The sixth vital sign: Patient distress

Detecting distress is the first step to helping patients recover.distress June15

When going to see a health care provider for an office visit, we expect to be asked about our physical health and have a physical exam that measures our vital signs. Emotional health, sometimes called the sixth vital sign, is harder to figure out. In fact, emotional or psychosocial problems can persist for years without a provider being aware that their patient is in distress.

This has changed for cancer patients, many of whom do experience high levels of distress. The National Comprehensive Cancer Network describes distress as “an unpleasant emotional experience of a psychosocial, social, and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment.” So what is being done to address this?

The American College of Surgeon’s Commission on Cancer requires all cancer centers it accredits to have in place a process so that all diagnosed cancer patients can be screened at prescribed intervals for issues that negatively impact treatment and outcomes. Patients who have concerns are then provided with resources and or referrals to behavioral health professionals. This kind of distress screening takes place routinely at the U-M Comprehensive Cancer Center and patients are quickly matched with services that can help.

Since distress is all encompassing, exists on a continuum, and is subjective, it is very difficult to measure. In order to help both the patient and provider, there are a series of “distress screening tools” available including:

  • The NCCN Distress Thermometer looks like a temperature thermometer and asks the patient to rate their level of distress over the past 7 days using a scale ranging from “no distress” (cold) to “extreme distress” (hot)
  • The Edmonton Symptom Assessment Tool asks cancer patients to rate their level from 0 (none)-10 (worst) of the following symptoms: pain, tiredness, nausea, depression, drowsiness, shortness of breath, anxiety, appetite, and wellbeing
  • Brief Symptom Inventory consists of a five point scale assessing nine symptom areas: somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism
  • Psychological Distress Inventory consists of a five point scale looking at 13-items which measure psychological distress

A distress tool is completed by the patient before (ideally) or during the clinic visit and then given to the health care provider who reviews them with the patient. Depending upon the level of distress and the areas of distress noted the health care provider then either work with the patient to identify ways to address their areas of concern, or they may bring in other health disciples such as nurses, social works, chaplains, counselors, or psychologists to assist the patient. They may also refer the patient outside the cancer center to other community resources or local support groups. The provider and patient must establish a plan, and must follow-up again in a specified period of time just as they would to treat a physical complaint.

There are many benefits to the implementation of such screenings including a more holistic approach to care as other needs besides the physical are being addressed and treated, early identification and intervention for patients experiencing difficulties, and improved quality of life for patients.

Continue reading about distress and tools to reduce it:

Still have questions? Call the nurses at the University of Michigan Cancer AnswerLine™. They can help patients or their loved ones find a clinical trial or provide insights into the newest and latest cancer treatments. Feel free to call at 1-800-865-1125 or send an e-mail.


SusanDaron no captionThe Cancer AnswerLine™ nurses are experienced in oncology care, including helping patients and their families who have questions about cancer. These registered oncology nurses are available by calling 800-865-1125 Monday through Friday, 8 a.m. – 5 p.m. Your call is always free and confidential.



University of Michigan Comprehensive Cancer CenterThe University of Michigan Comprehensive Cancer Center’s 1,000 doctors, nurses, care givers and researchers are united by one thought: to deliver the highest quality, compassionate care while working to conquer cancer through innovation and collaboration. The center is among the top-ranked national cancer programs, and #1 in Michigan according to U.S. News & World Report. Our multidisciplinary clinics offer one-stop access to teams of specialists for personalized treatment plans, part of the ideal patient care experience. Patients also benefit through access to promising new cancer therapies.