Evaluating the “Good Death” Concept from Iranian Bereaved Family

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P E E R V I E W P O I N T Challenging Personalities in the Oncology Setting Matthew Doolittle, MD, and Jimmie C. Holland, MD Commentary on “Personality Disorders in the Oncology Setting” by Meyer et al (page 44) The effective treatment of cancer in patients who may already suffer from significant heart disease, poorly controlled diabetes, or another chronic medical condition requires extra monitoring, consultation, or even modification of chemotherapy regimens or surgeries. In general, however, these additional needs are known to the oncologist through clear history, symptoms, and objective measures, and oncologists therefore have readily available means to manage the attendant risks. Patients who have challenging personality traits or personality disorders will require as much or more attention and management, both for the success of their own treatments and for the sake of minimizing disruption in the clinic itself. The needs of these patients are usually less clear to the oncologist at the outset. Many personality disorders remain unidentified in the community or are never treated consistently, and the oncologist may have no knowledge of the diagnosis. Further complications may arise when a patient’s challenging personality traits that have not previously risen to a diagnosable disorder worsen under the stress of a cancer diagnosis. The patient’s behavior may become increasingly disordered at precisely the time when the challenges of a serious illness require the most fully adaptive response. In this issue, Meyer and Block 1 address the problem of personality disorders in the oncology setting and offer some practical information about identifying and responding to the needs of these patients. The complexity of diagnosing personality disorders is suggested by the multiple classification systems summarized by the authors (ie, formal diagnostic criteria for individual disorders, “clusters” of personality traits, as well as descriptive categories Correspondence to: Matthew Doolittle, Memorial Sloan- Kettering Cancer Center, 1275 York Avenue, New York, NY 10065. E-mail: doolittm@mskcc.org J Support Oncol 2011;9:53 © 2011 Published by Elsevier Inc. doi:10.1016/j.suponc.2011.02.004 that emerge from James Groves’ classic work on “the hateful patient” 2 ). Whatever the challenges of describing personality disorders, they differ from other chronic conditions complicating cancer care in one important way: the emotional responses of physicians themselves provide information that can be critical to identifying and managing the problem. Meyer and Block provide a useful summary of observable behaviors and emotional reactions in both patients and clinicians, along with general principles and particular responses for managing those behaviors. Of equal interest to the oncologist is the question of when managing such behaviors will require psychiatric involvement for treatment of the patient, for advice to staff, or both. Although the authors do not address this issue directly, they do introduce the principle of regarding the physician’s behaviors and reactions as sources of information that are as important as observations of the patients themselves. Returning to this principle may be the most useful strategy for oncologists who might seek psychiatric consultation. A psychiatric referral might be helpful when: (1) interactions of staff members regarding a particular patient become less effective or less professional than usual; (2) emotional responses of staff members become difficult for themselves or others around them to understand or tolerate; or (3) the patient is consuming more resources or staff time than the clinic can sustain. In general, referral may become not only helpful but also necessary if the behaviors of a given patient and the responses of staff have reached the point at which the patient is no longer receiving the same standard of oncology care as other complicated patients. Although the literature on personality disorders is vast, this summary by Meyer and Block, and in particular its emphasis on attending to staff responses, may be of use in meeting everyday needs of oncologists, oncology clinics, and some of their most vulnerable patients. References 1. Meyer F, Block S. Personality disorders in the oncology setting. J Support Oncol 2011;44–51. 2. Groves JE. Taking care of the hateful patient. N Engl J Med 1978;298:883–887. Dr. Doolittle is with the Memorial Sloan- Kettering Cancer Center, New York Presbyterian Hospital (Cornell Campus), New York, New York. Dr. Holland is with the Wayne E. Chapman Chair in Psychiatric Oncology Attending Psychiatrist Department of Psychiatry and Behavioral Sciences, Memorial Sloan- Kettering Cancer Center, New York, New York. VOLUME 9, NUMBER 2 � MARCH/APRIL 2011 www.SupportiveOncology.net 53
H O W W E D O I T Recognizing Depression in Patients with Cancer Alicia Morgans, MD, and Lidia Schapira, MD Caring for the “whole person” across the continuum of disease remains a top priority for clinicians. Strides in basic and translational research have opened new therapeutic pathways that provide better targeted and effective treatments with fewer side effects. New ancillary and supportive therapies have transformed and improved the experiences of patients undergoing anticancer treatments. Also, with increasing acceptance of multidisciplinary teams, we have the opportunity to make timely referrals to colleagues who provide supportive and palliative care and targeted interventions to treat pain and disabling symptoms. If our goal is to recognize the full impact of cancer on the lives of patients and their families, it is important to address the emotional and psychological toll of diagnosis and treatment. Recognizing depressive symptoms and clinical depression is an important step toward optimizing the quality of life for patients with cancer. Data summarized in an excellent review by Pirl published in 2004 show that up to one in five Americans will experience depressive symptoms over the course of their lifetime and that approximately 10%–25% of cancer patients meet criteria for clinical depression. 1,2 As our ability to treat depression has improved over the years, thanks in great part to advances in pharmacology and behavioral therapies, it is now critically important to recognize and treat this debilitating disease in individuals with cancer. 3 Evidence exists that untreated depression is associated with a worse overall survival for some cancer patients and, paradoxically, that up to half of patients with cancer and concurrent depression are undertreated or receive no treatment. 4–6 Medical Manuscript submitted August 2, 2010; accepted December 20, 2010. Correspondence to: Alicia K. Morgans, MD, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114; telephone: (617) 724-4000; fax: (617) 643-0798; e-mail: amorgans@partners.org J Support Oncol 2011;9:54–58 © 2011 Published by Elsevier Inc. doi:10.1016/j.suponc.2011.01.004 oncologists receive little or no formal training in psycho-oncology yet are often faced with patients who exhibit changes in mood and become progressively disabled by psychiatric symptoms. Methodical assessment and frequent inquiry may identify patients with cancer and depression. Peeling Back the Onion: Sorting through Symptoms to Reach a Diagnosis A diagnosis of cancer often precipitates intense emotions such as fear, sadness, and sometimes anger. 2 Individuals who may never have given much thought to their own death are confronted with the very real possibility of a shortened life and future suffering. Roles and relationships shift, careers are interrupted, and daily routines may be sacrificed to make room for cancer treatment. Add to this the financial worries that often accompany a serious illness and it is not surprising that patients may require some level of professional guidance or intervention in order to cope with the crisis. As a quick rule of thumb, it takes about 3–4 weeks after diagnosis to adjust, and during that period it is quite normal for patients to experience intense feelings. 7 Weissman and Worden, among the first psychiatrists to study distress in cancer patients, described an acute syndrome of distress over existential plight with the diagnosis and with a recurrence that lasts about 100 days. 8 Most individuals, given time and adequate support, will find the inner resources to cope with distressing symptoms and find a new normal. Not all do however, and it is important for oncologists to inquire at regular intervals about how the patient is feeling and coping with illness. A recent study by Lo et al 9 found that predictors of depressive symptoms in patients with solid tumors included younger age, antidepressant use at baseline, lower self-esteem and spiritual well-being, greater attachment anxiety, hopelessness, the physical burden of symptoms, and proximity to death. 54 www.SupportiveOncology.net THE JOURNAL OF SUPPORTIVE ONCOLOGY
Page 1 and 2: Editor-in-Chief Michael J. Fisch, M
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Evaluating the “Good Death” Concept from Iranian Bereaved Family

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