Psychosocial and Communication Issues in Cancer Care - Assignment Example

Psychosocial and Communication Issues in Cancer Care 2005 Outline: A) Introduction B) Patient assignment on the basis of Faulker and Maguire model C) Basic communication skills of the care-taker D) Empathy as a key communication skill Description: In this paper we try to find out the basic communication skills of the care-taker when he or she communicates with the cancer-diagnosed person and the role of empathy as a key communication skill. Introduction Clinicians have long recognized the importance of identifying and addressing psychosocial aspects of cancer. Professional clinicians groups insisted that a strong focus on comprehensively meeting the needs of persons with cancer should be made. For half a century various service groups throughout the world offer support services for persons with cancer and their care-takers. Oncology research about psychosocial issues also has a long tradition. The foundation for the field was formed by Bard and Sutherland and by Abrams and her colleagues in 1950’s. Today, we find ourselves in a changing health care arena, one where psychosocial care may be seen as an adjunct, "value added" rather than essential, and where the need for psychosocial research is considered questionable. In this current era of cost containment and minimal standards of care, the discoveries made by researchers to date may be disregarded, and the opportunity for advancing the field of psychosocial oncology may be greatly diminished. The billions of dollars spent on research to eliminate cancer have been tremendously successful in refining treatments designed to kill cancer. Little resources have been spent to decrease the impact of treatment on survivors. As a result, cancer survivors’ symptoms are managed inadequately in a system of care. Although cancer care experts increasingly acknowledge the value of non-curative approaches, these options have historically been offered only after curative measures are no longer considered effective. This care model misses the mark. The best quality cancer care should include comprehensive access to all care options for survivors living with, through and beyond cancer. Patient assignment on the basis of Faulker and Maguire model One can use several evaluating model for assigning the psychosocial status of the person with cancer diagnosis. In this paper I used the Faulker and Maguire model 1994, which presupposes defining of some key characteristics for successful care-services. These include: history of the patients illness how the patient perceived the information and advice given the current state of the patients disease and its impact current psychosocial status current mood state what coping strategies have been utilized and how successful are they overall level of functioning other important life events. The patient for basing this assignment around is a 39 year old gentleman that has been diagnosed with widespread abdominal cancer, with unknown origin (primary). Intra-abdominal cancer is one of the most fatal diagnoses. Patients with such a diagnosis typically live about three to six months after diagnosis without treatment. Advanced abdominal cancer usually starts in the colon or the appendix and spreads to the abdominal wall. When a doctor suspects abdominal cancer, he will likely perform a magnetic resonance imaging test, computerized tomography scan or X-ray in order to obtain a view of the chest and abdominal cavities. In the case under analysis, the patient was admitted to the surgical ward with nausea and haemotemosis. During his admission a chest x-ray found that he had bilateral plurel effusion. Such a diagnosis could affect the course of chemotherapy being delayed, in turn the treatment of his cancer prolonging the symptoms suffering at present. The patient perceived the information and advice given with great concern, as he had to be treated for two diseases, and the treatment of one could interfere the treatment of the other. The doctor considered the case and came to conclusion that chemotherapy is the first step in his treatment. In two weeks the patient is due to commence a course of chemotherapy. Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells (including leukaemia and lymphoma). There are over 50 different chemotherapy drugs. Some are given on their own but often several drugs may be combined (this is known as combination chemotherapy). The type of chemotherapy treatment the patient is given for cancer depends on many things, particularly the type of cancer one have, where in the body it started, what the cancer cells look like under the microscope and whether they have spread to other parts of the body. Chemotherapy is carefully planned and is usually given as a series of sessions of treatment. Each session is followed by a rest period. The session of chemotherapy and the rest period is known as a cycle of treatment. A series of cycles makes up a course of treatment. Each session of chemotherapy destroys more of the cancer cells, but the rest period allows the normal cells and tissues to recover. After the admittance of the patient, the nurse instigated the interview. The assessment model of the patients current psychosocial functioning and of the patients significant social resources/stressors showed that the patient was depressed, scared, felt helplessness. His state was also characterized by the feeling of being a burden and thoughts of never seeing his children grow up. The current psychosocial status and current mood state remained almost the same. To the initial problems added confusion (because of double diagnoses) and irritation caused by a feeling of wanting to lead a normal life instead of people asking if there is anything that they can do. The assessment included a review of the patients psychosocial development and history. It concluded with the patients tentative discharge plan. The purpose of holding an assessment of the patients current functioning and resources/stressors and psychosocial and developmental histories is done for the following purposes: To assess his achievement of, or failure to achieve, significant developmental milestones from birth to the present. To evaluate the impact of the family of origin and any nuclear families on the patients development and functioning To assist in the elaboration of a treatment and discharge plan that will promote the patients maximum independent functioning. In the course of treatment we employed several coping strategies. Coping strategies refer to the specific efforts, both behavioral and psychological, that people employ to master, tolerate, reduce, or minimize stressful events. Usually two general coping strategies are distinguished. These include problem-solving strategies and emotion-focused coping strategies. Problem-solving strategies are efforts to do something active to ease stressful circumstances, whereas emotion-focused coping strategies involve efforts to regulate the emotional consequences of stressful or potentially stressful events. In this case we used both types of strategies to combat the stressful events. An additional distinction that is often made in the coping literature is between active and avoidant coping strategies. (Folkman & Lazarus, 1980). Active coping strategies are either behavioral or psychological responses designed to change the nature of the stressor itself or how one thinks about it, whereas avoidant coping strategies lead people into activities (such as alcohol use) or mental states (such as withdrawal) that keep them from directly addressing stressful events. Generally speaking, active coping strategies, whether behavioral or emotional, are thought to be better ways to deal with stressful events, and avoidant coping strategies appear to be a psychological risk factor or marker for adverse responses to stressful life events (Holahan & Moos, 1987). Coping refers to the attitudes and behaviors that you use to maintain your emotional well-being and to adjust to the stresses caused by cancer. Currently, the patient under analysis is coping with his diagnosis, but later on he will have to cope with treatments and their side effects, with pain and disability. As his life has been disrupted and altered by the illness, he will face coping with the effect on the loved ones. The patients responded to his diagnosis, the initial medical work-up, and subsequent test results by confronting the full reality of the illness. He asked questions about the seriousness of his condition and the pros and cons of the various treatment options. This way of coping has been found to promote his psychological adjustment. After facing the reality of his illness, he felt optimistic about the future course of events. Not surprisingly, the patient being hopeful and optimistic shows a better adjustment to the illness. The emotional response of the patient was not only optimism and hope. He was also upset and worried, at least to a certain degree. This was caused, in my opinion, by the statistics which indicates a certain chance of survival, but also a certain chance of dying of cancer. Of course, the chance of survival and the risk of dying vary greatly from case to case. And the patient takes both aspects into account: he experiences a degree of hope that was proportional to the positive survival chances that applied to him, but he also experiences a degree of worry that was proportional to the mortality rate in similar cases. That is, he doesn’t feel overly worried, upset, or preoccupied, but neither does he feel overly cheerful, complacent or optimistic. Basic communication skills of the care-taker. Good care-takers communicate effectively with patients - they identify patients problems more accurately, and patients are more satisfied with the care they receive. When care-takers use communication skills effectively, both they and their patients benefit. Firstly, care-takers identify their patients problems more accurately. [Maguire 1986] Secondly, their patients are more satisfied with their care and can better understand their problems, investigations, and treatment options. Thirdly, patients are more likely to adhere to treatment and to follow advice on behaviour change. [Silverman 1998] Fourthly, patients distress and their vulnerability to anxiety and depression are lessened. [Roter 1995] Key tasks in communication with patients include [Maguire & Pitceathly 2004] Eliciting (a) the patients main problems; (b) the patients perceptions of these; and (c) the physical, emotional, and social impact of the patients problems on the patient and family Tailoring information to what the patient wants to know; checking his or her understanding Eliciting the patients reactions to the information given and his or her main concerns Determining how much the patient wants to participate in decision making (when treatment options are available) Discussing treatment options so that the patient understands the implications Maximising the chance that the patient will follow agreed decisions about treatment and advice about changes in lifestyle Unfortunately, care-takers often fail in these tasks. Only half of the complaints and concerns of patients are likely to be elicited. [Silverman 1998] Often care-takers obtain little information about patients perceptions of their problems or about the physical, emotional, and social impact of the problems. [Stewart 1989] When care-takers provide information they do so in an inflexible way and tend to ignore what individual patients wish to know. They pay little attention to checking how well patients have understood what they have been told. [Silverman 1998] Less than half of psychological morbidity in patients is recognised. [Hardman 1989] Often patients do not adhere to the treatment and advice that the care-takers offer, and levels of patient satisfaction are variable. [Butler 1996] Until recently, undergraduate or postgraduate training paid little attention to ensuring that care-takers acquire the skills necessary to communicate well with patients. Care-takers have therefore been reluctant to depart from a strictly medical model, deal with psychosocial issues, and adopt a more negotiating and partnership style. [Stewart 1989] They have been loath to inquire about the social and emotional impact of patients problems on the patient and family lest this unleashes distress that they cannot handle. They fear it will increase patients distress, take up too much time, and threaten their own emotional survival. Consequently, they respond to emotional cues with strategies that block further disclosure. [Maguire & Pitceathly 2004] Even if care-takers have the appropriate skills, they may not use them because they are worried that their colleagues will not give sufficient practical and emotional support if needed. [Booth 1996] Care-takers may also not realise how often patients withhold important information from them or the reasons for this. [Maguire & Faulkner 1996] A "good" care-taker, wanting to audit and improve his or her skills, should ensure that any course or workshop they attend includes three components of learning: cognitive input, modelling, and practice of key skills. Provide evidence of current deficiencies in communication, reasons for them, and the consequences for patients and doctors Offer an evidence base for the skills needed to overcome these deficiencies Demonstrate the skills to be learned and elicit reactions to these Provide an opportunity to practise the skills under controlled and safe conditions Give constructive feedback on performance and reflect on the reasons for any blocking behaviour If care-takers are to acquire skills and relinquish blocking behaviour, they must have an opportunity to practise and to receive feedback about performance. However, the risk of distressing and deskilling the care-taker must be minimised. Practising with simulated patients or actors has the advantage that the nature and complexity of the task can be controlled. "Time out" can be called when the interviewer gets stuck. The group can then suggest how the interviewer might best proceed. This helps to minimise deskilling. In contrast, asking the doctor to perform a complete interview may cause the care-taker to lose confidence because "errors" are repeated. Asking care-takers to simulate patients they have known well and portray their predicament makes the simulation realistic. It gives care-takers insights into how patients are affected by different communication strategies. For a simulation exercise to be effective, care-takers must be given feedback objectively by audiotape or videotape. [Maguire & Pitceathly 2004] To minimise deskilling, clear ground rules should be followed like positive comments should be offered about what strategies (oral and non-oral) were liked and why; constructive criticism should be allowed only after all positive comments have been exhausted; participants offering constructive criticisms should be asked to suggest alternative strategies and give reasons for their suggestions, etc. Practising communication skills with simulated patients leads to the acquisition of skills and the relinquishing of blocking behaviour. However, care-takers do not transfer these learned skills to clinical practice as comprehensively as they should. [Heaven 2001] Offering care-takers feedback on real consultations should ensure more effective transfer of skills. Empathy as a key communication skill Effective care-taker-patient communication is an integral part of good clinical care. Telling a patient that he/she has cancer can be a daunting task. If done with empathy and sensitivity it can create an important bond between the doctor and patient. If done brusquely and without tact it can create barriers and lasting hostility. Several key steps help make the breaking of bad news easier for care-takers and patients. There is not one right formula but appreciation of and responsiveness to the patients verbal and non-verbal signals are core skills which can be developed. Such basic communication skills as attending and listening make the communication between the care-taker and the patient an effective one. These skills are especially important when communication happens between the care-taker and a cancer-diagnosed patient. Attending refers to the ways in which care-taker can be “with” his/her patient, both physically and psychologically. Effective attending tells patients that they can share their world. It also puts the care-taker in a position to listen carefully to what patients are saying. Affective attending can be achieved by facing a patient, adopting a bodily posture that indicates involvement with him, communicating with posture openness and availability. Eye contact with a patient conveys the message of interest in what he has to say. Effective attending puts the care-taker in a position to listen carefully to what their patients are saying or not saying. Listening refers to the ability of the care-taker to capture and understand the messages patients communicate. The care-taker must be ready to the situation when the bulk of the messages are transmitted nonverbally rather than verbally. Active listening involves the following four skills [Goodman & Esterly 1988]: Listening to and understanding the patient’s verbal messages. When a patient tells his or her story, it usually comprises a mixture of experiences, behaviours, and affect. Experiences usually stands for things that happened to him or her, behaviours reflect what the client did or failed to do, and affect is understood as the feelings or emotions associated with the experiences and behaviour. The care-taker has to listen to the mix of experiences, behaviour and feelings the patient uses to describe his or her problem situation. Which is more important the care-taker should also “hear” what the patient is not saying. Listening to and interpreting the patient’s nonverbal messages. Care-takers should learn how to listen to and read nonverbal messages such as bodily behaviour (posture, body movement and gestures), facial expressions (smiles, frowns, raised eyebrows, twisted lips), voice?related behaviour (tone, pitch, voice level, intensity, inflection, spacing of words, emphases, pauses, silences and fluency), observable physiological responses (quickened breathing, a temporary rash, blushing, paleness, pupil dilation), general appearance (grooming and dress), and physical appearance (fitness, height, weight, complexion). [Goodman & Esterly 1988] Care-takers need to learn how to “read” these messages without distorting or over-interpreting them. Listening to and understanding the patient in context. The care-taker should listen to the whole person in the context of his or her psychosocial settings. Listening with empathy. Empathic listening involves attending, observing and listening (“being with”) in such a way that the doctor develops an understanding of the patient and his or her world. The care-taker should put his or her own concerns aside to be fully “with” the patient. In any case care-taker must differentiate between sympathy and empathy. Many people believe the two terms are synonyms. Some people on the contrary view sympathy and empathy as not being synonyms [Goodman & Esterly 1988]. They believe that sympathy involves being less active when listening as compared with empathy. Tuning into the talkers inner world often readily happens for the listener using sympathy because he focuses on aspects with which he agrees. By contrast, the listener using empathy sometimes has to work at tuning. In order to understand this aspect of the talkers inner world, he would need to listen carefully to the talker. Sympathizing and empathizing differ in the activity of judging or evaluating. The person using sympathy agrees with a certain belief which means that he has a positive evaluation of it. By contrast, the person using empathy is not interested in whether he has a positive or negative evaluation of a certain belief but in understanding the talkers positive evaluation of that belief. Being non-judgmental is central for the person using empathy. Sympathy emphasizes sharing distressing feelings whereas empathy does not emphasize any particular type of feeling. The listener using empathy shares (experiences) whatever feelings the talker is expressing at the moment, regardless of whether the feelings are distressing (grief, for example) or pleasant (love, for example). The listener using empathy usually responds more comprehensively to the talker as compared with the listener using sympathy. Sympathy focuses on sharing (experiencing) a persons bad news or feelings, feeling sorry for the person suffering the bad news/feelings, and whether the sympathizer agrees with any of the persons beliefs, opinions, or goals whereas empathy focuses on sharing (experiencing) a persons bad and good news or feelings and understanding the bad or good news/feelings rather than feeling sorry for the persons bad news/feelings or agreeing or disagreeing with the persons beliefs, opinions, or goals. [Goodman & Esterly 1988] Basic empathy involves listening to clients, understanding them and their concerns as best as we can, and communicating this understanding to them in such a way that they might understand themselves more fully and act on their understanding [Egan 1998]. Llistening with empathy means that the doctor must temporarily forget about his or her own world and try to see the patient’s world and the way the patient sees him or herself as though he or she were seeing it through the eyes of the patient. Empathy is thus the ability to recognise and acknowledge the feelings of another person without experiencing those same emotions. It is an attempt to understand the world of the patient by temporarily “stepping into his or her shoes”. This understanding of the patient’s world must then be shared with the patient in either a verbal or non-verbal way. Some of the stumbling blocks to effective empathy are the following [Egan 1998].: Avoiding of distracting questions. Doctors often ask questions to get more information from the patient in order to pursue their own agendas. They do this at the expense of the patient, i.e. they ignore the feelings that the patient expressed about his or her experiences. Empathy is not interpreting. The doctor should respond to the patient’s feelings and should not distort the content of what the patient is telling the doctor. Although giving advice has its place in treatment, it should be used carefully to honour the value of self-responsibility. To merely repeat what the client has said is not empathy but parroting. Doctors who “parrot” what the patient said, do not understand the patient, are not “with” him, and show no respect for him. Empathy should always add something to the conversation. Empathy is not the same as sympathy. To sympathise with a patient is to show pity, condolence and compassion - all well-intentioned traits but not very helpful in treatment. Communication skills should be integrated in a natural way in the treatment process. Skilled care-takers continually attend and listen, and use a mix of empathy and probes to help the patient to come to grips with their problems. 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