A worldview of the professional experiences and training needs of pediatric psycho-oncologists.

BACKGROUND: Thirty years after the origin of the field of psycho-oncology, limited data exist about the work practices of professionals providing psychosocial care to children with cancer and their families. METHOD: A survey was designed to assess training, work environment, theoretical orientation, services provided, subspecialty areas or areas of special interest, satisfactions, challenges, and continuing education needs of pediatric psycho-oncologists. Members of national and international psycho-oncology organizations were invited to participate in the web-based survey. RESULTS: Seven hundred eighty-six professionals from 63 countries responded. The sample consisted mostly of psychologists (41%), physicians (20%), and social workers (14%). Approximately half of the participants worked in a designated psycho-oncology unit. Psychologists and social workers provided the majority of psychosocial services. Individual sessions with parents were most common (42%), followed by sessions with children (41%), survivors (36%), families (31%), and siblings (25%). Therapies provided include cognitive behavioral therapy (50%), relaxation (43%), psychodynamic psychotherapy (27%), play therapy (26%), and imagery (23%). Two-thirds reported having appropriate supervision, 37% were conducting research, and only half felt their salary was appropriate. Differences in therapeutic modalities were found by country. Clinicians desire training on clinical interventions, improving communication with medical staff, research, and ethics. CONCLUSIONS: An international cohort of clinicians providing pediatric psycho-oncology services perform a wide variety of tasks, use a range of therapeutic approaches, and report considerable work satisfaction. Problem areas include professional inter-relations, inadequate supervision, and need for additional specialized training. Opportunity exists for global collaboration in pediatric psycho-oncology research and practices to enhance clinical effectiveness and reduce professional isolation.

[Supporting the siblings of a child suffering from cancer]. / Accompagner la fratrie d'un enfant atteint de cancer.

As soon as a child is diagnosed with cancer, the family dynamics are overturned. The parents, destabilised by their feelings of powerlessness, must establish a dialogue with the caregivers, and the siblings must be supported from the moment the diagnosis is made. A psychoanalyst should be brought in early on in the end-of-life phase to offer support to the family members undergoing this ordeal.

Optimal care for the child with cancer: A summary statement from the SIOP Working Committee on Psychosocial Issues in Pediatric Oncology.

Since its foundation in 1991, the SIOP Working Committee on Psychosocial Issues in Paediatric Oncology1 has developed and published 12 sets of Guidelines for health-care professionals treating children with cancer and their families. Those elements considered essential in the process of cure and care of children with cancer are summarized in this document as a formal statement, developed at the 2007 SIOP annual meeting in Mumbai. Elaboration of the concepts with detailed strategies for practice can be found in the referenced guidelines [1-12] and in a companion publication [13]. This article is a summary of what practitioners considered critical elements in the optimal care of the child with cancer, with the goal of stimulating a broader application of these elements throughout the SIOP membership.

[Doctor-patient relationship in oncology: how to prevent and solve some conflicts?]. / La relation médecin-malade en oncologie: comment prévenir et résoudre certains conflits ?

The inequality between doctor(s) and patient(s) is a frequent cause of ethical and relational difficulties. To know the elements of this inequality is a requirement to improve their relationship. The major elements of this inequality: the patient experiments suffering and may die; the doctor belongs to a group, has a wide knowledge, the ability to cure, is active. Some elements diminish this inequality: patients associations; new laws (the right to be informed, to give one's informed consent, to have free access to one's medical file, to refuse the treatment, etc.); relinquishing paternalism and making shared decision; improving doctor's competence in information. Equality also means solidarity and reciprocal knowledge, respect and trust. Specific objectives have to be acknowledged: the patient's and the doctor's ones can be different. Patients and doctors should have an equal exigency of rights and duties: they cannot do or demand anything. Both of them need to be recognized as competent in their own tasks, and responsible towards each other, the other patients, themselves. They equally require to preserve one's ideals, to keep one's identity, one's sense of dignity and value. Equal freedom to think and act can be hindered by the influence of others, but also by inadequate emotions, fantasies, unconscious thoughts and memories. The psycho-oncologists and the psychoanalytic experience are therefore useful to overcome these unconscious obstacles. Medical staff should also have the experience of solving the ethical difficulties that inequality can raise.

[How to help the child and his/her family to go through the ordeal of cancer]. / Aider l'enfant et sa famille à traverser l'épreuve du cancer.

Experiencing cancer is an ordeal for a child and his/her family, even if the majority of these children are cured. In order to alleviate destabilization or possible psychological sequels, the medical staff must be competent and also provide supportive care and information, so that mutual knowledge and confidence can be established. The child's and adolescent's specific landmarks must be protected (school, friends, play, fantasy, creativity, body image, sense of beauty and of identity, self confidence and trust in their parents, relation with their siblings, plans...). Parents also need assistance for possible practical, social, financial difficulties and, most of all, to maintain confidence in their parental competence. Siblings need help to understand the situation and to cope with it. Accompanying the child when the treatment is over will allow him/her to resume a normal life or to cope with possible sequels. If the child dies, accompanying the parents and the siblings through the grieving process is helpful. The psycholo-oncologist helps the child and his/her family to understand their emotions and their conscious and unconscious thoughts, and to live through this ordeal.

[Refusing treatment: patient responsibility and autonomy. About a French National Consultative Ethics Committee statement(no 87, April 2005)]. / Refuser le traitement: responsabilité et autonomie du patient. A propos de l'avis no 87 (avril 2005) du Comité consultatif national d'éthique.

A recent French National Consultative Ethics Committee statement confirms that medical doctors are required by law to accept a patient's refusal of treatment, even if the consequence is the loss of chances of being cured. This refusal raises difficult clinical and ethical issues. Respecting a patient's decision is only valid when he/she is fully responsible, able to understand the proposed treatments and the consequences of his/her refusal, uninfluenced by friends and relatives, ignorance, disarray, an excessively pessimistic appraisal of the situation, a conflict with the doctors or with medicine. Doctors must avoid passively accepting a refusal without discussion but must also avoid paternalism or moral pressure. Adequate mutual knowledge of the way they think, their values and their objectives helps to maintain mutual respect and confidence in the patient-doctor relationship: the doctor is not a "supertechnician" nor is the patient a treatment consumer. Information, knowledge of the possibilities and limits of current medicine and of patients'complex, conscious and unconscious motives (which justifies the psycho-oncologist's role), recommendations of medical societies, experience of difficult ethical issues help to avoid unauthentic refusals, conflicts and staff burnout.

An ethics dilemma: when parents and doctors disagree on the best treatment for the child.

The increasing complexity of present day medicine--with highly effective and yet risky treatments, individual and collective expectations, and evolving ideological and cultural landmarks--often gives rise to difficult ethical problems. Specific meetings are valuable for understanding such problems, acquiring the relevant skills and for gaining and transmitting experience on how to solve them. Parents and doctors may disagree about what is the best treatment. Such a difference of opinion is not rare but usually a solution can easily be found. This is not the case when the child is treated for a severe illness and when there is no clearly defined or satisfactory treatment for him\her. We present how a dramatic conflict arose between the parents and the doctors faced with such a case (mostly because the staff failed to understand early enough the psychological factors at the root of the father's demands), how clinical, institutional and ethical problems were analysed during a meeting, and how they were solved.

[Psycho-oncology and the present tasks of psycho-oncologists]. / La psycho-oncologie et les tâches actuelles des psycho-oncologues.

This article aims to contribute to a better apprehension by oncologists of the work done by psycho-oncologists, by diminishing misconceptions and misunderstandings end promoting collaboration between them. First, we describe the main aspects of their practice, which is still too poorly apprehended, the landmarks they use (when they support a patient they take into account his/her body, social and professional position, personal and family history, objectives, psychopathology and the family), and the tools they have at their disposal. We then describe how psycho-oncology is currently organised, the "players" in the field and their allies (oncology on one side, social and human sciences on the other) and the main practice and research themes as reported in recent congresses and articles. More and more psychotherapeutic groups, community support, the patient's social, cultural and ethnic specificity and family, information, genetic issues, burn out among care providers, and children are being considered important. We hope this article gives a true image and a sufficiently detailed, though not exhaustive, account of psycho-oncology today, of the range of its possibilities, of its central interests.

Valid informed consent and participative decision-making in children with cancer and their parents: a report of the SIOP Working Committee on psychosocial issues in pediatric oncology.

This is the tenth official document of the SIOP Working Committee on psychosocial issues in pediatric oncology, instituted in 1991. It is addressed to the pediatric oncology community. Children clearly have a right to participate in medical decisions regarding their own treatment, based on the developmental level of the child. The objective of these guidelines is to encourage physicians to share with the child developmentally relevant medical information specific to that particular child's health status, in the context of the child's own culture, so that he or she can actively participate in the decision-making process regarding his or her own health. These guidelines, geared toward this objective, discuss the child's right to medical information, the parents' legal responsibility for but not exclusive right over the child's health, and ways of encouraging the younger child's active participation in his or her own health care at an age-appropriate level of understanding. For adolescents, there should be a full and legally mandated power to make their own decisions regarding medical treatment.

[Difficulties in coping with treatment: causes, solutions]. / Une difficulté d'adaptation au traitement: ses causes, sa résolution.

We present a case of parents who had difficulties accepting their child's treatment (HD chemotherapy and stem cell transplantation) and coping with it. The conversation between the paediatrician and the mother revealed that she feared being dispossessed of her maternal role by the nurses, that constraints would interfere with her relationship with her son, that the medical team would make her feel intellectually, culturally and socially inferior, that the conflict the couple was facing would be exacerbated in this setting. Collaboration between the paediatrician, the nursing staff and the psycho-oncologist allowed these conscious and unconscious elements to be understood. Talking, not conflict nor constraints, served to allay their fears, to avoid inappropriate reactions of the medical team, to preserve the therapeutic alliance. The child accepted this trying treatment because he saw that his parents were reassured about its quality and about preserving their sense of identity and their value. Coping difficulties may stem from fear of treatment (too trying physically and psychologically), from its consequences (destabilisation of the family, the individual's social and professional status, his/her sense of identity), from rekindled old problems that were not adequately solved (jealousy, revolt, trauma, bereavement). Dialogue and team work are necessary to solve them.

A child and parent illustrating non-compliance with treatment: understanding non-compliance with treatment.

BACKGROUND: In children and adolescents non-compliance with treatment is a major concern. To shed light on its mechanisms, we present a family demonstrating non-compliance. PROCEDURE: B, a 10 year-old boy, treated for medulloblastoma, refused high-dose chemotherapy and Autologous Bone Marrow Transplantation. Six psychotherapeutic interviews with B, his parents and staff resolved the causative issues. RESULTS: B's behavior expressed his parents' ambivalence, despite their informed consent. Their reasons were conscious and unconscious, rational and irrational, linked to both the past and present experiences. The mother was convinced that he would die. The discussions helped both parents to assume their parental role, B perceived their ability to truly accept the treatment and support him. CONCLUSIONS: Non-compliance should not be viewed as a child's or parents' intrapsychic problem, but as the result of multi-determined interaction between the child, the parents, the staff interacting with present and past events. When the child's death is a possibility, the parents' ambivalence confuses their understanding and acception of the therapy. The development of confidence between the staff, the child and parents and clear agreement about the goals of therapy is necessary to avoid the occurrence of and escalation of non-compliance, which raises difficult clinical, legal and ethical questions.

Laparoscopic resection of large adrenal tumors.

BACKGROUND: The maximum size of adrenal tumors that should be removed with a laparoscopic approach is controversial. It has been suggested that laparoscopic adrenalectomy is appropriate only for adrenal tumors < 6 cm in size. We report our experience with laparoscopic adrenalectomy in patients with adrenal tumors of > or =6 cm compared with patients with smaller tumors. METHODS: We retrospectively reviewed a consecutive series of patients who had a laparoscopic adrenalectomy. Patients were considered candidates for laparoscopic adrenalectomy if their computed tomography (CT) scan showed a well-encapsulated tumor confined to the adrenal gland. RESULTS: Sixty laparoscopic adrenalectomies were performed in 53 patients. Twelve of the adrenalectomies (20%) were for tumors that were > or =6 cm (median, 8 cm; range, 6 to 12 cm). There have been no local or regional recurrences, but one patient with adrenocortical carcinoma developed pulmonary metastases. When the 12 patients with large tumors were compared with the 36 patients with tumors < 6 cm, the median operative time (190 vs. 180 minutes; P =.32), operative blood loss (100 vs. 50 mL; P =.53), and postoperative hospital stay (2 vs. 2 days; P = 1.0) were similar. CONCLUSIONS: The size of an adrenal tumor should not be the primary factor in determining whether a laparoscopic adrenalectomy should be performed. Large adrenal tumors that are confined to the adrenal gland on CT can be removed with a laparoscopic approach.