TABLE 4.

Suggested actions based on literature

Root Causes	Suggested Actions
Triggers to assess	Develop a checklist using the NCCN distress management guidelines that includes warning signs and appropriate interventions to supplement the NCCN distress thermometer.18,23 Conduct a distress assessment in concordance with the NCCN distress management guidelines.18 Provide transition interventions including close follow-up, home visits, or engagement with mental health services.24–26 Identify and resolve factors that may contribute to patients leaving AMA, such as patient-provider communication, access to social services, or engaging family in decision-making conversations.24–26
Communication deficits	More widespread implementation of a comprehensive cancer center with interdisciplinary teams in one physical location.27–29 Develop a position dedicated to overseeing the entirety of patients care, such as a patient navigator or nurse case manager.29–31 Increase use of shared-decision making cognitive aids to solicit patient preferences.32 Establish a private consultation area for distress assessments and discussions.13
Response to mental health problem	Develop a checklist using the NCCN distress management guidelines that includes warning signs and appropriate interventions to supplement the NCCN distress thermometer.18,23 A psychiatric liaison provider should be placed in outpatient clinics to help coordinate mental health care. This would be a regularly scheduled person with an integrated presence for improved access and an easier follow-up system.13,27–29,33
Mental health treatment	Frequently refer to the NCCN distress guidelines to ensure mental health treatment is adequate (eg, patient’s current mental health status requires visit every 3 months rather than every 6 months).18
Pain	Conduct a pain assessment in concordance with the NCCN adult cancer pain guidelines.18 Use a multimodal approach to ensure optimal pain relief and minimal adverse effects.18
Assessment/referral	Conduct a distress assessment in concordance with the NCCN distress management guidelines.18