, CA: CPP Inc, 1 1996:1–52. 8. Gillman L, Adams J, Kovac R, et al. Strategies to promote coping and resilience in oncology and palliative care nurses caring for adult patients with malignancy: a comprehensive systematic review. JBI Database Of Systematic Reviews And Implementation Reports 2015;13(5):131-204. doi: 10.11124/jbisrir-2015-1898
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