How can morale be improved in patients with Hepatocellular Carcinoma (HCC)?

Improving Morale in Patients with Hepatocellular Carcinoma

Psycho-oncological support is strongly recommended for all HCC patients according to their condition, as it directly addresses psychological distress and improves quality of life. 1

Core Interventions for Morale Enhancement

Psycho-Oncological Support (Primary Recommendation)

• Implement structured psycho-oncological support as a standard component of HCC care, which has been shown to reduce negative feelings and enhance health-related quality of life 1, 2
• Address the five key domains that impact patient morale: physical symptoms, psychological distress (depression and anxiety), social function and stigma, spiritual wellbeing, and pervasive uncertainty 3
• Psychosocial interventions specifically reduce depression, anxiety, and feelings of uncertainty while improving overall quality of life 2

Symptom Management to Preserve Morale

Effective symptom control is critical because unrelieved symptoms directly worsen functional status, mood states, and quality of life 1. Pain management follows a stepwise approach:

• For mild pain: Acetaminophen (paracetamol) up to 3 g/day orally or intravenously is the preferred first-line agent 1
• For moderate-to-severe pain: Opioids are the drugs of choice, but must be paired with a proactive purging program using osmotic laxatives to prevent constipation and hepatic encephalopathy 1
• Avoid NSAIDs entirely in patients with underlying cirrhosis due to risks of gastrointestinal bleeding, ascites decompensation, and nephrotoxicity 1

Addressing Psychological Distress with Caution

• Exercise great caution when prescribing psychoactive drugs, particularly benzodiazepines, in patients with cirrhotic liver dysfunction due to increased risk of falls, injuries, and altered mental status 1
• This creates a clinical challenge: psychological distress requires treatment to maintain morale, but standard anxiolytics carry significant risks in this population 1
• Non-pharmacological psychological interventions should be prioritized over benzodiazepines whenever possible 1

Factors That Improve Morale Based on Evidence

Social and Informational Support

• Morale and social interactions improved significantly in HCC patients receiving comprehensive supportive care, with 16% able to return to work outside the home and 6.6% undertaking recreational travel 1
• Satisfaction with medical services correlates positively with better quality of life and morale 2
• Address the stigmatization of liver disease explicitly, as this impacts psychological wellbeing throughout the disease trajectory 4

Adequate Nutrition

• Adequate nutrition is recommended according to the patient's condition as part of comprehensive supportive care 1
• For patients with weight loss and reduced nutrient intake, supplemental parenteral nutrition may provide benefit when oral/enteral feeding is inadequate 1
• Nutritional support for patients surviving longer than 3 months on home parenteral nutrition showed improved or stabilized quality of life 1

Spiritual Wellbeing and Sense of Meaning

• Spiritual wellbeing and sense of self are central to quality of life in HCC patients 3
• Effective symptom management allows patients and families to focus on maintaining hope, reaffirming important connections, and attaining a sense of completion 1

Stage-Specific Considerations

For Terminal Stage HCC (BCLC Stage D)

• Only symptomatic management is indicated—no tumor-directed treatment should be pursued 1
• Focus exclusively on palliative and psychological support, pain management, and nutrition 1
• Life expectancy is approximately 3-4 months, making quality of remaining time the paramount concern 1

For Earlier Stage Disease

• Palliative care integration throughout the disease trajectory can complement treatments and improve outcomes 4
• Early palliative care helps with advanced care planning, decision-making support, and coping with prognostic uncertainty 4

Common Pitfalls to Avoid

1. Do not wait for severe symptoms before addressing psychological needs—proactive psycho-oncological support is more effective 1

2. Do not prescribe benzodiazepines routinely for anxiety in cirrhotic patients without carefully weighing fall risk and mental status changes 1

3. Do not use NSAIDs for pain control in patients with portal hypertension or cirrhosis, despite their effectiveness in other cancer populations 1

4. Do not neglect the social/family dimension—HCC patients actually report better social/family quality of life compared to the general population when properly supported 2

Multidimensional Assessment

Monitor these specific factors that correlate with morale:

• Depression and anxiety levels (negative correlation with quality of life) 2
• Uncertainty about prognosis and treatment (negative correlation) 2
• Physical symptoms: pain, fatigue, nausea, appetite loss (negative correlation) 5, 2
• Performance status and liver function (positive correlation with better morale) 2
• Social support and financial stability (positive correlation) 5

The evidence consistently demonstrates that morale in HCC patients requires addressing physical, psychological, social, and spiritual domains simultaneously, with psycho-oncological support serving as the cornerstone intervention 1, 3, 2.