Psychooncological care for patients with cancer during 12 months of the Covid-19 pandemic: Views and experiences of senior psychooncologists at German Comprehensive Cancer Centers.

INTRODUCTION

The new coronavirus SARS‐CoV‐2 had paralyzed Germany by March 2020. On March 22, a nationwide lockdown became reality. From May onwards, many restrictive measures were relaxed. However, in light of exponentially rising numbers of infected people, restrictions were reinstated gradually from November to January 2021. In March 2021 restrictions were relaxed despite rising numbers of infections in the “third wave” of the pandemic.

On 18 March 2020, one of us (FSK) contacted 14 senior psychooncologists from all over Germany, nearly all of whom affiliated with a Comprehensive Cancer Center (CCC). This became a regular monthly videoconference. Thirteen colleagues (12 heads of the psychooncological service; 9 clinical psychologists, 3 physicians, 1 clinical ethicist; 7 women, 6 men) joined at least once. The purpose of the videoconference was to discuss current problems and potential solutions regarding the provision of psychooncological care. During each call, the participants reported on their views regarding the current coronavirus‐related state in their hospital, the consequences for patient care, perceived staff needs, the challenges encountered and the solutions that were developed. Furthermore, this videoconference allowed the participants to express their concerns and to experience social support from colleagues dealing with similar challenges.

Here, we want to share our experiences during 12 months of the pandemic. These experiences are not representative for psychooncological care in Germany. But we hope that this selective, brief glimpse on challenges, obstacles and accomplishments during the coronavirus pandemic might be helpful for a reflection of psychooncological care during times of crisis. The report is based on notes that were taken during and after the videocalls, they form the basis for this narrative synthesis.

CRISIS… AND ADAPTATION

The initial governmental decisions had a strong impact on the healthcare system, as the focus shifted from usual practice to increasing capacities for intensive care, representing a shift from patient‐centered care to a more public health‐oriented approach. As cancer patients seem to be more vulnerable to the SARS‐CoV‐2 virus, , actions were undertaken that aimed at maintaining treatment and care while simultaneously protecting patients, and healthcare providers, from being infected with the new coronavirus. These included adaptation of treatment regimens and rescheduling of elective out‐patient visits. , ,

In the beginning of the pandemic, the immediate establishment of restrictions in personal contact and care represented a massive challenge. Restrictions ranged from complete suspension of specialized psychooncological care to a near‐normal support with reduced contact duration. The establishment of video and telephone consultations had highest priority. Many patients were thankful for the opportunity to join psychooncological care, despite ambivalent feelings with regard to the use of video technology. Some of the colleagues also had doubts whether video consultations could adequately replace personal contact. However, all of us learned that patients and therapists can join via video for helpful interactions. Video conferencing provided even unexpected, creative solutions and helped to maintain group therapeutic processes.

The attempts to cope with the restrictions also faced several problems. One problem was that video technology was not readily available for the members of the psychooncological team at some institutions. Hence, some colleagues used their own equipment for video consultations via certified, secure online hosts. Furthermore, adaptations were more easily implemented for out‐patients than for hospitalized patients. Here, attempts to apply telephone or video consultations often failed due to technical problems, for example, weak WiFi at the ward or lack of technical equipment on the side of the patient. Furthermore, some of us made the experience that cancer out‐patients felt very positive about diagnostic and supportive phone calls, while in‐patients were reluctant to use the phone and favored personal contact instead.

Sometimes, patients' wish for personal contact was in conflict with the psychooncologist's fear of becoming infected with the coronavirus or the fear to infect patients. Especially during the first months of the pandemic, sufficient protective clothing and face masks were not available at some sites. Here, the head of the team was in conflict between keeping the psychooncological service at work and protecting team members' health. All team members had to adapt to a different mode of patient contact that was unfamiliar to most of them as it was characterized by physical distance and a limited perception of facial and non‐verbal cues, and they had to decide how much risk they were able to tolerate.

These challenges and conflicts had an impact on team dynamics, and continuing open discussion about these aspects seemed to be helpful. However, team dynamics could also be challenged by other factors, for example, limited resources. At some sites, some team members became pregnant and thus were not allowed anymore to have personal contact with patients. Other limiting factors were the division of teams in order to have back‐ups, or the personal challenge of combining homeoffice, homeschooling and presence at the hospital.

The Covid‐19 pandemic also affected interprofessional team dynamics in some cases. Some oncologists were critical of suspended or limited psychooncological support for their patients. They argued that on the one hand psychooncological services aimed at being part of the interprofessional team and at being regularly involved in the care of the patient, on the other hand, when it comes to the point they resigned from patient care. However, restrictions for psychooncological care were typically enacted by the hospital management. So, psychooncology team members had to reconcile with the interprofessional team, explaining their own inner conflicts between wanting to provide support and not being allowed to. A second, quite different aspect relates to role change. In some cases, psychooncologists were asked to offer supervision for teams or to offer services for healthcare providers experiencing psychological distress due to the Covid‐19 pandemic.

Finally, many colleagues faced some personal challenges. Coping with the fear of becoming infected was one significant issue, the frustration and grief about the limited opportunities to support the patients who often were not allowed to receive visits from their family members or who had to cancel out‐patient consultations represented another challenge. Seeing cancer patients who were young mothers or who were dying being cut off from professional support was hard in many cases. In addition, ethical considerations emerged. Many indicated that they feared the moment when triaging cancer patients would become reality. Actually, in some cases psychooncological care was provided using triage, as limited resources affected the decision which patients would be offered psychooncological support.

A NEW NORMAL

It was interesting to see that new routines emerged quickly, adaptation to the coronavirus crisis was quite successful. During summer and fall 2020, one could get the impression of near‐normal medical and psychooncological care. Protective measures were used during personal contact with patients, carers and healthcare providers. In some cases, psychooncologists were integrated in the care of patients suffering from Covid‐19. The experiences of therapeutic contact characterized by additional administrative requirements, physical distance and face masks or mobile safety walls ranged from “no problem” to “unbearable”, but it worked. All felt relieve that triaging had not been necessary. However, ethical considerations remained, as it had become evident that advances in infection control at the population level were of superior importance compared to individual patient care.

BACK TO CRISIS?

In November 2020, the situation changed. In light of rising numbers of infected people and deaths associated with Covid‐19, restrictions like a visitation ban for patients' relatives were re‐activated. In the following months the situation at the population level became even worse. However, this has not led to the same amount of restrictions in psychooncological care as in spring 2020. Psychooncology teams, as well as patients and carers, seem better prepared. But uncertainties remain. As vaccination is available in Germany since the end of December 2020, there is the hope that the infection will be controlled in the course of 2021. However, vaccination in the community progresses slowly, and doubts regarding vaccination are prevalent not only in the general population, but also among some patients and healthcare providers. Furthermore, the reports of new mutant variants of the coronavirus which are associated with higher infection rates make people worry about a new crisis in the future. Most members of the psychooncological teams are in favor of vaccination, but they are not among the first in the priority list to have a vaccination. Finally, it is noteworthy that opportunities for recreation are reduced due to ongoing restrictions, raising concerns about negative effects of continuing work demands and perceived stress on team members' well‐being and work ability.

CONCLUDING REMARK

The Covid‐19 pandemic poses huge structural and personal challenges for psychooncological care. Social contacts have become a new quality, changing from helpful to dangerous. Many of us felt frustrated and helpless at some time, others felt a need to keep their fighting spirit. Fears and uncertainties have accompanied our work. Thus, many of us have felt like many cancer patients do feel in the process of coping with cancer. So, actually, coping with the coronavirus crisis also teaches us to better understand our patients. Finally, looking into the future, we feel that flexible organizational structures, versatile minds and social connectedness are key ingredients for successfully dealing with crisis.

CONFLICT OF INTEREST

All authors declare no conflict of interest.