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Distress: The Sixth Vital Sign?

Meeting the emotional needs of patients is mandatory, cancer expert says

FRIDAY, June 23, 2006 (HealthDay News) -- In assessing a patient's condition, doctors traditionally check five vital signs -- pulse, breathing, temperature, blood pressure and pain. But one cancer physician wants to add another vital sign to the list -- distress.

A patient's mental well-being is an essential part of overall health and should be monitored -- even during routine medical examinations, said Dr. Jimmie C. Holland, who holds the Wayne E. Chapman Chair in Psychiatric Oncology at Memorial Sloan-Kettering Cancer Center, in New York City.

"Can distress become the sixth vital sign?" Holland asked. "I ask this, because we must find a way to incorporate psychological care into total care," she said.

"No patient with distress should be unrecognized or untreated in quality cancer care. I don't think you can have quality cancer care that does not integrate this psychological side. There should be a minimum standard for psychosocial care," she added.

Holland explained her proposal Thursday at a cancer briefing sponsored by the American Medical Association, in New York City.

One big problem is that doctors often don't consider the psychological component of total health, and patients are reluctant to bring it up, because they don't want to bother the doctor, Holland said. Part of the barrier comes from the doctor -- "Hey, I'm doing science not touchy-feely stuff. And patients are going to tell me when they're upset," she said, paraphrasing a typical physician.

As for patients, Holland believes many are embarrassed discussing psychological issues. "The doctor will think I'm a wimp," Holland said, again paraphrasing.

But studies have found that as many as 45 percent of cancer patients have significant mental distress, Holland said. "Those most at risk are those with the most serious tumors, young patients, patients with low income and those with less social support," she said.

To help get physicians to evaluate a patient's mental condition, Holland and colleagues at the National Comprehensive Cancer Network have developed a questionnaire for patients to complete at routine doctor visits. The questionnaire alerts doctors to those patients who may need to be referred for counseling.

Along with the questionnaire, Holland and her colleagues have developed practice guidelines for dealing with patient distress. Holland created a scale that rates a patient's distress on a 1-to-10 scale, what she calls a "distress thermometer."

"Patients who score 4 or greater, that's the trigger that doctors should note," she said.

Based on this scale, patients can be referred to psychiatrists, psychologists, social workers or pastoral counseling. "Distress should be monitored continually," Holland said.

Holland believes that adding distress to regular evaluations leads to more open communication and encourages treatment; hence, fewer patients will become overly anxious, and there will be fewer patient visits because of worry.

"We can decrease distress and improve the quality of patient's lives," Holland said. "We don't change their survival, but it is about changing what happens to them," she said.

One cancer expert agreed that instituting a method to monitor patient distress is essential to good care.

"Whenever you go into a hospital, the nurses and physicians are very tuned into the pain scale," said Dr. Carolyn D. Runowicz, president of the American Cancer Society and director of the Carole and Ray Neag Comprehensive Cancer Center at the University of Connecticut Health Center.

"I would hope that for cancer and all patients, that something like the distress thermometer is incorporated," Runowicz said. "It may take regulation to get it incorporated, but whatever it takes, we will end up with a better result," she said.

More information

The National Comprehensive Cancer Network can tell you more about distress and cancer.

SOURCES: Jimmie C. Holland, M.D., Wayne E. Chapman Chair in Psychiatric Oncology, Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York City; Carolyn D. Runowicz, M.D., president, American Cancer Society, and director, Carole and Ray Neag Comprehensive Cancer Center, University of Connecticut Health Center, Farmington; June 22, 2006, American Medical Association briefing, New York City
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