Distress management. Clinical practice guidelines.

The evaluation and treatment model expressed in the NCCN Distress Management Guidelines recommends that each new patient be rapidly assessed in the office or clinic waiting room for evidence of distress using a brief screening tool (the Distress Thermometer and Problem List) presented in Figure 1 (see page 369). A score of 5 or greater on the thermometer should trigger further evaluation and referral to a psychosocial service. The choice of which service should be determined by the problem areas specified on the Problem List. Patients with practical and psychosocial problems are referred to social work, emotional or psychological (excessive sadness, worry, nervousness) problems to mental health, and spiritual concerns to pastoral counselors. The primary oncology team members--doctor, nurse, and social worker--are central to making this model work. Team members collect information from the brief screening and problem list and expand it with the clinical evaluation. It is critical for at least one team member to be familiar with the mental health, psychosocial, and pastoral counseling resources available in the institution and the community. A list of the names and phone numbers for these resources should be kept in all oncology clinics and updated frequently. The first step in implementing this model is to establish a multidisciplinary committee in each institution or office responsible for 1) revising and modifying the standards of care to fit the particular clinical care setting and 2) implementing and monitoring the use of these standards. Because each institution has its own culture, standards must be implemented in ways that are compatible with each institution. The second step is to institute professional educational programs to ensure that staff is 1) aware that distress is under-recognized, 2) knowledgeable about the management of distress, and 3) aware of the resources available to treat it. It is important to have access to mental health professionals and clergy who are trained to deal with cancer-related distress. The benefits of treating distress in cancer accrue to the patients and their families, to the treating staff, and to improved efficiencies in clinic operations. Health care contracts often allow these services to "fall through the cracks" by failing to reimburse for them through either behavioral health or medical insurance. Reimbursement for services to treat psychosocial distress must be included in medical health care contracts to prevent fragmentation of services for the medically ill. For patients with cancer, integration, not separation, of mental health services and medical services is critically important. Also outcomes research studies that include quality-of-life assessment and analysis of cost-effectiveness are needed. Patients and families should be informed that management of distress is part of their total medical care. Finally, the multidisciplinary committee, office practice, or institution must be responsible for evaluating the quality of the distress management (see guidelines algorithm [page 368]), with CQI studies making an important contribution. Presently, the quality of the psychological care patients receive is not routinely monitored. Accrediting bodies have not directly examined the quality of psychosocial care, nor have they established minimal performance standards for its delivery. The panel believes that psychosocial care should and will eventually be on our institution's report cards.