EDUCATION OF PATIENTS AND FAMILIES Patients and their families should be educated to expect attention to and treatment of their distress by their primary care team or by an appropriate resource that is viewed by the patient as an extension of the team. They should experience a seamless flow of medical and mental health services. As nearly as possible, psychosocial and psychiatric services should be given in the same site as medical care to reduce embarrassment and ensure easy access to care for seriously medically ill patients and their families.

PATIENTS’ BILL OF RIGHTS This document should explicitly include the patient’s right to management of distress as an integral part of comprehensive cancer care.

ACCOUNTABILITY Regulatory bodies (e.g., Joint Commission on Accreditation of Healthcare Organizations, Health Care Financing Administration) must include in their reports for medical centers the quality of doctor-patient communication and their ability to recognize and treat distress and to refer to the appropriate psychosocial resource.

PROFESSIONAL STANDARDS FOR MENTAL HEALTH AND PASTORAL SERVICES It is essential to have standards for training mental health professionals and pastoral counselors in palliative and end-of-life care, as has been done for physicians and nurses. This is particularly true of pastoral services where cost cutting may lead to use of clergy untrained in counseling techniques. The National Association of Professional Chaplains has developed the requisite standards.

MULTIDISCIPLINARY TEAM The team giving end-of-life care must include a mental health professional and a qualified pastoral counselor either on the team, or available to the team for consultation, as well as a psychiatrist for evaluation and management of neuropsychiatric disorders and depression when patients express the desire for hastened death.

REIMBURSEMENT FOR PSYCHOSOCIAL SERVICES Reimbursement for psychosocial services given at the end of life has to be addressed at a public policy level with attention to the inequity in payment for these services compared to medical services.

RESEARCH Clinical practice guidelines and critical care pathways have proven effective in improving quality of care through the use of evidence-based guidelines. There is a great need to apply this approach to managing the problems of distress so that a gold standard will exist for the psychosocial as well as the physical domains.

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