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TRANSCRIPT
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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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