Supporting cancer patients

Introduction

For cancer patients, the trauma of diagnosis, protracted and sometimes toxic curative treatments, possible disease relapse, with progression to incurable and increasingly disabling or terminal disease, provokes intense, often distressing emotional and psychological reactions. These may include:

♦ Alienation

♦ Sadness/depression

The cancer not only impacts on the patient personally, but also on family, friends, their work, and finances. Up to one-third of cancer patients suffer significant psychological morbidity. Appropriate support interventions can help alleviate much of their distress.

Palliative care is synonymous with good supportive care, at every stage of a cancer illness. Palliative care ameliorates all distressing symptoms, whether physical, psychological, social, or spiritual in an integrated approach, as essential in achieving the best of quality of life for patients and families. For patients with a terminal diagnosis, it strives to enable them to live as actively as possible until death, while offering support of the family during the patient's illness and in their own bereavement.

Detecting patients in need of support

All patients benefit from support but assessment of the following can identify patients at particular risk:

♦ Degree of physical disability

♦ Internal resources of the patient

♦ Past history of functioning

♦ Social supports—family (marital status, living arrangements, number of family members in the immediate geographical area and their capacity and willingness to provide support), friends, community/church links

♦ History of substance abuse

Use a standardized measure of psychological morbidity and quality of life such as:

♦ Hospital Anxiety and Depression Scale (HADS)

♦ Functional Assessment of Cancer Therapy (FACT)

♦ Functional Living Index-Cancer (FLIC)

♦ Cancer Rehabilitation Evaluation Systems (CARES)

♦ European Organisation for Research and Treatment Quality of Life Questionnaire (EORTC QLQ-C30)

♦ The Schedule for Evaluation of Individualised Quality of Life (SEIQoL)—allows patients to nominate the aspects of life they consider important in the evaluation of QoL, and they are scored on these

Providing support

We can all offer support to cancer patients. Cancer patients tell us that they need to find meaning and hope in the midst of deterioration, distress, and despair. Our challenge is to find the balance in providing hope and alleviating fears throughout the cancer journey.

Communication

Effective communication is the cornerstone of good supportive care. Patients should be able to participate in decisions about their care, allowing them to retain some control over their lives. Doctors are not legally or ethically obliged to provide treatments that are futile or prolong life (and sometimes the distress of dying) at all costs. Competent patients are entitled to refuse life-prolonging or life-sustaining treatments. Potential conflict about such decisions can be avoided by good communication. Patients need honest, compassionately delivered information.

Poor communication and breaking of bad news are consistently mentioned by patients and families as a cause of stress and dissatisfaction. Good communication builds trust, reduces uncertainty, and allows appropriate adjustment (practical and emotional) by patient and family, thus reducing psychological morbidity. Breaking bad news is not a single, isolated event. The process is ongoing and recurring, involving telling the diagnosis, updating the patient and family on changes and, possibly, preparing them for death.

Breaking bad news—a ten-step approach

This approach can be used as a general framework and adapted for specific situations. Remember, a patient has a right but not a duty to hear bad news.

1. Preparation: (know the facts; arrange the meeting; find out who the patient wants present).

2. Establish what the patient already knows (both doctors and family generally underestimate the level of patient's knowledge).

3. Establish whether the patient wants more information.

4. Allow denial (denial is a defence and a way of coping). Allow the patient to control the amount of information.

5. Give a warning shot (allows patient time to consider their own reactions and whether they feel able to ask for more information).

6. Explain (if requested—be clear and simple; avoid harsh statements; avoid medical jargon; check understanding; be as optimistic as possible).

7. Listen to concerns (avoid premature reassurance or excessive explanations).

8. Encourage ventilation of feelings (the key phases, as it conveys empathy).

9. Summarize and make a plan (reduces confusion and uncertainty; fosters hope).

10 Offer availability (communicating bad news is an ongoing process).

Formal counselling/psychological therapies

Some patients will need more formalized support—trained counsellors, social workers, hospital chaplains may provide this. Cognitive-behavioural and brief psychotherapeutic interventions are effective for more significant levels of anxiety or depression e.g. adjuvant psychological therapy.

Psychiatric interventions

When psychological interventions are inadequate, psychotropic medication may help. Drug therapy benefit 20-25% of cancer patients suffering significant anxiety and depression.

Support groups and information services

These can help to reduce the sense of alienation and isolation sometimes associated with cancer. They facilitate the sharing of experiences, the ventilation of feelings in a supportive environment, and the exchange of information about the physical, psychological, and social consequences of cancer and its treatment (e.g. Bristol Cancer Help Centre, Cancer BACUP, Cancerlink).

Support in death

Often it is the actual mode of death that patients fear rather than the fact of dying e.g. 'What will it be like?' or 'I'm afraid of dying in agony'. Patients need reassurance that any physical distress can be alleviated and that death is normally peaceful. Issues of spirituality may be important for individual patients and religious ritual should be facilitated where possible. Doctors need to be sensitive to psychological distress (a sense of hopelessness, despair, meaninglessness; questions such as 'why me?') as it often masks intractable, distressing, physical symptoms (e.g. pain).

During final hours, patients should never be left alone to feel isolated or abandoned. Families need to be involved, and this includes children; they need to be kept updated on changes and encouraged to be present. Good care of a patient's family will reduce the likelihood of complicated bereavement. If the family can't be there, a member of staff should sit with the patient.

Staff stress

Supporting cancer patients is stressful to the health professionals involved. Staff also need support structures (including training in communication skills, as well as direct supportive measures such as counselling and relaxation therapies).

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