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GOOD MORNING! PSYCHOLOGOCAL ASPECTSTERMINAL ILLNESS

Dr Sudha SarnaProfessor Palliative Medicine

PSYCHOLOGICAL RESPONSES…

They occur with major loss of any kind:

� Loss of a job� Amputation� Divorce� Bereavement� Anticipated loss of

one’s own life

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WHEN…

Psychological responses do not occur in sequence.

Oscillations in patient’s

feelings are natural and

When Do They Occur

1. At or shortly after diagnosis

2. At first recurrence

3. As death approaches

natural and common. approaches

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PSYCHOLOGOCAL ASPECTSTERMINAL ILLNESS

1. Emotional Reactions2. Denial3. Collusion4. Anger5. Anxiety6. Depression7. Paranoid Problems8. Family Problems

WHAT…PHASE SYMPTOMSPHASE SYMPTOMS

DISRUPTION(Days to Weeks) Disbelief, Denial, Shock/numbness,

Despair

DYSPHORIA(Weeks to Months) Anxiety, Insomnia, Poor

Concentration, Anger, Guilt, Sadness, Depression, Activities Disrupted

ADAPTATION(Months) Implications confronted, New goals

established, Hope refocused and restored, Activities resumed

1. HANDLING EMOTIONAL REACTIONS DIFFERENT FACIAL REACTIONS!

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DIFFERENT FACIAL REACTIONS! HANDLING EMOTIONAL REACTION

� Acknowledge the reaction

� Explore concerns

� Allow the patient to express feelings

� Help the patient to take a decision

� Remain silent if we do not have an answer

Do not find solutions for the � Do not find solutions for the patient

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CALM & PEACEFUL MIND! “The Tumour Is Getting Bigger”

ROLE PLAY

“THE TUMOUR IS GETTING BIGGER”

PATIENT:“My tumour is getting

bigger!”

DOCTOR:“Yes, it was 4 mm and

now it is about 6mm.”

Physicians are trained to be medically oriented, not

psychologically oriented; this is the communication

gap.Patients often express their

emotions very indirectly when they complain, this represents an opportunity

for doctors to acknowledge the

emotions of the patients

THINK OVER!

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2. HANDLING DENIAL

COMMON DEFENCE MECHANISM

1. A psychological anaesthetic

to an otherwise unbearable

reality.

2. The psychological shock-

broker that allows us to

suppress mentally what we suppress mentally what we

can not accept emotionally.

HANDLING DENIAL

� Denial, which is an unconscious

effort

� Suppression which is a

conscious or semi conscious

process and is directed to an

intra psychic event

� Avoidance, where the patient

knows but makes a voluntary

effort to shun any circumstance

that will remind him

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HANDLING DENIAL

� It is a coping mechanism

� It has varying effects on the person

� It may reduce anxiety and promote optimal functioning

� It may also result in excessive delay in seeking and complying with medical treatment

Nodal points that trigger denial

� Diagnosis� Recurrence� Termination of treatment� Metastasis� Death of other familiar or

similar patient

WHEN TO BREAK DENIAL?

� Must be broken if it prevents the patient from

taking treatment

� If the state of denial is pushing the patient into

doing something disastrous and can not plan

future

� It interfers with interpersonal relationships

HOW TO HANDLE DENIAL

� Gently challenge the denial

� Explore reasons

� Discuss consequences

� Keep a gentle pace

� Remember it is a coping mechanism

HOW TO HANDLE DENIAL

THE SKILL POOR LISTENING� Set the scene

� Active Listening� Understand insight

� Listening to what is not said

� Be aware of strengths and weaknesses

� Think creatively within the system

� Spacing out

� Word listening

� Selective listening

� Self-centred listening

� Judgmental / patronizing

� Moralizing / philosophizing

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3. ANGER

Appropriate short-term reaction to

diagnosis of serious illnessillness

ANGER & GRIEF

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ANGER…

If displaced AlienationIf displaced or projected on staff…

Alienation

If suppressed…

Patient may become withdrawn, uncooperative or depressed

If persisted…

May stop a patient from making positive adjustment to physical

4. ANXIETY

It relates to uncertainty and fear of future or

threat of separation from

loved ones

ANXIETY: SYMPTOMS

PHYSICAL MENTAL

� Palpitations, Breathlessness

� Dry Mouth� Dysphagia� Anorexia� Diarrhoea� Dizziness, Sweating� Tremor, Headache� Muscle Tension

� Bad Sleep� Frightening Dreams� Fear of Loneliness

5. DEPRESSION

Recognising Depression is important because patients have a good

response to antidepressant drugs.

However, it is often missed because

symptoms overlap with appropriate

response to terminal illness

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POINTERS TO DEPRESSION

� Persistent low mood for more than two weeks

� Loss of interest and ability to feel pleasure

� Feeling of guilt or unworthiness� Hopelessness/despair� Physical manifestations of anxiety� Suicidal attempts� Request for Euthanasia

6. PARANOID STATE

Patients are unable to accept that they

are dying, they may believe that there is a plot to kill them or they

believe that deterioration is

May be caused by1. Biochemical

Disturbances2. Cerebral Metastate3. Psychological

Factorsdeterioration is

caused by treatment

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7. FAMILY PROBLEMS

Serious illness Serious illness changes family psychodynamic

s.Within families,

there is a conflict between

the wish to confide or to protect loved

WITHDRAWN PATIENTS

CAUSES� Personality� Pathological� Pharmacological� Psychological� Psychiatric

MANAGEMENT: WITHDRAWN PATIENTS

� Acknowledge your difficulty� Offer the invitation which they can reject

or accept� If patient gives a clue then follow firmly� It is important to establish frequency and

intensity of any mood disturbance� Ask for specialists help if you achieve no

success

DIFFICULT PATIENTS

It is important to remember that the problem is primarily ours

and not the patient’s;

although, it could be a joint

problem

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CAUSES: DIFFICULT PATIENTS

Patients or relatives perceived as:

�Unpleasant�Seductive�Ungrateful�Critical

�Antagonistic�Demanding�Manipulative�Over dependent

PATIENT’S BEHAVIOUR PATIENT’S SYMPTOMS

� Withdrawn� Psychologically

Volatile� Angry� Depressed

� Gross Disfigurement

� Malodour� Poor Response to

Symptom Management

� Summarization

CAUSES: DIFFICULT PATIENTS

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MANAGEMENT: DIFFICULT PATIENTS

� Acknowledge responsibility with the rest of Team

� Explore possible reasons why patient seems difficult

SOME PSYCHOLOGICAL PROBLEMS CAN BE PREVENTED BY…

1. Good Staff-1. Good Staff-Patient Communication

2. Good Staff-Patient Relationships

3. Patients to have some control over management of their illness

THIS IS THE ANSWER!

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