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Newsletter of Hong Kong Society of Palliative MedicinePalliative Medicine Grand RoundDealing with Anger in Palliative Care SettingDr. Bryan CW Li, Palliative Medical Unit, Grantham HospitalCorrespondence: Lcw167@hotmail.comCase HistoryMdm W was a 57-year-old woman whosuffered from metastatic cancer of cervix. Shewas found to have pelvic recurrence at sixmonths after commencement of chemotherapyand radiotherapy. She was referred to ourpalliative care consultative service because ofdifficult pelvic pain control, and later transferredto our palliative care ward after stabilization formassive per vaginal bleeding.Mdm W was widowed, and she lived with herelder son. She was a traditional Chinese herbalmedicine dispenser, but retired with onset of herdisease.Mdm WMr TFigure 1 : Family TreeHer elder son, Mr T, was single and lefthome in his teens when he had seriousbehavioral problems. He moved back to live withhis mother after she was diagnosed to havecancer. He was the main caregiver of the patientand he was unemployed. The second son wasmarried and worked in a pharmacy as dispenser.Mdm W had poor compliance to medicaltreatment and complained of intolerance tomultiple analgesics, making pain control difficult.She had always been skeptical about westernmedicine. Instead, she preferred to take the overthe counter herbal medication brought to her byMr T daily.She developed acute renal failure withanuria, and ultrasound revealed bilateralobstructive uropathy resulting from the pelvictumor mass. An urgent transfer to acute hospitalwas arranged and percutaneous nephrostomywas performed subsequently. Her sons wereinterviewed on several occasions before thetransfer, and grave prognosis wascommunicated. During the interviews, theyappeared upset, while hoping the herbalmedication might help, they realized she wasdeteriorating and agreed with do-not-resuscitatedecision.Despite a partial recovery of her renalfunction post operatively, she was febrile withsevere metabolic acidosis and post obstructivediuresis. Her general condition was furthercompromised, and she was bedbound,lethargic, anorexic, and had acidotic breathing.Intravenous fluid replacement, bicarbonateinfusion and antibiotics were given.As Mr T was confronted with patient’sdeterioration, our nurses started to reportproblems with his behaviour in ward. He becameoverwhelmed, and was very emotional andagitated. He would demand the nurses to giveimmediate attention to his mother with theslightest signal of any change in his mother’sphysical state. Despite the irreversible organfailures, the patient appeared calm and sleepymost of the time. However, any frowning or noisefrom breathing would trigger a huge emotionalresponse in Mr T.On one occasion, in the middle of the night,Mr T yelled and shouted in the ward, requestingimmediate transfer of patient to a privatehospital. He thought her mother should be underbetter care. However, the patient was too ill fortransfer and he did not have any specific ideas inhis mind. Eventually he settled down and he wasinterviewed again with an attempt to align thegoals of care. On another occasion, the focalmuscle twitching of patient was interpreted as amajor seizure by Mr T. He yelled and appearedfurious; he scolded the nurse who attended thepatient immediately. The nurse felt threatenedand intimidated by his emotions and behaviour.The doctor immediately came to assist toexplain that the muscle twitching was related touraemia and calmed Mr T down.Dealing with Anger in Palliative Care SettingHKSPM Newsletter 2009 Sep Issue 2 P36