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Fellows are expected to develop the following competencies in Psychosocial Oncology:

1. Psychosocial Oncology – The competency areas for training in psychosocial oncology were developed by the American Psychosocial Oncology Society and respresents a formal approach to educating oncologists, psychiatrists, psychologists, nurses, and social workers on the psychological and behavioral dimensions of cancer. At the completion of training, fellows will demonstrate knowledge and/or skills in the following areas:

  1. Epidemiology of cancer – Familiarity with the incidence, course, mortality and risk and preventive factors across the most common sites of disease
  2. Medical knowledge – Basic concepts in cancer biology, tumor sites, stages including understanding of role and basic mechanisms of treatments including chemotherapy, radiation, surgery, hormonal interventions, and transplantations, psychoneuroimmunology and cancer.
  3. Fundamental psychosocial aspects of cancer – impact on family, role of family in providing support and caregiver distress, impact of developmental stage of patient/family, gender differences in response to cancer, impact on sexuality, understanding of the psychosocial stages of illness, role of race and SES on adaptation and survival, impact and adaptation of children (as patients and as family members), areas of psychosocial distress by site of cancer
  4. Psychiatric disorders – common disorders among cancer patients: adjustment disorders, depressive disorders, suicide and risk factors, anxiety disorders, delirium, substance abuse disorders, somatoform and factitious disorders, personality disorders, neuropsychiatric side effects of chemotherapeutic agents, metabolic disorders and neuropsychiatric symptoms, psychodiagnostic assessment in the context of complex medical illness, side effects and other physical symptoms
  5. Intervention/Treatment modalities – psychopharmacological, psycholotherapeutic interventions (cognitive, behavioral, cognitive-behavioral, interpersonal, supportive, existential), various therapy structures (individual, group, family, couple) and when to use each, intervention across the disease continuum (diagnosis, treatment, survivorship, recurrence, progression, end of life, bereavement), application of short and long-term therapies, complementary therapies
  6. General psycho-oncologic issues – role of culture in psychosocial adaptation, ethics in clinical and research work with cancer patients, psychosocial oncology research methods, consultation as a psychosocial oncology specialist

2. Palliative Medicine – The competency areas for training in palliative care were developed by the National Consensus Project for Quality Palliative Care. At the completion of training, fellows will demonstrate knowledge and/or skills in the following areas:

  1. Structure and processes of care
    1. Complete comprehensive interdisciplinary palliative care assessment of patient and family including disease status, diagnosis and prognosis, co-morbid medical and psychiatric disorders, physical and psychological symptoms, functional status, social, cultural, spiritual and advance care planning concerns and preferences, patient and family expectations, goals for care and for living, understanding of disease and prognosis, preferences for site and type of care
    2. Assess adjustment of children with consideration of age and stage of neurocognitive development
    3. Contribute to plan of care developed with input of patient, family, caregivers, involved health care providers, palliative care team, other specialists, and other involved parties (school personnel, clergy, patient friends, etc.)
    4. Clearly document and communicate plan of care with all involved health professionals when patients transfer to different care settings
    5. Assist with treatment decisions based on goals of care, assessment of risk and benefit, best evidence, and patient/family preferences with regular review of the plan of care with the patient and family considering changing benefits/burdens at critical decision points during the course of illness
    6. Learn to prioritize referrals and respond in a timely manner
    7. Assume an active role in quality improvement in the areas of safety, timeliness, patient/family-centered care, beneficial and/or effective care, equitable care
    8. Develop an awareness of the emotional impact of palliative care work and take active steps to reduce caregiver burnout
    9. Gain experience working in inpatient, outpatient, community, and home settings to ensure the best possible continuity of care
    10. Provide transdisciplinary care including an understanding of the role of surgical, medical, and radiation oncology, nursing, social work, palliative medicine, and pastoral care

  2. Physical aspects of care
    1. Conduct comprehensive, systematic symptom assessment including pain and non-pain symptoms including but not limited to dyspnea, nausea, fatigue, weakness, anorexia, insomnia, anxiety, depression, confusion, and constipation
    2. Recognize that the relief of suffering must be comprehensive, addressing physical, psychological, social and spiritual aspects
    3. Understand the variability in symptom assessment based on age (child, adult, older adult), cognitive impairment, gender, race, SES, and phase of illness (initial diagnosis vs end of life)
    4. Incorporate non-pharmacologic, complementary, and supportive therapies in treating distressing symptoms and side effects including cognitive-behavioral management of pain, dyspnea, and insomnia
    5. Serve as a patient advocate in order to ensure the pain and symptom management is safe, timely, and documented and to achieve a level of symptom control that is acceptable to the patient
    6. Address barriers to effective pain management including fears of the risks of side effects, addiction, respiratory depression, and hastening of death in association with opioid analgesics
    7. Coordinate with the palliative care and primary teams to develop risk management plans when controlled substances are prescribed for symptom management
    8. Assess patient and family understanding of disease and its consequences, symptoms, side effects, functional impairments and treatments, ability to cope, families ability to provide necessary care and patient’s ability to secure and accept needed care
    9. Educate families regarding their important role in symptom management including non-pharmacologic and pharmacologic symptom management interventions

  3. Psychological and psychiatric aspects of care
    1. Assess and treat or provide guidance on management of common psychiatric co-morbidities of serious illness including depression, anxiety, delirium, and cognitive impairment
    2. Assess and provide assistance for patients and families experiencing psychological reactions to serious illness including stress, anticipatory grief, adaptation to multiple losses, functional decline, fears of recurrence and death, and family adjustment difficulties
    3. Assess patient and family understanding of disease, symptoms, side effects and treatments as well as caregiving needs, capacity, and coping strategies
    4. Ensure that pharmacologic, non-pharmacologic, and psychotherapeutic measures are employed in the treatment of psychological disorders and psychological distress as appropriate. Review and clearly document treatment alternatives, allowing the patient and family to make informed decisions.
    5. Regularly re-evaluate and clearly document patient and family distress and treatment plan
    6. Identify psychiatric comorbidities in family/caregivers and provide treatment or refer for appropriate care
    7. Provide developmentally appropriate assessment and support to pediatric patients, their siblings, and the children or grandchildren of adult patients
    8. Communicate with children and cognitively impaired individuals using verbal, nonverbal, and/or symbolic means appropriate to their developmental stage and cognitive capacity
    9. Base treatment decisions on goals of care, assessment of risk and benefit, best evidence and patient/family preferences
    10. Facilitate and promote adjustment and support opportunities for emotional growth, healing, reframing, completion of unfinished business at the end of life
    11. Provide support and education through the bereavement period for surviving family members
    12. Utilize quality improvement efforts to monitor the effectiveness of treatment and alter clinical practice as indicated
    13. Develop an understanding of grief risk assessment to prevent complicated grief, depression, and other co-morbid behavioral patterns
    14. Direct surviving parents to resources to assist with their own grief and that of their children
    15. Refer to other health care professionals (e.g., chaplains, social workers, support groups, educational programs, children’s grief programs) when clinically indicated

  4. Social aspects of care
    1. Complete and document a comprehensive social assessment including family structure and geographical location, relationships, lines of communication, existing social and cultural network, perceived social support, medical decision-making, work and school activities, finances, legal issues, sexuality, intimacy, living arrangements, caregiver availability, and access to transportation, prescription medications, nutrition, necessary equipment, and community resources including contact with school and work settings as needed.
    2. Collaborate with members of the primary medical team including social work to ensure that patient and family goals of care are met, to provide information and assist with decision-making, to complete advance care planning, determine wishes, preferences, hopes, and fears, provide emotional and social support, and enhance communication
    3. Plan interventions to minimize the adverse impacts of caregiving on the family and to promote caregiver and family goals and well-being
    4. Regularly re-evaluate family social needs and monitor implementation of social plan of care
    5. Refer to services to meet identified social needs and promote access to care, help in the home, school or work, transportation, rehabilitation, medications, counseling, and other community resources and equipment

  5. Spiritual, religious, and existential aspects of care
    1. Explore and document spiritual and existential concerns including but not limited to life review, assessment of hopes and fears, meaning, purpose, beliefs about afterlife, guilt, forgiveness and life completion tasks
    2. Incorporate assessment of religious or spiritual/existential background, preferences and related beliefs, rituals and practices of the patient and family into comprehensive psychosocial assessment
    3. Refer to pastoral care as indicated for spiritual/existential care needs and support for issues of life completion in a manner consistent with the patient and family’s cultural and religious values
    4. Facilitate contact with spiritual/religious communities, groups or individuals as desired by the patient and/or family with access to clergy in their own religious traditions
    5. Understand and respect religious diversity
    6. Periodically re-evaluate the impact of spiritual/existential interventions
    7. Coordinate with pastoral care to arrange for religious or spiritual rituals as desired by the patient and family, especially when death is imminent
    8. Document spiritual needs and care to allow for quality improvements in clinical care

  6. Cultural aspects of care
    1. Elicit and document the cultural background, concerns and needs of the patient and their family
    2. Address cultural needs in the care plan including but not limited to language needs (e.g. interpreter services), dietary and ritual practices
    3. Respect patient and family cultural preferences regarding disclosure, truth-telling, and decision-making in communication practices

  7. Care of the imminently dying patient
    1. Recognize transition to actively dying phase, when possible, and communicate to patient, family, and staff
    2. Address end of life concerns, hopes, fears, and expectations openly and honestly in the context of social and cultural customs in a developmentally sensitive manner
    3. Assess, document, and ensure treatment of symptoms at the end of life based on patient-family preferences
    4. Document patient and family wishes regarding care setting for the death and ensure that any inability to meet these preferences is addressed by the team
    5. Introduce hospice care as an option as the patient declines in coordination with patient’s primary care team
    6. Educate families regarding the signs and symptoms of approaching death in a developmentally, culturally, and age-appropriate manner

  8. Ethical and legal aspects of care
    1. Inquire about patient and/or surrogate and family wishes and ensure that these form the basis of the care plan
    2. Ensure that the adult patient with decisional capacity determines the level of involvement of the family in decision-making and communication about the care plan
    3. Seek and document patient preferences in the medical record. Advocate for patients such that failure to honor these preferences is documented and addressed by the team
    4. For minors with decision-making capacity, document the child’s views and preferences for medical care, including assent for treatment, and give appropriate weight in decision-making. When the child’s wishes differ from those of the adult decision-maker, ensure that appropriate professional staff members are available to assist the child.
    5. Promote advance care planning as a means of understanding and communicating about the patient’s or surrogate’s preferences for care across the health care continuum.
    6. When patients are unable to communicate, seek to identify advance care directives, evidence of previously expressed wishes, values and preferences, and the appropriate surrogate decision makers.
    7. Educate surrogate decision-makers on the legal and ethical bases for surrogate decision-making, including honoring the patient’s known preferences, substituted judgment, and best interest criteria
    8. Develop an awareness of and ability to educate others regarding common ethical concerns encountered in palliative care, using ethical principles to prevent or resolve ethical dilemmas including: beneficience, self-determination and informed consent, capacity assessment, confidentiality, assent and permission for persons not of legal age to consent, justice and non-maleficence, avoidance of conflicts of interest, cultural variations in truth-telling, disclosure, decisional authority and decisions to forego therapy, and role of children and adolescents in decision-making
    9. Seek to prevent, identify, and resolve ethical dilemmas of families related to specific interventions, withholding or withdrawing treatments (including nutrition and hydration), understanding DNR orders and the appropriate use of sedation in palliative care
    10. Consult with and understand the role of institutional ethics committees in resolving patient, staff, family conflicts
    11. Understand and apply the APA Ethical Principles of Psychologists and Code of Conduct to palliative care practice
    12. Develop knowledge of legal and regulatory issues in palliative care including federal and state statutes and regulations regarding medical decision-making, advance care planning and directives, the roles and responsibilities of surrogate decision-makers, barriers to pain relief, legal requirements for the use of controlled substances and the imperative that regulatory policy not interfere with patient care, pronouncing death, request for autopsy and organ transplant, and legal documentation requirements
    13. Advise patients and families of the need to seek professional advice on creating or updating property wills and guardianship agreements