Assessing Decision Making Capacity for Do Not Resuscitate Requests in Depressed Patients: How to Apply the "Communication" and "Appreciation" Criteria.

The Patient Self Determination Act (PSDA) of 1991 brought much needed attention to the importance of advance care planning and surrogate decision-making. The purpose of this law is to ensure that a patient's preferences for medical care are recognized and promoted, even if the patient loses decision-making capacity (DMC). In general, patients are presumed to have DMC. A patient's DMC may come under question when distortions in thinking and understanding due to illness, delirium, depression or other psychiatric symptoms are identified or suspected. Physicians and other healthcare professionals working in hospital settings where medical illness is frequently comorbid with depression, adjustment disorders, demoralization and suicidal ideation, can expect to encounter ethical tension when medically sick patients who are also depressed or suicidal request do not resuscitate orders.

End-of-life experiences in adolescents dying with cancer.

PURPOSE: This study explores the experiences of individuals in early, middle, and late adolescence dying from cancer. Place of death, medications used at end of life (EOL), and discussions prior to death are examined. METHODS: Data were obtained from a retrospective review of medical charts from 103 adolescents who died of cancer between 2000 and 2005. RESULTS: Adolescents with leukemia/lymphoma were relatively more likely to die in an intensive care unit (p = 0.028) where cause of death was more likely to be treatment-related (p < 0.001), and EOL discussions more likely to occur in the last 7 days of life (p = 0.002). Anxiolytic use was significantly higher during late adolescence (p = 0.037). CONCLUSIONS: Adolescents have unique developmental needs that should be considered at EOL. Timing of EOL discussions occurred very close to death for a significant number of adolescents, allowing very little time to psychologically prepare for death.

The burden and outcomes associated with four leukemias: AML, ALL, CLL and CML.

Given the recent advances in the treatment of hematologic malignancies and the many other treatments on the horizon, physicians and payers will be faced with the critical decisions of when to use new treatments in the clinical pathway and how to allocate healthcare resources. This review will provide an overall context for the clinical, economic and quality of life burden of leukemia, as well as provide cross-analysis among the four major types of leukemia: acute lymphocytic leukemia, chronic lymphocytic leukemia, acute myeloid leukemia and chronic myeloid leukemia.

Use of virtual reality as a distractor for painful procedures in a patient with pediatric cancer: a case study.

Virtual reality (VR) has been demonstrated as an effective tool to help people overcome a variety of anxiety disorders. In this case study, the use of VR as a distractor to alleviate pain and anxiety associated with an invasive medical procedure for a pediatric cancer patient was explored. An A-B-C-A design during four consecutive medical appointments in an outpatient oncology clinic compared no distraction (A), non-VR distraction on a computer screen (B), and VR distraction with a head set (C). Behavioral observations of distress by the researcher and reports of pain and anxiety by the patient, parent, and nurse were taken before and during the procedure. The child's pulse was monitored throughout the procedure. The findings from this case study suggest benefit from using VR distraction, as indicated by lower pain and anxiety ratings, reduced pulse, and fewer observed behavioral indices of distress. The need for larger scale studies and application of VR with younger children is discussed in the context of confirming effectiveness of this technique and providing more generalizable information about efficacy.

Family factors affecting bone marrow transplantation. A case report.

Bone marrow transplantation (BMT) is the last resort for children with leukemia for whom conventional treatments have failed. The case presented herein is one of an adolescent girl whose parents were unable to cope with the extreme challenge of BMT. Couple- and family-related data collected prior to the BMT showed this family was at risk. Indeed, throughout the ordeal the patient seriously regressed and her parents' reactions appeared to exacerbate her condition. At discharge, when left alone, the patient manifested somatic symptoms which required her parents to attend to her needs. How family factors may influence BMT outcome is discussed.

Parental psychopathology and children's adjustment to leukemia.

OBJECTIVE: The primary purpose of this study was to examine the relationship between parental psychopathology and psychosocial functioning of children in whom acute lymphocytic leukemia (ALL) has been diagnosed. METHOD: The sample consisted of 61 mother-child dyads. Twenty-one (34%) mothers met DSM-III-R criteria for at least one psychiatric disorder based on a Structured Clinical Interview for Diagnosis (SCID). RESULTS: Findings revealed that compared with children whose mothers did not meet DSM-III-R criteria for a psychiatric disorder, children with mothers who evidenced a psychiatric disorder self-reported more anxiety and a maladaptive attributional style and were reported by their mothers as evidencing more depression and a range of internalizing behavioral symptoms. CONCLUSIONS: Although our earlier research suggested that ALL children show relatively few symptoms of psychopathology, the present report reveals high rates of psychiatric difficulties in the mothers of ALL youth. These findings and their implications are discussed within a model that incorporates behavioral pediatrics and developmental psychopathology.

Neurobehavioral effects of central nervous system prophylactic treatment of cancer in children.

This article reviews 41 studies of the effects of prophylactic CNS treatment on the neurobehavioral development of children with cancer. This research is classified according to studies of (a) children in treatment; (b) long-term survivors; and (c) longitudinal follow-ups of children from the time of diagnosis. Studies vary considerably in design, sample, and outcome variables, so firm conclusions regarding the morbidity of CNS prophylaxis are not currently possible. However, the studies do suggest that CNS prophylaxis does impair cognitive development, particularly when cranial radiation therapy is part of the treatment. There is also evidence of greater impairment in younger children and some suggestion of more frequent impairment of non-language skills relative to language skills. The possible relationships among age, radiation, and non-language cognitive skills may be linked to disruption of white matter CNS structures apparent on autopsy and cerebral tomography following treatment.

Prediction of intellectual deficits in children with acute lymphoblastic leukemia.

Possible predictors of reported lower cognitive functioning in irradiated children with acute lymphoblastic leukemia (ALL) were investigated. Thirty-four subjects, 5-14 years old, with ALL in continuous complete remission and without evidence of current or past central nervous system disease, were examined 9-110 months after diagnosis, using standard measures of intelligence and academic achievement. Subjects with a history of post-irradiation somnolence syndrome were significantly older at diagnosis than nonsomnolent subjects. Intelligence (IQ) was found to be unrelated to history of somnolence syndrome. IQ and achievement were unrelated to age at irradiation, irradiation-examination interval, and radiation dosages. The strongest predictor of IQ by far is parental social class. The importance of controlling for social class differences when searching for treatment effects on IQ and achievement is stressed.

[Cognitive functions and school achievement of children who were treated for acute lymphatic leukemia at a young age]. / Cognitieve functies en schoolprestaties van kinderen, die op jonge leeftijd werden behandeld voor acute lymfatische leukemie.

Neuropsychologic tests were performed in 40 children with acute lymphoblastic leukemia. They all had been treated at a young age with systemic chemotherapy, cranial irradiation and intrathecal methotrexate. The test results showed a high risk for learning disabilities. Visual motor integration problems were present early after cessation of treatment, but most cognitive defects became apparent about 2 years after stopping therapy. At that time 23% (9/40) of the children required special school types and 30% (12/40) needed additional help within their residential school. Problems with arithmetic were most prominent. Future study of patients who did not receive prophylactic irradiation of the brain will help to clarify the potential causative role of cranial irradiation in these cognitive defects.

Acute lymphoblastic leukemia: long-term psychological outcome.

Children diagnosed with acute lymphoblastic leukemia (ALL) now have an excellent chance for a medical cure. Nearly 90% can expect to attain an initial remission and the majority of those will remain disease-free. There is increasing concern about the long-term consequences of ALL and its treatment on the psychological adjustment of the survivor. This article selectively reviews the available literature on the neuropsychological and psychosocial adjustment of long-term survivors of ALL. The risk of neuropsychologic deficiencies among children who have remained in continuous remission has been the focus of conflicting findings, while the risk among those who have survived CNS relapse is clearly elevated. Generally, long-term survivors of childhood cancer have a 30-40% risk of school-related problems. Moreover, children treated for ALL with cranial irradiation have 3-4 times the risk of school problems relative to those who are not irradiated. Early identification of problems would facilitate referrals for appropriate intervention and hopefully minimize future difficulties.

Serial neuropsychological studies of a child with acute lymphoblastic leukemia and subsequent glioblastoma multiforme.

A 10-year-old boy had a right posterior parietal glioblastoma 5 years after completing treatment for acute lymphoblastic leukemia. Interim findings included seizures, leukoencephalopathy, diffuse mineralizing microangiopathy, and abnormal changes in neuropsychological test performance, which, in retrospect, provided information about the location of the tumor. This case highlights unusual sequelae of childhood leukemia and its treatment, as well as the value of neuropsychological procedures in assessing functional status and integrity of the brain.