Cancer, Trauma and Care

The sound cancer mostly creates a panic environment when it’s supposed to involve our near and dear ones. It bites the nerves of the person, nerves of the family as well as the nerves of the surrounding society. We are in great trouble to cope the situation regarding the past, present, and future of this cancer. It breaks the physical, psychological, social, financial as well as spiritual equilibrium of the person. Along with the physical problem cancer patients and their caregivers suffer from psychological problems as well.

Mental breakdown happens mostly

• At or shortly after diagnosis
• At the time of the first recurrence
• As death approach

Most common disorders are Anxiety Disorders, Depressive Disorders, Adjustment Disorders but other different psychiatric disorders can be found.

1. Anxiety Disorders: Most common Psychiatric morbidity for the cancer patients is the anxiety disorders. Among the Anxiety disorders, Generalized Anxiety Disorder (GAD), Phobic Disorder, Panic attacks or disorder, mixed anxiety and depressive disorder may be found.
2. Depressive disorders: About 25% of the patients suffer from Depressive disorders. Reviews showed the prevalence of depression ranges from 3-69% among the cancer patients.

3. Adjustment disorders: About 20% of the cancer patients suffer from adjustment disorders as the disease breaks the existing equilibrium in all aspects of the patients as well as the family members.

4. Suicide

Ventilation of the news

It creates a difficult situation for both for the patient party, the caregiver or the family members as well as the physicians to communicate the diagnosis of cancer. In our socio-cultural aspects, we prefer not to tell the diagnosis to the patients as well as we create such an environment that the most of the patients can realize that he/she has a major illness. Ethically every patient has the right to know his/her diagnosis. Research shows that, in general, most patients want to know the truth about their condition. Various studies of patients with malignancies show that 80 to 90 percent want to know their diagnosis. Breaking news of terminal illness to the patients may help to complete the planned works of their last days.

Reaction to bad news

Elisabeth Kubler-Ross, a psychiatrist, and thanatologist made a comprehensive and useful organization of reactions to impending death.

Stage 1: Shock and Denial

On being told the bad news, persons initially react with shock. They may appear dazed at first and then may refuse to believe the diagnosis; they may deny that anything is wrong. Some persons never pass beyond this stage and may go from doctor to doctor until they find one who supports their position. The degree to which denial is adaptive or maladaptive appears to depend on whether a patient continues to obtain treatment even while denying the prognosis. In such cases, physicians must communicate to patients and their families, respectfully and directly, basic information about the illness, its prognosis, and the options for treatment. For effective communication, physicians must allow for patients’ emotional responses and reassure them that they will not be abandoned.

Stage 2: Anger

Persons become frustrated, irritable, and angry at being ill. They commonly ask, “Why me?”. They may become angry at God, their fate, a friend, or a family member; they may even blame themselves. They may displace their anger onto the hospital staff members and the doctor, whom they blame for the illness. Patients in the stage of anger are difficult to treat. Doctors who have difficulty understanding that anger is a predictable reaction and is really a displacement may withdraw from patients or transfer them to other doctors’ care.

Stage 3: Bargaining

Patients may attempt to negotiate with physicians, friends, or even God; in return for a cure, they promise to fulfill one or many pledges, such as giving to charity and attending church regularly. The treatment of such patients involves making it clear that they will be taken care of to the best of the doctor’s abilities and that everything that can be done will be done, regardless of any action or behavior on the patients’ part.

Stage 4: Depression

In the fourth stage, patients show clinical signs of depression, withdrawal, psychomotor retardation, sleep disturbances, hopelessness, and, possibly, suicidal ideation. The depression may be a reaction to the effects of the illness on their lives (e.g., loss of a job, economic hardship, helplessness, hopelessness, and isolation from friends and family), or it may be in anticipation of the loss of life that will eventually occur.

Stage 5: Acceptance

In the stage of acceptance, patients realize that death is inevitable, and they accept the universality of the experience. Their feelings can range from a neutral to a euphoric mood. Under ideal circumstances, patients resolve their feelings about the inevitability of death and can talk about facing the unknown. Those with strong religious beliefs and a conviction of life after death sometimes find comfort.

Ways of Communication

When breaking the news of impending death to the patient, as when relating any bad news, diplomacy and compassion should be guiding principles. Often, the bad news is not completely related during one meeting, but rather is absorbed gradually over a series of separate conversations. Advance preparations, including scheduling sufficient time for the visit, researching pertinent information, such as test results and facts about the case, and even arranging furniture appropriately can only make the patient feel more comfortable.

[wp_ad_camp_4]If possible, these conversations should take place in a private, suitable space with the patient on equal terms with the physician (i.e., the patient dressed and the physician seated). If it is possible and desired by the patient, the patient’s spouse or partner should be present. The treating physician should explain the current situation to the patient in clear, simple language, even when speaking to highly educated patients. Information may need to be repeated or additional meetings may be necessary to communicate all of the information. A gentle, sensible approach will help modulate the patient’s own denial and acceptance. At no time should physicians take their patient’s angry comments personally, and they should never criticize the patient’s response to the bad news.

Physicians can signal their availability for honest communication by encouraging and answering questions from patients. Also, physicians should make it clear to their patients that they are willing to see them through until death occurs. Ultimately, physicians must choose how much information to give and when on the basis of each patient’s needs and capacities.

The same general approaches apply as physicians seek to comfort members of the patient’s family. Helping family members deal with feelings about the patient’s illness can be just as important as comforting the patient, because family members are often the main source of emotional support for patients.

Telling the Truth

Tactful honesty is the doctor’s most important aid. Honesty, however, need not preclude hope or guarded optimism. It is important to be aware that if 85 percent of patients with a particular disease die in 5 years, 15 percent are still alive after that time. The principles of doing good and not doing harm inform the decision of whether to tell the patient the truth.

Doctors, however, should ask patients how much they want to know because some persons do not want to know all the facts about their illness. Such patients, if told the truth, deny that they ever were told, and they cannot participate in end-of-life decisions, such as the use of life-sustaining equipment. The patients who openly request that they not be given â bad news are often those who most fear death. Physicians should deal with these fears directly, but if the patient still cannot bear to hear the truth, someone closely related to the patient must be informed. Patients may take part in the decision of the terminal care services as well as the family members.

SPIKES Protocol can be used to break the news

S- Setting up the interview:

Appropriate environment, privacy, glass of water, tissue box,  presence of close relatives, sitting in front of the patient, eye to eye contact, appropriate time set up

P– Assessing the patient’s Perception:

Actively listening to the problems, previous investigation finding, understanding the current condition of the patient, treatment steps and any further details with full empathy.

I – Obtaining the patient’s Invitation:

Intelligently physician have to find out that how much they want to know and have to tell the truth positively  technically avoiding negative words.

K– Giving Knowledge and information to the patient:

Physicians have to provide facts gradually in easy language, positively without any false hope to the patients, further steps of investigations, treatment, and further care.

E– Addressing patient’s emotions and empathic response:

Physicians have to be prepared regarding the emotional outbreaks of the patient, relatives, and caregivers as well as to address the further steps with an empathic response.

S– Strategy and summary:

At last, the meeting should be closed after summarizing the key information and strategy for further steps. There should have another meeting schedule if the patient or relatives demand.

Holistic care for cancer patients

Cancer bites every aspect of life. So, there should have a holistic care for the terminally ill patients.  That care starts with relieving the physical symptoms, minimizing the psychological discomforts, increasing the social support by ensuring appropriate use of our social capital and all of the care circled by the spiritualistic care.