Behavioral Health Oncology Service: Building an Integrative Hybrid Bio-Medical, Psycho-Social, Spiritual-Existential Cancer-Care Model to Meet the Growing Needs of the 21 st Century Cancer Patient Shannon R. Poppito, Ph.D. Clinical Psychologist Psycho-Oncologist Behavioral Health Oncology Service Baylor University Medical Center Baylor Sammons Cancer Center, Dallas TX Nothing to disclose Financial Disclosure Learning Objectives To identify new Behavioral Health Oncology Consultation Service as an example of successfully building an integrative hybrid biopsycho-spiritual supportive cancer care model To Identify the multi-faceted bio-medical, psycho-social, spiritualexistential needs of cancer patients To identify ways of promoting an integrative supportive care model to effectively address, treat and meet the growing needs of cancer patients
Behavioral Health Oncology (BHOPE) Service: Baylor Sammons Cancer Center Launched April 2015 Common Cancer-Related Symptoms and Challenges PHYSICAL-MEDICAL SYMPTOMS Adjustment to Illness Cancer-Related Pain & Fatigue Anxiety/Worry/Panic Depression/Sadness Sleep Disturbance Hormone Dysregulation SPIRITUAL DEMORALIZATION Crisis in Meaning & Purpose Crisis in Faith & Hope (Religious/Spiritual Beliefs) End-of-Life Exploration/Discussion Post-Traumatic Cancer Stress Vs. Post-Traumatic Growth EXISTENTIAL SUFFERING Death Anxiety Existential Distress Existential Guilt Existential Ambivalence Existential Isolation Existential Despair Behavioral Health Oncology Services: Meeting the Needs of the 21 st Century Cancer Patient 19 th -20 th Century Existential Philosophy & Psychology Kierkegaard, Nietzsche, Heidegger, Frankl, Yalom PhD: Existential Psychology (U. Dallas + Duquesne U.) BODY INTEGRATIVE BEHAVIORAL HEALTH HEALTHY LIFE STYLE MANAGEMENT Diet / Exercise Mgmt Coping & Stress Reduction Cancer-Related Pain Mgmt Sleep Hygiene /Fatigue Mgmt Mood/Hormone Regulation SPIRIT MIND EXISTENTIAL-SPIRITUAL SUPPORT PSYCHO-ONCOLOGY Meaning-Centered Therapy Cancer-Related Stress Mgmt Purpose-Driven Support Life-Transitional Stress Mgmt Spiritual Care & Support Fear / Worry / Anxiety Mgmt Grief & Bereavement Demoralization/Depression Mgmt Post-Traumatic Growth Mindfulness & Relaxation Vital Involvement Restorative Self-Care 21st Century Integrated Behavioral Health Consultation Preventative Collaborative Care (PCMH) Model Population Science Approach Promoting Healthy Lifestyle Management Military IBHC Training: L.A. Air Force Base Late-20 th Century Psycho-Oncology Cancer-Focused Psycho-Social Support MSKCC: Pioneers in field Fellowship Training: MSKCC (Drs. Breitbart & Holland)
Behavioral Health Oncology Service Referrals By Disease Management TOTAL REFERRALS TO DATE = 497 TOTAL ENCOUNTERS TO DATE = 1303 Quarterly Comparison: Behavioral Health Oncology Service Numbers Total BHOPE Referrals To Date: 497 INITIAL CONSULT - NON-UTILIZERS = Pts referred, but did not utilize BHOPE services: No Shows Hospitalized Reconsidered Death Language Barrier Identifies to Medical Staff: Three Referral Domains 1. Adjustment to Illness 2. Healthy Lifestyle Mgmt 3. Relational Issues Identifies to Medical Staff: * Refer Only LOW clinical cancer-related issues
Behavioral Health Oncology Service: Appropriate / Inappropriate Physician Referrals + High Risk Triage 93% Referrals Appropriate 2% Referrals Morbid Ideation 3% Referrals High Risk Patients 2% Referrals Suicidal Ideation Adjustment to Illness Life-Transitional Stress Anxiety/Worry/Panic Depression/Sadness Demoralization Pre-Tx: Anticipatory Anxiety Survivorship Healthy Lifestyle Diet/Exercise Mgmt Sleep/Fatigue Mgmt Self-Care/Wellness GI Issues: IBS/GERD Appetite/Nausea Chronic Pain/Fatigue Relational Stress Marital/Relational Issues Familial/Parental Issues Doctor/Patient Communication Caregiver Fatigue/Burnout Work related stress Preparatory grief/bereavement Endorses thoughts of harming self on Duke QoL evaluation. Provided brief suicide risk assessment [eval: thoughts, plan, intent, rehearsal, lethality] Vague/free-floating thoughts of not wanting to live with cancer: Not wanting to be a burden to family [e.g., they d be better off without me ] Not wanting to live with the physical pain or cancer symptoms, or mental/emotional suffering of cancer [e.g., wish I could fall asleep + never wake up die in peace ] Tx/Plan: 1) support in Bhope, OR 2) triage to appropriate psychiatric +/or I.O.P. services INAPPROPRIATE REFERRALS Suicidal/Homicidal Ideation: Patient reports passive or active S.I./H.I. thoughts, plan, intent, rehearsal requiring psychiatric services +/or crisis management. Psychiatric Medication Management: Patient reports or appears to be neuro-chemically imbalanced / impaired requiring referral to Psychiatry services. Crisis Management: Patient (or family member) is combative, disruptive, aggressive or emotionally disregulated. Dual-Diagnosis: Patient reports long-standing mental health hx + ETOH/drug/pain med dependence or addiction. Long-Term Psychotherapy: Patient reports long-standing *non-cancer-related psychological issues + problems. Intensive Out-Patient Psych Services: Observed emotional disregulation, volatility, poor distress tolerance or psychiatric issues that cannot be managed in LOW clinical-level Bhope services. PASSIVE SUICIDAL IDEATION ACTIVE SUICIDAL IDEATION Neuro-chemical impairment Pt endorses active S.I. plan, intent, access requiring psychiatry intervention lethality, h/o suicide attempts, neurochemical impairment requiring psychiatry Access to lethality [guns, meds] **Bhope does not have referral rights; cannot See also: Baylor Sammons Cancer refer patients to psych services. Center - Suicide Protocol Bhope will identify patient issue to referring Bhope to identify S.I. issue to referring physician + need for referral to Psychiatry, physician + involve nurse or SW triage Intensive Out-Patient [I.O.P.] program or M.H. Have nurse or SW call Baylor Police Mobile Assessment Unit [4444] to escort pt to E.D for psych eval Assessing Health-Related Quality of Life (HR-QoL) Via: Duke QoL + Brief Symptom Screen at Each Time Point Assessing Meaning and Purpose in Life: SMiLE - Schedule for Meaning in Life Evaluation Example: 37y/o male = Dx GBM Frontal / Temporal Lobe Level of Satisfaction 3 Young Children Marriage/Spouse Close Friends Work Software Engineer God Faith, Church Writing - Journaling, Plays Outdoor activities with kids Level of Importance Fegg MJ, Kramer M, L hoste S, Borasio GD (2008) The Schedule for Meaning in Life Evaluation (SMiLE): Validation of a new instrument for meaning-in-life research. Journal of Pain and Symptom Management 35(4):356-364.
Cancer DIE-gnosis : AN EXISTENTIAL WAKE UP CALL! Cancer Diagnosis: Being hit by an Existential Mac Truck! CALLS into question one s humanity via: life-limits physical, mental, emotional, spiritual, existential CALLS into question: One s existence (mortality) One s identity (individuality) One s place in the world (belonging) Who will I BE if I lose my hair my job my life ME? Triggers an existential crisis of body-mind-spirit: Anxiety-ridden fight-or-flight - stress response OR Despair-ridden failure-to-thrive - depressed response Existential Suffering in Cancer: An Umbrella Concept Existential Care: - Taking CARE of one s authentic Being as a whole - Life-completion: Making & Finding Peace w/life Existential Ambivalence: - Being between two worlds - The space between Life & Death - Living with cancer & dying from it Existential Joy: - Moments of intense beauty & authenticity - Unshakeable Joy! Existential Angst: - Facing one s mortality - Death anxiety (dread) - Annihilation (non-being) Existential Despair: - Crisis of meaning & purpose - Life s randomness, futility - Demoralization / existential vacuum Existential Guilt: - the unlived life within - unfulfilled or wasted potential [Raison d'être] - Overcoming Bad faith Existential Isolation: - Fear of Being / dying alone - Being disconnected from Life - Slipping away unnoticed Existential Transitions in Cancer Initial Diagnosis = Existential Mack Track! Immediate shock, fear of unknown, dread of what is to come B.C. A.D. Before Cancer & After Diagnosis = Who am I? Who will I be? Why did this happen to me? Is this my fault? Transitions through Cancer = Existential Whip-Lash! Increased bodily changes: hair/weight loss, pain, fatigue Increased anxiety/depression re: future, fear of recurrence ( Sword of Damocles ) Coming to terms with life in shadow of (potential) death Recurrence/Terminal Cancer = Existential Sucker-Punch! Confronting death while facing ultimate choices & responsibilities re: life, living-legacy & loved ones How will I die? What is my unfinished business? What impact or mark will I leave? Will I slip away unnoticed?
Developmental Transitions in Cancer: Erikson s Adult Developmental Milestones EARLY ADULTHOOD: [20yrs 45yrs] INTIMACY vs. ISOLATION Virtue/Life-Lesson: LOVE Challenge: LONELINESS MIDDLE ADULTHOOD [45yrs 65yrs] GENERATIVITY vs. SELF-ABSORPTION Virtue/Life-Lesson: CARE Challenge: EGOCENTRICISM LATER ADULTHOOD [65yrs -?] EGO-INTEGRITY vs. DESPAIR Virtue/Life-Lesson: WISDOM Challenge: APATHY Three Existential Wake-Up Calls ANGST = Know Thyself! Death Anxiety as a call to action [fight or flight response] Triggered by major Life-transitions [endings and new beginnings] Being-towards-death OR Being-towards-possibilities! GUILT = To Thine Own Self Be True! Existential Guilt as a call to responsibility [taking ownership for MY Life] Calls us to PAY attention to Life by: Responding to Life by being responsible for MY Life Calls us to respond to one s authentic truth + unfulfilled potential = raison d'être Triggered by Life-Crises: medical crisis, identity crisis or mid-life crisis = existential crisis CARE = Take Care of Yourself! Existential Care as a call to back home to wholeness [being-at-home-in-world] Authentically caring for one s entire Being (past-present-future / body-mind-spirit) Informed by Martin Heidegger s Being & Time
Meaning-Centered Psychotherapy Interventions For Advanced Cancer Patients based on: Man s Search for Meaning Viktor E. Frankl, M.D. (1905-1997) Breitbart, W. & Poppito, S. Individual Meaning-Centered Psychotherapy for Patients with Advanced Cancer: A Treatment Manual. Oxford University Press. Sept 04, 2014. Breitbart, W. and Poppito, S. Group Meaning-Centered Psychotherapy for Patients with Advanced Cancer: A Treatment Manual. Oxford University Press. Sept 04, 2014. Cancer and Meaning Choosing One s Attitude: LIVING in the Face of Cancer He who has a why to live for can bear with almost any how. ~Nietzsche Cancer Suffering Physical Mental Emotional Spiritual Existential Enhance Meaning ( Changing Tragedy to Triumph ) Find Meaning (Via: Sources of Meaning) Lose Meaning ( Existential Vacuum ) Frankl, Man s Search for Meaning (1959). Beacon Press, Boston. Breitbart & Poppito. Individual Meaning-Centered Psychotherapy for Patients with Advanced Cancer (2014). Oxford University Press. Cancer May Trigger A Crisis in Meaning and Purpose MEANING PURPOSE CRISIS IN MEANING Being Mode Maternal = LOVE Attachment-based Relational Identity: Meaning-Based WHO & WHAT DO I LOVE? (RELATIONSHIPS) ABSENCE = DEPRESSION *Failure to Thrive* Challenge: DESPAIR CRISIS IN PURPOSE Doing Mode Paternal = LAUNCHING Goal-oriented Vocational Identity: Purpose-Driven WHY AM I HERE? (WORK / GOALS) ABSENCE = DEMORALIZATION *Failure to Launch* Challenge: GUILT
Guilt s Burden and Blessing: The Call Toward Self-Care GUILT: To Be In-Debt = Indebted / Responsible / Accountable Neurotic Guilt: What I OWE others = I owe! I owe! So off to work I go! FEAR-based = Freedom from guilt (*fears of not being enough) Reactive: I m a burden to others I owe them! Burden = Self-Imposed Imprisonment: Guilt, Shame, Doubt, Fear Authentic Guilt: What I OWE myself = Taking ownership for MY Life! Authentic Call: TAKE CARE OF YOURSELF! CARE-based = Freedom for living in the face of cancer! Responsive: Responding to Life by being responsible for MY life Blessing = Authentically FREE to take care of myself + my Life! CANCER ANGST + ANTS FEAR (of SOME-thing in the world) *VS* ANGST (Death Anxiety = NO-thingness = NON-existence) CANCER-RELATED FEARS, ANGST & DREAD: FEARS: chemo, radiation, f/u MRI s, Tx/Rx side effects (high pain/fatigue) ANGST: diagnosis, death, disability, disconnection Ontological Insecurity: Lack of embodied safety/protection TRIGGERING SURVIVAL MODE = Implement 3 C s of Self-Regulation BODY: Fight, Flight or Freeze Response = CALM BODY -- JUST BREATHE! MIND: Automatic Negative Thinking (ANTS) = CHALLENGE ANTS SPIRIT: Anticipatory Anxiety ( not-at-home ) = CONFRONT FEARS ~ HEALTHY LIFESTYLE MANAGEMENT~ Three healthy meals/day (+2-3 snacks): *all include high protein, fiber + water HIGH LEAN PROTEINS HIGH FIBER & COMPLEX CARBOHYDRATES REGULAR HYDRATION [8-10 glasses /day]
**Healthy ph Balance** Stress = Cortisol (stress hormone) = Acid = Inflammation = Dis-ease GOAL: Acid (sugar/sodium) rich foods/drinks + Alkaline (Acid-balancing) foods * Cut Out/Down: [white] processed/refined sugars + flour products The liver plays a major role in body s filtration system. Liver naturally processes healthy foods + creates acid to combat foreign chemicals [processed/refined sugars, preservatives, additives, nitrates, artificial coloring/flavoring, high fructose corn syrup, carcinogens, nicotine]. Baylor Palliative Care Referral to Behavioral Health Oncology Service Thank you for your time & interest Shannon.Poppito@BSWHealth.org