The Sixth Vital Sign


I learned recently that Canada’s National Comprehensive Cancer Network officially recognizes emotional distress as cancer’s sixth vital sign. (The vital signs apply to any disease or injury. They include temperature, respiratory rate, pulse rate, and blood pressure; under some circumstances, pain is the fifth; and the NCCN recognizes distress as the sixth vital sign as it applies to cancer.)

I think emotional distress stemming from a cancer diagnosis is completely understandable; it starts the moment a patient learns their diagnosis and continues, in varying intensity, throughout the disease’s progression and treatment. Measuring it is as important as measuring the other vitals. It may affect them profoundly.

The Oxford English Dictionary defines distress as “a feeling of great worry or unhappiness; great suffering.” It’s a natural and deeply human reaction to our innate fear of the unknown. Distress may affect a patient’s mental health, which may, in turn, affect their physical health.

But why does distress, as the sixth vital sign, have to pertain only to cancer?

Without minimizing its seriousness in any way, I’d like to point out that cancer is not the only acute or chronic illness that’s life threatening and life changing. Autoimmune disease such as diabetes, multiple sclerosis, vasculitis, pernicious anemia, asthma, and yes, rheumatoid disease all fit the description, as well.

Rheumatoid disease’s main target is the synovial joints, where it causes frequent, sometimes severe pain and damage. But it can also attack and damage the linings of the heart and lungs, the kidneys, and the vascular system. Damage to these organs is potentially deadly. The damage it can do to other organs like the eyes, the ears, and the larynx, may not be deadly, but it can absolutely cause changes that may affect nearly every aspect of a person’s life.

The drugs prescribed to treat RD may also be life-threatening—even as they help control the disease and its symptoms. Non-steroidal anti-inflammatory drugs (NSAIDs) can sometimes relieve a great deal of RD’s inflammation and pain, but they’re also extremely hard on the stomach, and some can cause deadly liver damage.

DMARDs (disease-modifying anti-rheumatic drugs) like methotrexate and plaquenil, can slow the disease’s progression down to a creeping crawl. But these, too, may come at a high price. Many of them have potentially serious or even deadly side-effects, including suppressing the immune system to the point that it’s hard put to fight off common infections. A cold can easily turn into pneumonia; a small cut that might not have been a problem before might become quickly—and dangerously—infected. Biologic DMARDs—the newest and most miraculous of the type in terms of relieving symptoms and slowing disease progression—work by suppressing the immune system even more efficiently. They pose the same potential dangers to those who use them.

RD is also, like cancer, a life-changing or life-altering disease. Its symptoms—swelling and stiffness, pain, malaise, fatigue, low-grade fever—can affect the patient’s every waking moment. They can also cause insomnia. The pain, along with the damage RD does to the joints, can cause sometimes permanent, profound disability. This, too, is life-altering.

And finally, unlike some cancers, there is no cure for rheumatoid disease. The person who has it can pretty much expect a lifetime of battling pain and disability, and of taking powerful, potentially deadly drugs in an attempt to relieve their pain and other symptoms, and slow the progression of the disease.

We should be treating emotional distress as seriously as we treat an elevated temperature or blood pressure. It can have a profound effect on our RD and our overall health. It may not be as simple to measure, but I believe it can be just as important.

Given all of this, in what way is RD not as emotionally distressing as cancer? I believe our American medical institutions need to give it, and pain, their serious consideration as the fifth and sixth vital signs. Patients are more than bodies that are ill or diseases alone. By recognizing these, doctors may more successfully treat their patients as individuals with hopes, fears, and lives.


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