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Cognitive behavioural therapy in palliative care. Kathy Burn. Cognitive Behavioural Therapy Lead Clinical Nurse Specialist St Christopher’s Hospice. Teaching foundation level skills Delivering CBT in a palliative care setting. CBT in palliative care.
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Cognitive behavioural therapy in palliative care. Kathy Burn. Cognitive Behavioural Therapy Lead Clinical Nurse Specialist St Christopher’s Hospice.
Teaching foundation level skills • Delivering CBT in a palliative care setting
CBT in palliative care It is possible to train clinical nurse specialists in basic CBT skills. Training increases both knowledge and reported use of CBT skills. Nurses valued the addition of these skills in clinical practice. The addition of CBT skills to the work of clinical nurse specialists significantly reduced the anxiety experienced by terminally ill patients. Moorey et al (2009).
Mean HADS Anxiety Scores 56% 19%
We have now developed and accredited two levels of course via City & Guilds: • Foundation level CBT knowledge • Competency level ‘CBT first aider’ course
Cognitive behavioural therapy in palliative care: evaluation of staff following a foundation level course
International Journal of Palliative Nursing 2017, Vol 23, No 6
Dissemination: Staff have their own beliefs that may limit a consultation: • ‘It is too distressing to probe about the distress.’ • ‘I need to calm the patient and offer reassurance’. • ‘This person needs to speak to someone more experienced’ or ‘I need to be the expert and come up with a plan’. • ‘Asking lots of questions and using assessment tools is intrusive and unkind’. • ‘Reality is bad, they are dying and it is awful; there is no place for CBT’. • ‘They feel guilty for causing their illness- its true’. • ‘Dying patients need TLC and reassurance not CBT’. • Bringing these thoughts and beliefs into consciousness, means they can be tested and loosened, to allow the professional to explore a different way of working.
Incorporating CBT into a standard assessment, as the physical is so central to the problem. • Useful and useable map of the issue. • Allows for shared collaborative goals. • Allows the team to formulate and even predict.
Jenny • Small cell lung cancer with brain metastases and was very breathless and unwell, with a prognosis of a few weeks. • Many breathless people fear dying at the height of a breathless episode, breathing so fast their ‘breathing switches off,’ or their heart beats so fast ‘it can’t go on and so stops.’ • However, her actual worst fear, in a breathless attack was not getting ‘enough oxygen in’ her lungs. • She feared long-term brain damage and living in a vegetative state unable to communicate her wishes. • Mindreading can get in the wayof careful listening, empathy and hearing fears.
Ray • In contrast, Ray panicked when his breathing was gentle, calm and relaxed. • He had heart failure and feared that when his breath slowed it too would ‘fail and switch off’ – he was terrified he would literally forget to breathe. • Believing we understand the thoughts behind a patient’s obvious distress means we may accurately empathise emotionally but fail to empathise cognitively.
Jason • Jason was 36 and quadriplegic. He was ventilated with a tracheostomy and needed 24 hour care. • He only left the nursing home to attend medical appointments. He was described as disruptive, aggressive, angry and unreasonable. • He was able to communicate via his eyes and via a ‘pointer’ attached to his head to write using an iPad. He very slowly spelled out how hopeless, sleep deprived and depressed he felt. • It would have been very easy to fall into the trap of thinking that this was in fact a hopeless situation and Jason could never feel better than this.
Jason (2) • Jason completed the HADS (Hospital Anxiety and Depression Scale; Zigmond and Snaith, 1983) and an activity diary rating his mood. • He recorded a mainly 2/10 with one pleasure rating of 6/10. The diary gave both him (and me!) hope that his mood could shift in the same way as someone in less extreme circumstances. • This led to a change from lying in bed all morning, declining to wash, to a day of planned activity. • 8/10! He even managed to engineer things so he missed the bus back and got to stay out for longer. He scored this very highly on achievement!
Empathising with the physical symptoms: • The five areas model, which gives equal weight to physical, cognitive, emotional and behavioural factors, is especially helpful in medical settings. • The acknowledgement of the importance and influence of physical symptoms allows the therapist to start working from where the patient perceives their problem to be. • ‘Ruth’ was certain her pain was entirely physical. • ‘Jan’ had a lump in her throat, was certain her cancer had spread and that she would gradually become unable to swallow at all and would die struggling for breath. • ‘Ian’ was frightened to sleep incase he died in his sleep
CBT is incorporated at a basic level into a standard assessment, as the physical is so central to the problem. • Working with people with life-threatening and life-limiting illness can be extremely rewarding as well as challenging. • It may be a one off session at the bedside of a very unwell person or a complex course of therapy, never dull!
……questions? k.burn@stchristophers.org.uk
