Evaluating the “Good Death” Concept from Iranian Bereaved Family

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C O M M E N T A R Y Holistic Quarterbacking and the 80/20 Rule Thomas Strouse, MD All oncologists face treating patients with varying forms of emotional distress. In this issue of the Journal of Supportive Oncology, Morgans and Schapira’s “Recognizing Depression in Patients with Cancer” offers a front-line approach to treat clinically depressed cancer patients. Meyer and Block’s “Personality Disorders in the Oncology Setting” provides oncology clinicians with practical tips on how to manage behaviorally “difficult” patients. Morgans and Schapira define cancer treatment as a marathon. Oncologists have the perspective of seeing their patient as a “whole person” over time. They can pick up on potential indicators of emerging depressed mood, such as distress and loss of characteristic resiliency. Similarly, as the “quarterbacks” of well-functioning interdisciplinary teams, oncologists can screen for depression and initiate pharmacotherapy before calling in the special teams (psychiatry, psychology, social work, clergy, etc.). Not all oncologists are ready to embrace the holistic quarterback approach. Fortunately, the National Comprehensive Cancer Network’s guidelines for distress management 1 identify screening for distress as a clinical responsibility of the system of care, not of the individual physician. The tools used to clinically assess a patient’s distress are a guide for further exploration and rational treatment. As Morgans and Schapira note, there is an overlap in some cancer patients of disease- and treatment-related symptom burden. Depression symptoms such as fatigue, sleep changes, appetite loss, and cognitive effects confound traditional diagnostic methods in the same way personal, cultural, linguistic, and other variables complicate the picture. Under such circumstances, even experienced psycho-oncologists find diagnostic clarity elusive. “Personality Disorders in the Oncology Setting” provides non-mental health oncology clinicians a Correspondence to: Thomas Strouse; e-mail: TStrouse@mednet. ucla.edu J Support Oncol 2011;9:43 © 2011 Published by Elsevier Inc. doi:10.1016/j.suponc.2011.02.006 vocabulary and clinical concepts to understand and manage “difficult” patients. These patients often prove the “80/20” rule; i.e., “20% of the people drive 80% of my work.” They frustrate, antagonize, and occasionally frighten the clinicians who care for them. The challenge for the authors was to write a review that would not do the same to their readers. Meyer and Block integrate basic concepts about the clinician–patient relationship. The clinician may have a need for control or a wish to be idealized. The patient may have issues with dependence, trust, abandonment, abuse, etc. These foundational concepts then blend with “modern” variations. For example, a patient who takes a consumerist approach to his or her cancer crisis and relies on Web-based pseudomedical information risks reducing the treatment relationship to a technician– consumer dyad. This perspective can be destructive for the personality-disordered patient who is anxious, demanding, and unselective about data sources and has difficulty investing trust in or developing dependence on a doctor. Add to this a physician who defaults under stress toward authoritarianism, impatience, avoidance, or hostile defensiveness and you have the opposite of a match made in heaven. Residents, fellows, and recently minted subspecialist physicians may find it easier, under circumstances of conflict and complex medical decision making, to neutrally offer choices and do as they are bid. For the personality-disordered patient, this approach may inadvertently fuel chaos. I worry that a generation of physicians has somehow gotten the message it is not appropriate to say “no” or to impose behavioral requirements as a condition of treatment. Meyer and Block provide us with the tools to achieve a significantly more nuanced view: It is hard work, but the benefits for patients and staff alike are worth it. Conflicts of interest: None to disclose. References PubMed ID in brackets 1. Holland JC, Andersen B, Breitbart WS, et al. Distress management. J Natl Compr Canc Netw 2010;8(4):448–485. Dr. Strouse is Professor of Clinical Psychiatry, Maddie Katz Endowed Chair in Palliative Care Research and Education, Medical Director Stewart and Lynda Resnick Neuropsychiatric Hospital at UCLA, Vice-Chair for Clinical Affairs, Department of Psychiatry and Biobehavioral Sciences, David Geffen-UCLA School of Medicine, Los Angeles, California. VOLUME 9, NUMBER 2 � MARCH/APRIL 2011 www.SupportiveOncology.net 43
R E V I E W Personality Disorders in the Oncology Setting Fremonta Meyer, MD, and Susan Block, MD Approximately 10%–30% of patients treated in health care settings exhibit difficult behavior, 1–3 although the specific frequency of difficult patient encounters in oncology practices is unknown. Difficult behavior takes many forms in the cancer setting: arriving late or not showing to appointments, intense questioning of the clinician, frequent pages or e-mails between appointments, and angry or demanding behavior toward staff and clinicians. Difficult patients tend to evoke negative emotions, such as guilt, irritation, anxiety, and aversion, in the clinician. They often have difficulties forming effective treatment alliances with both medical and mental health providers and may exhibit treatment nonadherence and high resource utilization. Although most cancer patients with high levels of psychological distress benefit significantly from supportive counseling with a mental health clinician, either difficult patients refuse referrals or their emotional symptoms are refractory to usual therapeutic interventions and medication management. Some difficult patients may even threaten legal action because of perceived medical negligence or improper treatment. 4 Many, but not all, difficult patients have personality disorders; cultural differences, other psychiatric disorders, circumstances, and relational styles can also manifest themselves as difficult behavior. Physician (or clinician) factors, as well as the challenges and frustrations of negotiating the health care system, may also contribute to patients’ difficult behaviors in the health care setting. This article will briefly address differential diagnosis of the difficult oncology patient and then describe the definition, subtypes, and clinical as- Manuscript submitted September 19, 2010; accepted January 6, 2011. Correspondence to Fremonta Meyer, MD, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, 44 Binney Street SW411, Boston, MA 02115; telephone: (617) 632-4566; fax: (617) 632-6180; e-mail: flmeyer@partners.org J Support Oncol 2011;9:44–51 © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.suponc.2011.02.002 Abstract This paper reviews differential diagnosis of the difficult oncology patient, focusing on how the patient, the physician, the patient– physician relationship, and the cancer setting may all contribute to clinicians’ experiences of difficulty. Because many difficult patients have personality disorders, we then review assessment and treatment of the personality disorders that tend to be most problematic in the cancer setting, suggesting a team-based approach for management. sessment of personality disorders. We will also examine how clinicians may contribute to or ameliorate difficult dynamics and describe treatment strategies targeting both the difficult patient and the treatment team in the oncology setting. Differential Diagnosis of the Difficult Oncology Patient All physician–patient relationships are influenced by the dynamics within the patient, within the physician, and within the relationship. Cancer and its associated treatments further determine the nature of the physician–patient relationship, often intensifying it and heightening its stakes. Optimal care requires open-minded attention to all of these areas (Table 1) when a difficult interaction or relationship occurs. THE PATIENT In a study of 500 adults presenting to a primary care clinic, Jackson and Kroenke 3 found that patients labeled “difficult” were more likely to have a depressive or anxiety disorder, poor functional status, and greater use of health care services. Patients with unmet expectations were more likely to be seen as difficult. 3 In the oncology setting, patients with anxiety disorders may be problematic when their high anxiety prevents them from retaining information about treatment options; they may then ask questions that make it appear they were not listening. Additional patient factors associated with being perceived as difficult include untreated psychotic disorders, organic brain disorders (particularly Dr. Meyer is from the Department of Pscychiatry at the Dana-Farber Cancer Institute Psychosocial Oncology Program, and is an instructor at Harvard Medical School, Boston, MA. Dr. Block is Chair and Professor of Psychiatry, Psychosocial Oncology and Palliative Care, Dana-Farbar Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School. 44 www.SupportiveOncology.net THE JOURNAL OF SUPPORTIVE ONCOLOGY
Page 1 and 2: Editor-in-Chief Michael J. Fisch, M
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