George Login S, Maciejewski Paul K, Epstein Andrew S, Shen Megan, Prigerson Holly G
Memorial Sloan Kettering Cancer Center, New York, New York, USA.
Weill Cornell Medicine, New York, New York, USA.
J Pain Symptom Manage. 2020 May;59(5):983-989. doi: 10.1016/j.jpainsymman.2019.12.366. Epub 2019 Dec 28.
Clinicians often worry that patients' recognition of the terminal nature of their illness may impair psychological well-being.
To determine if such recognition was associated with decrements to psychological well-being that persisted over time.
About 87 patients with advanced cancer, with an oncologist-expected life expectancy of less than six months, were assessed before and after an oncology visit to discuss cancer restaging scan results and again at follow-up (median time between assessments, approximately six weeks). Prognostic understanding (PU) was assessed at previsit and postvisit, and a change score was computed. Psychological well-being was assessed at pre, post, and follow-up, and two change scores were computed (post minus pre; follow-up minus post).
Changes toward more accurate PU was associated with a corresponding initial decline in psychological well-being (r = -0.33; P < 0.01) but thereafter was associated with subsequent improvements (r = 0.40; P < 0.001). This pattern remained controlling for potential confounds. Patients showed different patterns of psychological well-being change (F = 3.07, P = 0.05; F = 6.54, P < 0.01): among patients with improved PU accuracy, well-being initially decreased but subsequently recovered; by contrast, among patients with stable PU accuracy, well-being remained relatively unchanged, and among patients with decrements in PU accuracy, well-being initially improved but subsequently declined.
Improved PU may be associated with initial decrements in psychological well-being, followed by patients rebounding to baseline levels. Concerns about lasting psychological harm may not need to be a deterrent to having prognostic discussions with patients.
临床医生常常担心患者认识到自身疾病的终末期性质可能会损害其心理健康。
确定这种认识是否与随时间持续存在的心理健康下降有关。
约87例晚期癌症患者，肿瘤学家预计其预期寿命不足6个月，在肿瘤门诊就诊讨论癌症重新分期扫描结果前后进行评估，并在随访时再次评估（两次评估之间的中位时间约为6周）。在就诊前和就诊后评估预后理解（PU），并计算变化分数。在就诊前、就诊后和随访时评估心理健康状况，并计算两个变化分数（就诊后减去就诊前；随访减去就诊后）。
向更准确的PU转变与心理健康相应的初始下降相关（r = -0.33；P < 0.01），但随后与随后的改善相关（r = 0.40；P < 0.001）。这种模式在控制潜在混杂因素后仍然存在。患者表现出不同的心理健康变化模式（F = 3.07，P = 0.05；F = 6.54，P < 0.01）：在PU准确性提高的患者中，幸福感最初下降但随后恢复；相比之下，在PU准确性稳定的患者中，幸福感保持相对不变，而在PU准确性下降的患者中，幸福感最初改善但随后下降。
PU的改善可能与心理健康的初始下降有关，随后患者反弹至基线水平。对持久心理伤害的担忧可能不必成为与患者进行预后讨论的阻碍。
