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These NCCN Guidelines for Distress Management discuss the identification and treatment of psychosocial problems in patients with cancer. All patients experience some level of distress associated with a cancer diagnosis and the effects of the disease and its treatment regardless of the stage of disease. Clinically significant levels of distress occur in a subset of patients, and identification and treatment of distress are of utmost importance. The NCCN Distress Management Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights describe updates to the NCCN Distress Thermometer (DT) and Problem List, and to the treatment algorithms for patients with trauma- and stressor-related disorders.

ObjectivesOn 3–4 October 2022, the Memorial Sloan Kettering Cancer Center Supportive Care Service and Department of Psychiatry and Behavioral Sciences hosted the Third Annual United States (US) Celebration of World Hospice and Palliative Care Day (WHPCD). The purpose of this article is to reflect on the event within the broader context of the international WHPCD theme: “healing hearts and communities.” We describe lessons learned in anticipation of the fourth annual conference to be held on 3–4 October 2023.MethodsDescription of the third annual event, conference planning team reflection, and attendee evaluation responses.ResultsThe Worldwide Hospice Palliative Care Alliance launched WHPCD in 2005 as an annual unified day of action to celebrate and support hospice and palliative care globally. Since 2020, the conference has attracted an increasing number of attendees from around the world. Two primary aims continue to guide the event: community building and wisdom sharing. Fifty-two interprofessional palliative care experts, advocates, patients, and caregivers provided 13 unique interactive sessions. Four hundred and fifty-eight multidisciplinary registrants from at least 17 countries joined the program. Free registration for colleagues in low- and middle-income countries, students and trainees, and individuals experiencing financial hardship remains a cornerstone of inclusion and equitable access to the event.Significance of resultsThe US WHPCD celebration provides a virtual platform that offers opportunities for scientific dissemination and collective reflection on hospice and palliative care delivery amid significant local and global changes in clinical practice, research, policy and advocacy, and population health. We remain committed to ensuring an internationally relevant, culturally diverse, and multidisciplinary agenda that will continue to draw increased participation worldwide during future annual events.

Caregivers of patients with glioblastoma multiforme (GBM) are at significant risk for existential distress. Such distress negatively impacts caregivers’ quality of life and capacity to serve in their role as healthcare proxies, and ultimately, contributes to poor bereavement outcomes. Our team developed Meaning-Centered Psychotherapy for Cancer Caregivers (MCP-C), the first targeted psychosocial intervention that directly addresses existential distress in caregivers. The purpose of this study was to evaluate the feasibility, acceptability, and preliminary effects of MCP-C among caregivers of patients with GBM via a mixed-method pilot trial. Caregivers were randomized to seven sessions of MCP-C or Enhanced Usual Care (EUC), which included distress screening and the provision of targeted referrals and completed quantitative assessments at baseline (T1), after completion of MCP-C (T2), and at 2-month follow-up (T3). A subset of participants engaged in semistructured interviews at T2. Of 60 caregivers randomized, 55 were evaluable for preliminary efficacy analysis. Constrained linear mixed models indicated the MCP-C arm had statistically significant improvement relative to the EUC arm in the primary outcome of personal meaning and multiple secondary outcomes, including benefit finding, depressive symptomatology, and spiritual wellbeing. MCP-C demonstrated preliminary efficacy in facilitating caregivers’ capacity to experience a sense of meaning and purpose despite the challenges and suffering associated with providing care to patients with GBM. Future studies are needed among more diverse samples of caregivers and should include the opportunity for concurrent patient enrollment to allow for a reciprocal and augmented experience of meaning among patient–caregiver dyads.

Psychedelic-assisted therapy (PAT) is a burgeoning treatment with growing interest across a variety of settings and disciplines. Empirical evidence supports PAT as a novel therapeutic approach that provides safe and effective treatment for people suffering from a variety of diagnoses, including treatment-resistant depression, substance use disorder, and post-traumatic stress disorder. Within the palliative care (PC) field, one-time PAT dosing may lead to sustained reductions in anxiety, depression, and demoralization-symptoms that diminish the quality of life in both seriously ill patients and those at end of life. Despite a well-noted psychedelic renaissance in scholarship and a renewed public interest in the utilization of these medicines, serious illness-specific content to guide PAT applications in hospice and PC clinical settings has been limited. This article offers 10 evidence-informed tips for PC clinicians synthesized through consultation with interdisciplinary and international leading experts in the field with aims to: (1) familiarize PC clinicians and teams with PAT; (2) identify the unique challenges pertaining to this intervention given the current legalities and logistical barriers; (3) discuss therapeutic competencies and considerations for current and future PAT use in PC; and (4) highlight critical approaches to optimize the safety and potential benefits of PAT among patients with serious illness and their caregivers.

Pain is one of the most prevalent and impairing symptoms in the realm of palliative care. Although opioids remain at the center of most pain management strategies, it is critical to employ adjuvant analgesics effectively and to understand the impact of psychosocial variables on a person’s overall pain experience. Many psychotropics can be employed as analgesics and also leveraged for secondary benefits to sleep, nausea, appetite, depression, anxiety, and fatigue. A number of promising nonpharmacologic approaches to pain also exist. Practitioners with a clear picture of physiologic and psychosocial components of the pain experience will be able to optimally manage pain and help their patients enjoy the best possible quality of life.

Cognitive syndromes are prevalent in palliative care settings. Delirium is the most common and often serious neuropsychiatric disorder found in palliative care settings. Delirium is characterized by abrupt onset, fluctuating disturbance in awareness, attention, cognition, and perception. Delirium is associated with increased morbidity and mortality, causing distress in patients, family members, and staff. Delirium is often underrecognized or misdiagnosed and inappropriately treated or untreated. Clinicians who care for patients with advanced cancer and at the end-of-life must be able to diagnose delirium accurately, undertake appropriate assessment of etiologies, and understand the benefits and risks of pharmacologic and nonpharmacologic interventions currently available. Dementia and other neurocognitive disorders can also be encountered in palliative care settings, have multifactorial etiologies ranging from cancer-treatments to brain metastases, and include neurodegenerative illnesses comorbidly, especially in the oldest old patient population. This chapter presents an overview of the assessment and management of delirium in cancer patients in palliative care settings. Other cognitive syndromes will be briefly described with a focus on the assessment and differential diagnosis. Professional issues, including communication challenges, ethical dilemmas, legal requirements, and service development agendas will be considered.

ObjectiveOn October 5–6, 2021, the Memorial Sloan Kettering Cancer Center Supportive Care Service and Department of Psychiatry and Behavioral Sciences hosted the 2nd Annual United States (US) Celebration of World Hospice and Palliative Care Day (WHPCD). The purpose of this article is to describe the event within the broader context of the international WHPCD theme: “Leave No One Behind — Equity in Access to Palliative Care.” We reflect on lessons learned in anticipation of the 3rd annual conference to be held October 3–4, 2022.MethodsDescription of the 2nd annual event, conference planning team reflection, and attendee evaluation responses.ResultsThe Worldwide Hospice Palliative Care Alliance launched WHPCD in 2005 as an annual unified day of action to celebrate and support hospice and palliative care around the world. The 2021 US-based innovative virtual conference featured 37 interprofessional hospice and palliative care specialists and patient and family caregiver speakers across 11 diverse sessions with a focus on health equity and COVID-19 considerations. Two primary aims continue to guide the event: community building and wisdom sharing at the intersection of art and science. 278 registrants from at least 14 countries and 21 different states across the US joined the program, which served as a global debriefing for hospice and palliative care workers from diverse settings, contexts, and disciplines.Significance of resultsThe US WHPCD Celebration creates a virtual coming together for collective reflection on hospice and palliative care delivery amid vast changes in clinical practice, research, and policy, both locally and globally. In addition, our goal to ensure an internationally relevant, culturally inclusive, and multidisciplinary agenda will continue to draw increased participation worldwide during future annual events.

Gastrointestinal (GI) cancers that originate from outside the colon and rectum are common and distressing for reasons distinct from colorectal cancer. The GI tract includes the uniquely contributory organ functionality of the pancreas, liver, and stomach, which manifest as distinct cancer types with unique morbidity associations. While digestion is certainly the primary quality-of-life issue that is disrupted during the cancer experience and trajectory, there are various other important quality-of-life issues to consider. Unfortunately, these noncolorectal GI cancers tend to carry a worse overall prognosis and the morbidity is greatly influenced by cancer type, anatomic location, and treatment regimen (local and systemic). Pancreatic, esophageal, gastric, and hepatobiliary cancers affect digestion, nutrient absorption, and weight management and can cause significant pain and other physical morbidity such as edematous states. Aside from the stress of physical morbidity or unique treatment side effects, pancreatic cancer has a unique relationship with depression that should be explored for its biological implications in causing depressive symptoms. In addition, patients may be distressed by the novelty or rarity of many of these noncolorectal GI cancers (e.g., cholangiocarcinoma) that may fall into an orphan disease category without well-studied treatment paradigms. Understanding the key characteristics of the primary types of noncolorectal GI cancers (i.e., pancreatic, gastric, esophageal, and hepatobiliary cancers) allows the psycho-oncology clinician to approach these patients with appropriate concern and caring for the primary issues with which they are toiling.

This chapter gives an overview of the application, content, and scientific evidence of meaning-centered group psychotherapy for cancer survivors (MCGP-CS). Experiencing meaning is strongly related to adjustment and psychological well-being after cancer diagnosis and medical treatment for survivors. MCGP-CS is an eight-session group intervention that aims to help survivors enhance or maintain a sense of meaning, in order to improve their psychological well-being and decrease distress. The chapter describes two adaptations of MCGP for survivors: a US version developed specifically for breast cancer survivors and a Dutch version developed for general cancer survivors. This chapter includes summaries of the content of each session and examples of some of the exercises in the manual. Furthermore, it summarizes the results of two conducted pilot studies, a randomized controlled trial, and a cost-utility analysis, all showing positive effects. Finally, future directions for MCGP for cancer survivors are given.

Cancer-related fatigue (CRF) is abundantly represented in most cancer populations and is highly distressing, causing significant psychological and functional morbidity. It does not receive enough attention from cancer clinicians as a certain amount of fatigue is expected from cancer and treatments. However, CRF is a distinct entity and category of fatigue that does not respond to usual restorative measures. This chapter reviews its definition, prevalence, pathophysiology, and assessment including unique contributory causes and distinguishing CRF from other symptoms such as depression and pain. Measurement tools are discussed. Strategies for the management of CRF including pharmacologic and nonpharmacologic interventions are reviewed and tips are provided. Evidence is presented for the use of psychostimulants and other drug therapy as well as exercise, psychotherapies, and mind-body interventions (e.g., yoga, acupuncture). CRF is a distinct entity with significant consequences for patients. Its assessment should be thorough and treatment directed toward underlying causes.

COVID-19 has unveiled and amplified the burnout, grief, and other forms of distress among healthcare providers (HCPs) that long preceded the pandemic. The suffering of the healthcare workforce cannot be simply and sufficiently addressed with a single psychotherapeutic intervention. Nevertheless, the National Academies of Sciences, Engineering, and Medicine Studies recommended prioritizing interventions that generate an increased sense of meaning in life and in work to reduce burnout and cultivate clinician wellbeing. Despite their guidance, there is a dearth of interventions for HCPs specifically targeting meaning and purpose as an avenue to reduce HCP distress. In a time when such an intervention has never been more essential, Meaning-Centered Pyschotherapy (MCP), a brief, evidence-based intervention designed for patients with advanced cancer may be key. This piece describes the principles underlying MCP and how it might be adapted and applied to ameliorate burnout among HCPs while providing a rationale to support future empirical studies in this area. Importantly, the systemic factors that contribute to the emotional and mental health burdens of HCPs are discussed, emphasizing the need for systems-level changes that are needed to leverage the potential outcomes of MCP for HCPs.

Pain is a common problem in populations with advanced illness and has been best characterized in those with cancer or AIDS. Despite the high prevalence of pain in populations with advanced illness, there is evidence that pain is frequently under-diagnosed and inadequately treated. Undertreatment has multiple causes, one of which is the complex presentation of pain in these populations. Pain is not a purely physical experience, but involves many aspects of human functioning, including personality, affect, cognition, behaviour, and social relations. This complexity is best managed using a multimodality approach, including psychiatric and psychological interventions. These interventions may be psychotherapeutic, cognitive behavioural, or psychopharmacologic.

Delirium is the most common and serious neuropsychiatric complication in palliative care settings. It is a source of significant morbidity in patients, and often distresses family members and staff. Delirium is often a harbinger of impending death and can significantly interfere with pain and symptom control. Unfortunately delirium is often under-recognized or misdiagnosed in the terminally ill, and even when recognized, it frequently goes untreated or is inappropriately treated. Clinicians who care for patients with advanced illness must be able to diagnose delirium accurately, undertake appropriate assessment of aetiologies, and understand the risks and benefits of the pharmacological and non-pharmacological interventions currently available for managing delirium. Symptomatic treatment with antipsychotics or sedative medications is often necessary for the delirious patient with advanced illness to minimize distress to patients, families, and staff.

This chapter provides instructions for conducting the eighth session of meaning-centered group psychotherapy. The reader is instructed to help members to reflect on their group experience in light of the last seven sessions. Facilitators will facilitate dialogue and reflection around members’ thoughts and feeling surrounding the finality of their group experience in light of facing important transitions and facing their own mortality due to their cancer illness. They will also guide the group in exploring what it has been like to share their cancer experiences and life stories with others in the group and to witness others’ stories in return. Time should be given to share and explore members’ final ‘Legacy Projects,’ as well as meaningful experiences within the group process. Time should also be allotted for patients to offer feedback regarding their group experience and hopes for the future.

The importance of spiritual well-being and the role of "meaning" in moderating depression, hopelessness and desire for death in terminally-ill cancer and AIDS patients has been well-supported by research, and has led many palliative clinicians to focus on the development of non-pharmacologic interventions that can help their patients address these issues. Individual Meaning-Centered Group Psychotherapy (IMCP), an intervention developed and rigorously tested by the Department of Psychiatry & Behavioral Sciences at Memorial Sloan-Kettering Cancer Center, is a seven-week program based around the work of Viktor Frankl, and which utilizes a mixture of didactics, discussion and experiential exercises that focus around particular themes related to meaning and advanced cancer. Patients are assigned readings and homework that are specific to each session's theme and which are utilized in each session. While the focus of each session is on issues of meaning and purpose in life in the face of advanced cancer and a limited prognosis, elements of support and expression of emotion are inevitable in the context of each group session.

This chapter provides instructions for conducting the seventh session of meaning-centered group psychotherapy. The reader is instructed to introduce and explore the topic of ‘Experiential Sources of Meaning’ by way of the guiding theme ‘Connecting with Life.’ By the end of Session 7, group members will have a solid understanding of the significance of connecting with life through experiential sources of meaning—particularly through the experiential sources of love, beauty, and humor.

This chapter provides instructions for conducting the second session of meaning-centered group psychotherapy. The reader is instructed to reintroduce the basic concepts and sources of meaning from the first session, and to explore the topic of ‘Cancer and Meaning’ in light of the guiding theme ‘Identity before and after Cancer Diagnosis.’ By the end of Session 2, the facilitator will have ensured that group members have a general understanding of what their authentic sense of self is and the impact cancer has had on it.

This chapter provides instructions for conducting the fifth session of meaning-centered group psychotherapy. The reader is instructed to explore the topic of ‘Attitudinal Sources of Meaning’ and the guiding theme ‘Encountering Life’s Limitations.’ Leaders will pick up where they left off from Session 4 by continuing to explore the concept of ‘legacy’ in historical context (e.g., past, present, future dimensions) in light of confronting the ultimate limitation of death and the lasting legacy they will leave. By the end of Session 5, group members will have a solid understanding of ‘attitudinal sources of meaning’ based on the core theme that our last vestige of human freedom is to choose our attitude toward suffering and life’s limitations. Group members will come to understand that life presents us with many circumstances that may be opportunities or limitations, and while we often don’t have control over what life gives us, we always have the freedom to choose how we respond to and the attitude we take toward what life gives us, good or bad.

This chapter provides instructions for conducting the sixth session of meaning-centered group psychotherapy. The reader is instructed to introduce and explore the topic of ‘Creative Sources of Meaning’ and the guiding theme ‘Creativity, Courage, and Responsibility.’ By the end of Session 6, group members will have a solid understanding of the significance of the creative sources of meaning (creativity, courage, and responsibility) as important resources for meaning in their lives.

This chapter provides instructions for conducting the first session of meaning-centered group psychotherapy. The reader is instructed to introduce facilitators and group members to one another, introduce patients to a general overview of the intervention (including treatment goals, structured weekly topics, and logistics), become familiar with each patient’s story of illness, introduce patients to the first session topic of Viktor Frankl’s work and foundations of meaning, and share definitions of meaning and conduct the “meaningful moments” experiential exercise.

Suicide, suicidal ideation, and desire for hastened death are all important and serious consequences of unrecognized and inadequately treated clinical depression. Desire for hastened death is one the most controversial topics in palliative care. Despite legal prohibitions against assisted suicide, a substantial number of patients think about and discuss those alternatives with their physicians, family, and friends. This chapter provides a comprehensive overview of the prevalence, assessment, and management of suicide, suicidal ideation, and desire for hastened death in palliative care settings.

Fatigue is highly prevalent in palliative care settings. Studies suggest that as many as 60% to 90% of advanced cancer patients experience fatigue. Fatigue is frequently under-recognized and undertreated in the terminally ill. This chapter provides a comprehensive overview of the prevalence of fatigue in palliative care settings, instruments used in screening and assessment of fatigue, common contributing factors of fatigue in advanced cancer patients, and the most recent evidence on the strategies for management of fatigue in palliative care settings.

A range of psychotherapeutic and behavioural interventions have been demonstrated to be effective and useful for patients struggling with advanced life-threatening illness. Despite lack of evidence for prolonged survival, psychosocial interventions have been shown to be effective in decreasing depressive symptoms and suffering in advanced cancer patients. This chapter provides an overview of the commonly used, effective individual, group, and family psychotherapy modalities among advanced cancer patients and their families.

Delirium is the most common and serious neuropsychiatric complication in palliative care settings. Delirium is often under-recognized or misdiagnosed in terminally ill patients. Delirium is highly prevalent and is a source of morbidity in patients, family members, and staff. Delirium is often a harbinger of impending death and can significantly interfere with pain and symptom control among terminally ill. This chapter provides an overview of the prevalence, assessment, and management of delirium among advanced cancer patients reviewing the most recent evidence-based data on the use of psychopharmacological agents in treatment and prevention of delirium in this patient population.

In addition to the diagnosis and treatment of psychiatric disorders in palliative care settings, pain and other troublesome physical symptoms must also be aggressively treated in efforts aimed at the enhancement of the patient’s quality of life. These symptoms must be assessed by the psycho-oncologist concerned with the assessment and treatment of affective and other syndromes in the terminally ill population. This chapter provides a brief overview of the prevalence, assessment, and management of the commonly encountered, distressing physical symptoms such as pain, insomnia, and nausea among patients with advanced cancer.

Palliative medicine refers to the medical discipline of palliative care. Modern palliative care has evolved from the hospice movement into a more expansive network of clinical care delivery systems with components of home care and hospital-based services. Palliative care begins with the onset of a life-threatening illness and proceeds past death to include bereavement interventions for family and others, with a mission to meet the physical, psychological, social, spiritual, and existential needs of the “whole patient.“ This chapter includes an overview of definitions of palliative care, the global need for palliative care, and ideal components of palliative care programs. A comprehensive review of the most recent research findings on impact of early palliative care on quality of life and survival is provided.

Spirituality is important in the lives of patients with serious illnesses. Terminally patients may experience a number of spiritual issues, including lack of meaning, guilt, shame, hopelessness, loss of dignity, loneliness, anger toward God, abandonment by God, feeling out of control, grief, and spiritual suffering. Assessment of a patient’s spiritual beliefs, assessing the importance of spirituality in his or her life, exploring whether he or she belongs to a spiritual community, and offering chaplaincy referral or connection with the patient’s religious or spiritual leaders comprise essential components of a spiritual assessment. Psycho-oncologists should seek both specialized training, as well as referrals to appropriate sources, in order to help patients deal more effectively with the often complicated and painful spiritual issues that arise as a consequence of serious illness. Existential concerns are intrinsic to the human experience of facing mortality in palliative care settings. Patients diagnosed with terminal cancer often confront universal existential issues such as death anxiety, isolation, and meaninglessness. Psycho-oncologists must therefore be familiar with these existential concerns, their manifestations, and approaches to deal with existential issues. Psycho-oncologists have the unique ability to use a variety of psychotherapeutic interventions to alleviate existential distress in palliative care settings including cognitive therapies to help patients and families modify their appraisal of their lives with terminal illness, known as cognitive restructuring, life review techniques to facilitate a constructive reappraisal of life events, dignity-conserving therapies, and meaning-centered therapies have been shown to effectively reduce existential distress in this patient population.

Psycho-oncologists must be familiar with the information on why, when, where, and how patients die to best understand and manage psychiatric issues of terminally ill patients. This chapter provides an overview of the common causes of death, age and location of death, including a discussion on patient preferences for the location of death. World Health Organization guidelines for a “good death“ and Weisman’s criteria for an “appropriate death“ are reviewed to serve as general guidelines for psycho-oncologists in caring for terminally ill patients.