Psychosocial Issues Influence Decisions on BMT Eligibility

AMELIA ISLAND, Florida—Psychosocial factors influence life-or-death eligibility decisions in bone marrow transplant (BMT) procedures, and yet there is a serious lack of consensus as to what these factors are and how they should be weighted, Larry W. Foster, PhD, said at the American Psychosocial Oncology Society (APOS) Third Annual Conference (abstract VII-1). Most BMT clinical protocols have eligibility criteria based on biomedical factors, but evidence is beginning to show that psychosocial factors are also important determinants of outcome after allogeneic transplant. However, there is a dearth of literature on psychosocial eligibility criteria and allogeneic BMT, said Dr. Foster, associate professor of social work, Cleveland State University. "Lacking clarity, psychosocial issues are potentially divisive among members of the multidisciplinary team caring for these patients," he said.

In a pioneering effort to see how professionals actually make these decisions, Dr. Foster, together with associates at the Cleveland Clinic Foundation, surveyed doctors, nurses, and social workers specializing in BMT utilizing a self-administered questionnaire. The investigators asked the survey respondents whether they had ever recommended not proceeding with an allogeneic BMT based on psychosocial problems, if they had ever cared for an allogeneic BMT patient whom they believed should not have been transplanted due to psychosocial reasons, and, finally, whether the decision to proceed with allogeneic BMT is made by a multidisciplinary team or solely by the attending oncologist.

Dr. Foster and his colleagues also constructed 17 case vignettes of different psychosocial problems and asked respondents to indicate whether they would or would not recommend proceeding with allogeneic BMT if any of these vignettes applied (see Table on page 34).

Survey Results

The survey results showed significant differences in characteristics and responses among the professions. The physicians were older and had significantly more experience in BMT than either the nurses or social workers and were also much more likely to have had recommended not proceeding with the procedure based on psychosocial factors.

Nurses were much more likely to have taken care of an allogeneic BMT patient who they believed should not have been transplanted due to psychosocial factors than were either doctors or social workers. "This is remarkable because nurses were least likely to say they had ever recommended not proceeding," Dr. Foster commented.

In answer to the question about who makes the decisions, physicians were significantly more likely than nurses and social workers to say that it was a multidisciplinary effort, whereas nurses and social workers said the decision was made by the attending oncologist.

The majority of respondents said "do not proceed" for 6 of the 16 vignettes: Suicide ideation emerged as the number one reason for a "do not proceed" decision, followed by use of illicit addictive drugs, history of noncompliance, lack of a post-transplant caregiver, alcoholism, and mild dementia or early-onset Alzheimer's disease.

Responses to some vignettes differed significantly among the three groups. For example, in the case of mild dementia, major depression, personality disorder, and prior suicide attempts, nurses were significantly more likely to say "do not proceed" than were physicians or social workers. The most disagreement was over patients with financial difficulties, with nurses less likely than physicians or social workers to say "do not proceed."

Dr. Foster cautioned: "The BMT team must be mindful of the currency, acuity, and severity of the psychosocial issues and their manageability because difficult patients will pose unacceptable tradeoffs in terms of risks and benefits post-transplant, and may place staff at risk for burnout as a result. This is a significant issue, especially for BMT nurses who are on the front lines at the bedside."