Psychosocial Aspects of Cancer

d l n i

Oncology Social Work in

Palliative Care

W ith regard to cancer, two facts are clear: cancer is the second leading cause of death in the USA,1 and the consequences of unmet psychosocial needs for those with terminal cancer have

evastating consequences for quality of life experienced.2 The medical iterature on this topic recognizes the importance of addressing these eeds and recommends that the education and training for oncologists nclude skills necessary for assessing and handling psychosocial issues.3-5

This body of literature, however, does not address the importance of oncologists understanding the role of the oncology social worker, whose training and experience is focused exclusively on insuring that the psycho- social needs of individuals diagnosed with cancer are addressed. The oncology social worker is an important resource for oncologists, whose time allotted to patients is often focused out of necessity on medical issues and less on psychosocial needs. As the number of palliative care teams continues to grow, oncologists and oncology social workers will increas- ingly find themselves working together. If the team is to address holistically the needs of individuals with cancer, capitalizing on the social worker’s expertise and skills will be crucial.

This article seeks to heighten the awareness and understanding of oncology social work, as well as the contribution this profession can make to oncologists and other members of the palliative care team. First, the reported psychosocial needs of cancer patients and their families are discussed. Next, the skills, knowledge, and theoretical approaches a social worker uses to meet those needs are detailed. Finally, the relationship between oncology social workers and the oncologists with whom they work daily is addressed. It is hoped that the information provided in this article will result in an increased recognition of what oncology social work has to offer individuals grappling with the devastating effects of cancer, and to the oncologists who work to provide these individuals with

quality care.

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sychosocial Needs of Patients Diagnosed with erminal Cancer Much has been written about the psychosocial needs of individuals iagnosed with terminal diseases, many of whom had a cancer diagnosis. ne line of research that has contributed a great deal of insight into the sychosocial needs of individuals at the end of life is the study of the actors that motivate individuals diagnosed with cancer and other terminal llnesses to consider a hastened death. Research has been conducted both retrospectively with health care rofessionals and family members and prospectively with terminally ill ndividuals. In regard to the retrospective reporting, individuals who ought a hastened death were motivated by psychosocial factors, such as ack of enjoyment in life,6 loss of control,6,7 fear of future pain,6,8 loss of eaning in life,9 feelings of being a burden,6,9 and loss of dignity6,9 and

utonomy.6 Prospectively, terminally ill individuals, many of whom were iagnosed with cancer, reported the same psychosocial factors as those eported retrospectively, as well as others. In regard to social support, ndividuals reported having few social supports,10,11 a lower quality of ocial support,10,12,13 conflictual social support,11 low satisfaction with ocial support,14 and a lack of social support.15 In addition to social upport needs, individuals also reported anxiety,12 depression,12,13 a lack f enjoyment in life, feelings of being a burden and useless,16 and a lack f control.16

Studies focused solely on cancer patients have also found psychosocial eeds to be prevalent. In a large study of oncologists, 72% reported that heir patients experienced psychosocial distress over issues that included ogistics, coping with their illness and treatment, and addressing the oncerns of their partner and children.17 In a qualitative study, researchers nterviewed young adults diagnosed with cancer, who reported experi- nces with emotional distress and a lack of social support.18 Researchers onducted a review of studies on depression and cancer and discovered vidence that depression can make coping with cancer more difficult, and t can negatively affect immune functions.19 A major study of 4500 atients diagnosed with cancer found that 35% reported experiencing sychological distress, and this distress was greatest for respondents hose cancer had a poor prognosis.20 In another study, fatigue, a key

ymptom of cancer, was found to be correlated with depression.21 Finally, n a systematic review of 94 studies conducted on the prevalence of unmet sychosocial needs, such needs were determined to be present both during

nd after cancer treatment.22

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ypes and Times In studies of individuals diagnosed with cancer, evidence has been

ound concerning the psychosocial distress associated with a particular uncture in the cancer journey or with a particular type of cancer. In a ualitative study of 96 terminally ill elders, 15 reported 4 critical events n their dying process that resulted in psychosocial suffering: two-thirds f these individuals were diagnosed with cancer.23 These 4 events ncluded being given a terminal diagnosis in what was perceived of as an nsensitive and uncaring manner; suffering unbearable and untreated hysical pain; not addressing the feelings individuals had about having to eceive chemotherapy or radiation treatment; and receiving care in a tressful environment. Concerning types of cancer, researchers have ound that persons with lung cancer had a significantly high risk of xperiencing psychosocial problems, such as depression and anxiety, fter both diagnosis and treatment.24 Forty-seven percent of 236 newly iagnosed breast cancer patients were determined to have experienced igh levels of distress resulting from worry, nervousness, and depres- ion.25

Knowledge of the types of psychosocial issues experienced by individ- als diagnosed with cancer, as well as particular times of vulnerability nd cancers that may put people at higher risk of psychological distress, s key to determining how best to intervene and address such issues. onsistently, authors of these studies point out the need for psychological

creening and early intervention,16,20,25 particularly at the time of iagnosis.24 Researchers also agree on the need for more research to efine current assessment procedures and develop interventions that ddress more effectively emotional distress in individuals diagnosed with ancer. Both assessment of psychosocial issues and intervention are the ey areas of expertise possessed by trained oncology social workers.

ncology Social Work The main providers of psychosocial services in cancer centers and ealth care settings in the community are oncology social workers.26

hese professionals possess significant knowledge of cancer, the resulting sychosocial issues, and the intervention strategies for addressing such ssues. The training and skills provided to social workers through their graduate

ducation makes them uniquely suited to work with cancer patients. First, he social work profession is distinctive in its use of a person-in-

nvironment approach, which takes note of the reciprocal relationship

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etween the person and his or her environment, and how he or she is nfluenced by interactions with the environment. Social workers view ndividuals as being dynamically involved with systems in the environ- ent that include family, friends, work, social service organizations,

eligions, health care, educational, government, and culture, to name a ew. The person in his or her environment is a whole in which the person nd the situation are both cause and effect in a complex set of elationships. The social worker does not assess the person and then his r her environment; rather, social workers advocate treatment of the erson within the context of his or her environment. When seeking to ddress the psychosocial needs of a client, the social worker directs the ntervention at improving the interactions between the person and his or er environment. In regard to oncology social workers, this unique approach provides the

ocial worker with assessment skills that “reflect a patient’s place in a roader environment of relationships, resources, and copying history vailable to him as he struggles to integrate his prognosis and meet the emands of treatment.”27 The resulting assessment “communicates that he social worker is interested in the patient as a person who has a valued ife beyond cancer treatment.”27 Furthermore, it assists in creating and mplementing interventions aimed at concurrently strengthening the lient’s adaptation to being diagnosed with cancer, as well as strength- ning the environment’s responsiveness to that individual’s needs.26

The second aspect of social work training that prepares oncology ocial workers for their work is the practice of defining the unit of care s both the client and his or her family. This aspect evolves from the erson-in-environment approach and, as has been found by research- rs, recognizes that family members of cancer patients are also mpacted by a cancer diagnosis, particularly when the cancer is dvanced and incurable. Research has shown that providing care and upport to a loved one at the end of life can be both emotionally and hysically challenging; therefore, recognizing and being sensitive to amily members’ needs are crucial.28

Finally, advocacy and resource acquisition are also skills possessed by ocial workers, which relate directly to the work performed by those orking with individuals diagnosed with cancer. Individuals with ad- anced cancer may lack the strength necessary to advocate for their references concerning care and treatment provided. The oncology social orker can step in and serve as an advocate for the client with family embers and/or medical professionals, as well as advocate for family

embers’ needs. In addition, advocating for the client unit also requires

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hat the social worker be skilled at acquiring the resources requested and eeded. Again, the person-in-environment approach comes into play in hat the social worker’s initial assessment of the client includes the nvironment in which he or she lives. Recognition of family, neighbor- ood, community, state, and federal systems provides the social worker ith knowledge of available resources and how to acquire them.

elationships with Oncologists on a Palliative are Team The growth of palliative care teams in hospitals has reportedly increased

rom 600� teams in the year 2000 to approximately 1500 in 2011, a rowth of about 138%.29 Data remain limited as to the effect of palliative are teams but some studies have found that family satisfaction is ncreased30; the benefit is greatest for home care,31 and experiencing egular oncological care along with the early involvement of the palliative are team can lead to increased quality of life and survival.4 Evidence is vailable, however, showing that nonmedical team members experience hallenges concerning communication and collaboration with team mem- ers. In particular, the nonmedical team members have been shown to xpress some dissonance because of the dominance of physicians around ecision-making.32 The discord experienced between medical and non- edical team members may be due in part to a lack of education

oncerning the expertise and skills that each professional brings to the eam. Education on the part of all disciplines should include such nformation, as well as more training on working effectively as a team. In regard to the relationship between physicians and social workers, the

raining provided to each differs. Physicians are trained to be team leaders nd to serve as the “final authority for all decisions,” a trait that is nderlined by the life and death decisions they make, as well as the ossibility of malpractice suits.33 By contrast, social workers are trained o “collaborate and build consensus on teams and that they are experts in ommunications and counseling” such that decision-making is to be hared.”33 In addition to the differences in their training, personality, level f self-confidence, and control needs can also present as challenges. Recognition of differences and strengths may serve to contribute to a ore collaborative relationship between oncologists and oncology social orkers. It is hoped that articles such as this one will increase the

wareness of the role that oncology social workers can play in meeting

he psychosocial needs of individuals diagnosed with cancer.

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onclusions The training and education provided to oncologists often focus on how

o initiate discussions of patients’ psychosocial issues, as well as how best o address them. Research continues to show, however, that although ncologists recognize the importance of doing so, a large proportion of hem do not follow through in practice.5 Just as the oncology social orker’s expertise lies with assessing and developing interventions to

ddress the psychosocial needs of cancer patients, the expertise of the ncologist is to address the medical needs of these patients. Working ogether on interdisciplinary palliative care teams, oncologists and oncol- gy social workers can each bring their expertise to the table and insure hat cancer patients and their families receive the quality holistic care they o richly deserve.

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