Linda McLellan

Utility of the psychosocial assessment of candidates for transplantation (PACT) scale in allogeneic BMT

The psychosocial assessment of candidates for transplantation (PACT) scale was completed before the transplant on 120 patients who underwent allogeneic transplant from November 2003 to June 2007. The PACT has eight subscales, each rated on a 5-point scale, and an initial and final rating independently based on the raters overall impressions of the candidates acceptability for transplant. This exploratory study assessed the clinical utility of the PACT scale for psychosocial screening in allogeneic BMT. Associations of the PACT subscales and the final rating with sixteen post transplant medical outcomes were examined using the Jonchkheere–Terpstra test, the Cochran–Armitage test or the Cox proportional hazards analysis. Significant relationships (P⩽0.05) between PACT subscales and medical outcomes are as follows: better compliance with medications and medical advice associates with lower in-hospital mortality, shorter length of stay and readmission duration, and faster neutrophil and platelet engraftment; better scores on drug/alcohol use associates with faster platelet engraftment; better scores on family/support system availability and on relevant knowledge and receptiveness to education associates with decreased risk of mortality. The final rating score and medical outcomes are not significantly related; however, study findings underscore the prognostic value of the PACT subscales and the potential utility for screening of BMT candidates.

Validating the positive impact of in-hospital lay care-partner support on patient survival in allogeneic BMT: a prospective study

This prospective study validates the finding from retrospective research that having an inpatient lay care-partner (CP) is associated with better survival following allogeneic BMT. Compared with patients without a CP (n=76), patients with a CP (n=88) have significantly better OS (P=0.017) and relapse-free survival (RFS) (P=0.020). Four-year and median survivals were 42% and 36 months among patients with CPs, compared with 26% and 10 months among those without CPs. Four-year survival and median RFS were 39% and 25 months among those with CPs, compared with 23% and 7 months among those without CPs. Further, better survival and RFS were associated with CP visit duration of >3 h per day (P=0.005 and P=0.007, respectively) and with CP frequency of visits >75% of inpatient days (P=0.004 and P=0.010, respectively). A CP support program should encourage not only presence of a CP but also duration and frequency of CP visits associated with better patient survival.

Translating Psychosocial Insight into Ethical Discussions Supportive of Families in End-of-Life Decision-Making

ABSTRACT A large number of Americans would rather rely on family and friends more than their physicians about end-of-life care and decisions. Moving beyond traditional clinical ethics and its dyadic focus on the physician-patient relationship, this article presents an approach to ethical decision-making at the end of life that is more inclusive of the patients family and has the potential to advance social work practice in end-of-life care. Initial attention is given to how psychosocial and bioethical perspectives and practices interact to shape understanding of moral issues in end-of-life decisions. Morally relevant principles are then adapted from contextual therapy as being useful for including more of a family focus and viewing ethical decision-making at the end of life as a family process. Specifically, focus is on exploring the ethical dynamics of family systems that impact the decision-making process and translating psychosocial insight into ethical discussions that are supportive of families. The case of a patient with sudden and unexpected brain death and without advance directives demonstrates one familys unresolved grief and illustrates how its members were helped to reason morally about end-of-life choices. Contributions of a social worker and bioethicist are illustrated.

Allogeneic BMT and patient eligibility based on psychosocial criteria: a survey of BMT professionals

BMT professionals were compared regarding their willingness to proceed with allogeneic BMT given select psychosocial issues. A questionnaire was sent to 660 physician members of ASBMT, 92 social work members of BMT Special Interest Group, Association of Oncology Social Work, and 626 nurse members of BMT Special Interest Group, Oncology Nursing Society; 597 responded with a response rate of 43.5%. Items included background information, followed by 17 case vignettes; each represented a different psychosocial issue to which respondents indicated whether or not they would recommend proceeding with allogeneic BMT. In every vignette, at least 10% of respondents indicated they would not proceed. In six vignettes, at least 64% indicated do not proceed: suicidal ideation (86.8%), uses addictive illicit drugs (81.7%), history of noncompliance (80.5%), no lay caregiver (69.3%), alcoholic (64.8%), and mild dementia/Alzheimers (64.4%). In 10 vignettes, at least 73% indicated proceed. On four vignettes, professional subgroups differed in their recommendation on whether or not to proceed with allogeneic BMT. Qualitative data suggest that this decision is contingent on the perceived acuity, severity, and currency of the psychosocial issue, patient ability to comply with treatment given the issue, and its manageability as a risk factor for treatment related vulnerability and outcomes.

Ethical reasoning about patient eligibility in allogeneic BMT based on psychosocial criteria

Chairpersons of the hospital ethics committees (HECs) and BMT clinicians were compared with regard to their willingness to proceed with allogeneic BMT given select psychosocial risk factors. A self-administered questionnaire was sent to 62 HEC chairpersons at hospitals with an accredited BMT program; the response rate was 37%. Items included background information, followed by six case vignettes from a 2006 national survey on which BMT physicians, nurses and social workers agreed not to proceed with allogeneic BMT on the basis of the following risk factors: suicidal ideation; use of addictive, illicit drugs; history of non-compliance; absence of a caregiver; alcoholism; and mild dementia from early onset of Alzheimers disease. Opinions regarding transplant differed in one case only, in a patient with mild dementia; 27% of HEC chairpersons recommended not proceeding with BMT, which was significantly lower than that of nurses (68%, P<0.001), physicians (63.5%, P<0.001) and social workers (51.9%, P=0.05). Qualitative data show patterns of informal reasoning, linking transplant decisions to patients responsibility for their psychosocial risk factor(s), as well as to medical benefit and outcome.

Quality of life and outcomes in patients⩾60 years of age after allogeneic hematopoietic cell transplantation.

Hematopoietic cell transplantation (HCT) has become an established standard of care for many older patients with hematologic malignancies. The effect of transplantation on the quality of life (QOL) of older patients, however, has not been well studied. We thus analyzed QOL in patients ⩾60 undergoing an allogeneic HCT compared with patients <60 years. Prospective psychometric instruments were administered to 351 patients who underwent HCT from 2003 to 2010. Psychometric data were assessed longitudinally by validated questionnaires: Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT), Coping Inventory and the Profile of Mood State-Short Form. Patients ⩾60 reported better social (P=0.006) and functional well-being (P=0.05) with FACT assessment, and had better total scores, (P=0.043) across all time points. When adjusted for baseline QOL scores as a covariate, social well-being remained significantly better, whereas the other scores became non-significant. With a median follow-up of 49 months, there were no significant differences in OS, relapse-free survival, relapse or chronic GVHD. This study provides further evidence that advanced age should not be a barrier in the decision to pursue allogeneic HCT. Older patients achieved comparable QOL when compared with younger patients.

Cognition and the cancer experience. Clinical implications.

Objectives: The authors demonstrate the application of cognitive therapy in oncology care by presenting a brief review of theory and relevant case studies. Materials and methods: In light of the life and death nature of the fears evoked by cancer, it is important for the oncology clinician to recognize the role that cognition plays in patient responses to the diagnosis and treatment of cancer. After presentation of a theory base that creatively links cognition and the cancer experience, key cognitive concepts are defined and discussed. Case material illustrates the application of these concepts and how oncology clinicians can use select interventions adapted from the brief mental health treatment modality of cognitive therapy to promote adjustment to cancer. Results: Patient and family views about cancer have emotional and behavioral consequences, influence ability to cope with diagnosis and treatment, and serve to focus clinical intervention. Cognitive interventions can help patients and families think about cancer in objective, adaptive ways. Focusing on perceptions and questions of meaning, clinicians can be effective using cognitive lines of questioning that expand patient stories and elicit beliefs about cause, control, and responsibility for their cancer. Conclusions: Cognitive interventions are brief and solution-focused interventions that acknowledge and build on generalist interviewing skills common to each discipline. As such, they are particularly useful in physical health settings where work is fast paced and clinicians are faced with the challenge of dealing in a collaborative manner with patient and family coping responses as they apply to the medical problem and care plan.

Prognostic significance of pre-transplant quality of life in allogeneic hematopoietic cell transplantation recipients

Quality of life (QOL) is an important outcome for hematopoietic cell transplantation (HCT) recipients. Whether pre-HCT QOL adds prognostic information to patient and disease related risk factors has not been well described. We investigated the association of pre-HCT QOL with relapse, non-relapse mortality (NRM), and overall mortality after allogeneic HCT. From 2003 to 2012, the Functional Assessment of Cancer Therapy-Bone Marrow Transplant Scale instrument was administered before transplantation to 409 first allogeneic HCT recipients. We examined the association of the three outcomes with (1) individual QOL domains, (2) trial outcome index (TOI) and (3) total score. In multivariable models with individual domains, functional well-being (hazard ratio (HR) 0.95, P=0.025) and additional concerns (HR 1.39, P=0.002) were associated with reduced risk of relapse, no domain was associated with NRM, and better physical well-being was associated with reduced risk of overall mortality (HR 0.97, P=0.04). TOI was not associated with relapse or NRM but was associated with reduced risk of overall mortality (HR 0.93, P=0.05). Total score was not associated with any of the three outcomes. HCT-comorbidity index score was prognostic for greater risk of relapse and mortality but not NRM. QOL assessments, particularly physical functioning and functional well-being, may provide independent prognostic information beyond standard clinical measures in allogeneic HCT recipients.

Music Therapy for Symptom Management After Autologous Stem Cell Transplantation: Results From a Randomized Study

High-dose chemotherapy followed by autologous stem cell transplantation (ASCT) is frequently performed in patients with hematologic malignancies. ASCT can result in significant nausea, pain, and discomfort. Supportive care has improved, and pharmacologic therapies are frequently used, but with limitations. Music has been demonstrated to improve nausea and pain in patients undergoing chemotherapy, but little data are available regarding the effects of music therapy in the transplantation setting. In a prospective study, patients with lymphoma or multiple myeloma undergoing ASCT were randomized to receive either interactive music therapy with a board-certified music therapist or no music therapy. The music therapy arm received 2 music therapy sessions on days +1 and +5. Primary outcomes were perception of pain and nausea measured on a visual analog scale. Secondary outcomes were narcotic pain medication use from day -1 to day +5 and impact of ASCT on patient mood as assessed by Profile of Mood States (POMS) on day +5. Eighty-two patients were enrolled, with 37 in the music therapy arm and 45 in the no music therapy arm. Patients who received MT had slightly increased nausea by day +7 compared with the no music therapy patients. The music therapy and no music therapy patients had similar pain scores; however, the patients who received music therapy used significantly less narcotic pain medication (median, 24 mg versus 73 mg; P = .038). Music therapy may be a viable nonpharmacologic method of pain management for patients undergoing ASCT; the music therapy patients required significantly fewer morphine equivalent doses compared with the no music therapy patients. Additional research is needed to better understand the effects of music therapy on patient-perceived symptoms, such as pain and nausea.