Evaluating the “Good Death” Concept from Iranian Bereaved Family

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Table 2 Personality Disorders and Management Strategies (Continued) SUGGESTED THERAPEUTIC RESPONSE ILLUSTRATIVE MANAGEMENT QUOTE Take empathic stance, rather than overtly challenging patient’s paranoid thoughts Acknowledge effects of patient’s actions on you and others; set limits without unilaterally terminating or dismissing patient; protect safety of staff Schedule regular follow-up visits regardless of symptom levels, acknowledge that treatment may not be entirely curative Set appropriate expectations of doctor– patient relationship, acknowledge limits of knowledge/skill as well as time and stamina, educate patient about cancer care Do not challenge entitlement, but channel it into partnership in providing the best care; emphasize and align with patient strengths Work empathically and diligently but lower expectations and adjust goals; set nonpunitive limits; share care with other clinicians to reduce burnout; regular team meetings (including support staff, if appropriate) to coordinate plan of care Give patient control when possible; acknowledge and empathize with vulnerability produced by medical illness Encourage patient to consider realistic possibilities in addition to worst case scenarios; enlist family support to help patient notice and revise negative thoughts; review decisions about stopping treatment with colleague to assure that you are not giving up prematurely Patient: “You are trying to poison me with this chemotherapy.” Clinician: “I can certainly see why you feel that way. Chemotherapy is tough. If I were having chemotherapy I’d be suspicious too. Let’s see how we can address the side effects.” “You are scaring me and my staff. We want to continue to treat you, but we need to think about our safety and will call security to have you escorted out of the clinic if you again talk about having a knife.” “The pain may get better than it is now, but you will probably always have some flare-ups, because our medications are only 80% effective. I don’t think we need to get another bone scan right now but I want to monitor you closely and would like to see you every 3 months to check on this.” “I am committed to be with you for your whole cancer treatment. When you call me about questions that could easily wait until your next appointment, I get stressed, and it makes it harder for me to be there in the way I want to be for you.” “You deserve the best medical care we can give, and that’s why I need you to be here on time so that you get the most out of our visit.” “You have been very successful in managing a large company in difficult times; you are the leader of your treatment team, and we will do our best to meet your goals.” “Like you, I’m only human, so when you swear at me, I get upset—and that interferes with my thinking clearly about what you need.” “You are the one who ultimately decides whether you will go to an addiction treatment program. I will keep encouraging you, but I cannot offer treatments that will be unsafe when you are using IV drugs.” “I need a psychiatrist on the team to help me take care of you, because I get rattled and scared by some of your behaviors.” “It is really hard to feel so out of control. While you are in infusion, I’d like you to keep a careful log of everything that you experience with chemo so you can report it to me.” “What do you think the worst case scenario is? How likely is that?” “Even though things didn’t work well with this chemo, I am not going to give up on you and we have other treatments we can try.” COMMENTS ON MEDICATION MANAGEMENT Atypical antipsychotics for paranoia Possible risk of diversion of opioids and benzodiazepines; avoid the latter in favor of atypical antipsychotics or SSRIs SSRIs for comorbid depression or anxiety SSRIs or low-dose benzodiazepines for comorbid anxiety SSRIs for comorbid depression Mood stabilizers or antipsychotics for mood lability/irritability SSRIs for irritability, comorbid depression/anxiety; atypical antipsychotics for anger/impulsivity Avoid benzodiazepines —high risk of abuse Close monitoring of opioids SSRIs for depression or low-dose benzodiazepines for comorbid anxiety Unlike other personality disordered patients, these patients are unlikely to abuse benzodiazepines or other medications SSRIs to target depression Meyer and Block VOLUME 9, NUMBER 2 � MARCH/APRIL 2011 www.SupportiveOncology.net 49
Personality Disorders in the Oncology Setting mood stabilizers and anticonvulsants. Anger and impulsivity can be treated with antipsychotics, mood stabilizers, and anticonvulsants, all of which demonstrate significant positive effects. 22 Distorted thinking, particularly suspiciousness, also responds well to antipsychotics. Benzodiazepines, because they are often disinhibiting, may amplify dysfunctional behavior. Because they are used ubiquitously in the cancer setting, clinicians should be aware of this potential risk. In general, for patients with suspected personality disorders antipsychotics are a safer and more effective treatment for anxiety than benzodiazepines. 23 In the absence of prior hypomanic or manic symptoms, SSRIs are a good first-line choice for depression, anxiety, and irritability; when potential hypomanic or manic symptoms, or explosive anger, are present, it is best to start with an atypical antipsychotic or mood stabilizer. Medication of patients with personality disorders generally requires the expertise of a psychiatrist. PSYCHOTHERAPY Although clearly a valuable treatment for patients with personality disorders, psychotherapy aimed at altering underlying maladaptive personality patterns can often take years to be effective and thus is often not feasible for patients with advanced disease. Therefore, it is important for clinicians in the cancer setting to lower their expectations and focus on behavioral containment. Patients who agree to mental health treatment can benefit from having a structured supportive psychotherapy, where a clinician allows ventilation of negative emotions, assists in reality testing, follows up on behavioral plans and expectations, and helps the patient work through challenges in receiving medical treatment. For patients with a favorable medical prognosis, dialectical behavioral therapy has been shown to reduce self-injurious behaviors and help patients to modify their interpersonal communication styles, regulate their emotions, and tolerate distress without acting out destructively. 24 Because difficult patients often contribute to clinician distress and burnout, it is also important to take time for personal reflection, debrief with other team members, and/or share the patient’s care with a colleague. A trusted colleague can help the treating clinician gain perspective, avoid being pulled into dysfunctional responses, and serve as a sounding board for the References PubMed ID in brackets 1. Hahn SR. Physical symptoms and physicianexperienced difficulty in the physician–patient relationship. Ann Intern Med 2001;134:897–904. [11346326] 2. Hahn SR, Thompson KS, Wills TA, Stern V, Budner NS. The difficult doctor–patient relationship: somatization, personality and psychopathology. J Clin Epidemiol 1994;47:647– 657. [7722577] 3. Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic: clinical predic- frustration that often is part of treating patients with personality disorders. Conclusion: Difficult Patients, Difficult Doctors, and Difficult Dyads Clinicians must consider their own personal vulnerabilities and countertransference responses as well as constraints imposed by time limitations and productivity requirements before simply labeling a patient as difficult. In addition, feelings of helplessness in halting the progression of cancer, disappointment at new treatments that prove to be ineffective, discomfort with patient decisions to undertake end-of-life treatments that are futile, and impatience with the challenges of patients coming to terms with death and dying may all contribute to the clinician’s perception that a patient is difficult. The patient who demands a specific tumor marker blood test or a regular breast magnetic resonance imaging in the face of research evidence to the contrary may be “narcissistic,” may have an anxiety disorder, and/or may be operating within a “consumer advocate” model of the doctor–patient relationship that sometimes encourages unrealistic expectations of health care delivery. Based on personal life experiences, some clinicians find entitled, angry, narcissistic patients particularly distressing, whereas others are more troubled by intense dependency and neediness. Developing insight into one’s personal triggers promotes less impulsive and more thoughtful responses to difficult patients. Setting appropriate boundaries and not being pulled into offering “special treatment” for certain patients protects clinician morale and the integrity and sustainability of the physician– patient relationship. Curiosity can also be an effective stance in dealing with a patient who has a personality disorder. In seeking to understand and explore the patient’s behavior, the clinician conveys a sense of interest and connection while providing some intellectual distance from the emotional intensity of the patient. Finally, clinicians should make every effort not to suffer alone with challenging patients. Consultation and team-based care both protect physicians and improve patient outcomes. Acknowledgments: We acknowledge the thoughtful comments of Dr. John Peteet on the manuscript. Conflicts of interest: None to disclose. tors and outcomes. Arch Intern Med 1999;159: 1069–1075. [10335683] 4. Wasan AD, Wootton J, Jamison RN. Dealing with difficult patients in your pain practice. Reg Anesth Pain Med 2005;30:184–192. [15765460] 5. Schafer S, Nowlis DP. Personality disorders among difficult patients. Arch Fam Med 1998;7: 126–9. [9519915] 6. Ashworth CD, Williamson P, Montano D. A scale to measure physician beliefs about psy- chosocial aspects of patient care. Soc Sci Med 1984;19:1235–1238. [6523166] 7. Parsons T, Fox R. Illness, therapy and the modern urban American family. J Social Issues 1952;8:31–44. 8. Freidson E. Professional Dominance: The Social Structure of Health Care. New York: Atherton Press; 1970. 9. Potter SJ, McKinlay JB. From a relationship to encounter: an examination of longitudinal and lateral dimensions in the doctor- 50 www.SupportiveOncology.net THE JOURNAL OF SUPPORTIVE ONCOLOGY
Page 1 and 2: Editor-in-Chief Michael J. Fisch, M
Page 3 and 4: Michael J. Fisch David Cella Thomas
Page 5 and 6: Mission The mission of The Journal
Page 7 and 8: R E V I E W Personality Disorders i
Page 9 and 10: Personality Disorders in the Oncolo
Page 11: Personality Disorders in the Oncolo
Page 15 and 16: P E E R V I E W P O I N T Personali
Page 17 and 18: H O W W E D O I T Recognizing Depre
Page 19 and 20: Recognizing Depression in Patients
Page 21 and 22: Recognizing Depression in Patients
Page 23 and 24: Evaluating the “Good Death” Con
Page 25 and 26: Evaluating the “Good Death” Con
Page 27 and 28: O R I G I N A L R E S E A R C H Sym
Page 29 and 30: Symptom Experience in Patients with
Page 35 and 36: O R I G I N A L R E S E A R C H Est
Page 37 and 38: Estimating MIDs for the Worst Pain
Page 43 and 44: Truthful Information all three onco
Page 45 and 46: Truthful Information Table 2 Commen
Page 47 and 48: Truthful Information these prelimin
Page 49: Truthful Information with metastati

Evaluating the “Good Death” Concept from Iranian Bereaved Family

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