Evaluating the “Good Death” Concept from Iranian Bereaved Family

Table 1
Factors Contributing to Difficult Patient Encounters
in the Oncology Setting
FACTOR EXAMPLE
Patient Depression, anxiety, somatization, substance
abuse, personality disorder, delirium, psychosis
Physician High need for control, high expectation of
physician’s role, perceived lack of time to
address or lack of interest in psychosocial
concerns, difficulty setting limits
Patient–physician
relationship
Cultural or socioeconomic mismatch, mismatch
in information-sharing preferences, “patient” vs
“consumer”
Cancer context “Life-or-death,” pressure on clinician for a
“save,” disinhibiting adjuvant medications,
intense treatment demands and schedules,
high expectations fostered by tertiary care
ethos
undetected mild delirium), trauma, and substance abuse/dependence.
Other studies have reported a higher prevalence of
multiple somatic symptoms 1 and personality disorders 5 in difficult
patients. Patients with chaotic lifestyles resulting from
poverty or patients from non-Western cultures who have
different expectations of medical care may be less adherent to
treatments, miss appointments, or arrive late, contributing to
difficult encounters.
THE PHYSICIAN
Physicians bring many qualities and attitudes to the physician–patient
relationship that can make patients seem more
or less difficult. Physicians may dislike engaging with patients’
psychosocial challenges and concerns for personal or financial
reasons (eg, discomfort with intense emotion, nonreimbursement
for time spent talking about psychosocial issues). Less
psychosocially minded physicians 6 were more likely to experience
difficult patient encounters as classified by the difficult
doctor–patient relationship questionnaire, a validated instrument
in primary care. 2,3 Physician views about “appropriate”
patient behavior, their abilities to tolerate strong emotions in
their patients, perceptions of their own responsibility, and
level of control of patient outcomes are among many factors
that can contribute to physicians’ views of patients as difficult.
For example, when a patient has refractory pain/nausea/dyspnea
or other symptoms that are unresponsive to usual treatments,
some physicians may feel incompetent and respond to
those feelings by distancing themselves and making the patient
more anxious, thus contributing to behavioral disturbance.
Difficult patients tend to provoke strong emotions in
their clinicians, a phenomenon known as countertransference.
When unrecognized, these emotions can prompt a variety
of maladaptive clinician responses: distancing or becoming
overinvolved with the patient, lack of empathy for the
patient, failing to set appropriate limits on patient behavior,
or, in some cases, even inappropriately terminating the patient’s
care. Difficulty tolerating a patient’s expressed emo-
Meyer and Block
tions such as tearfulness or anxiety may lead the physician to
ignore emotions, thereby eliciting amplification of the patient’s
emotional expression with the goal of engaging the physician.
Lack of awareness of one’s own negative emotions such as anger
may contribute to a physician being curt, brusque, or distant.
Finally, clinicians who are particularly attached to the ideal of
physicians as inexhaustible caregivers, giving their utmost for
each patient, may be uncomfortable setting limits on patients’
unreasonable demands. Especially in the setting of advanced and
terminal cancer, clinicians can feel powerless to alter the course
of the illness and may view gratifying these demands as the only
way to be of help to a dying patient.
THE PHYSICIAN–PATIENT RELATIONSHIP
Patients and physicians may also have different models of
the physician–patient relationship that create tension and
conflict. Until the mid-20th century, physician–patient relationships
were asymmetric, reflecting a paternalistic model,
with the physician using his/her power and influence for the
good of the patient. This idealistic model further assumes
patient trust, physician availability, and physician connections
with the patient’s family and community. 7 However,
other theorists suggest that, as the power differential increases
because of advances in medical technology and exploding
medical information, abuses of power may increase. 8 In recent
years, the consumer metaphor, in which the doctor–patient
relationship is viewed as an economic transaction and health
care as a commodity, has coexisted with the paternalistic
metaphor. The patient may demand “fair value,” with attention
to his/her rights and preferences, and the presentation of
all relevant treatment options. 9 Physicians and patients therefore
may have divergent ideas about the boundaries of a
treatment relationship. For example, certain patients, encouraged
by family/friends and the popular press to advocate for
themselves, may question the physician both in person and by
e-mail about additional treatment options they have researched
on the Internet, causing some physicians to feel
demeaned and to perceive that their expertise is in question.
Conversely, those patients who have a more traditional, paternalistic
view of the doctor–patient relationship or who are
seriously regressed because of their illness may experience
difficulty with a physician who presents the risks and benefits
of several complex treatment protocols and then expects the
patient to evaluate this detailed information and decide. Recent
work on the doctor–patient relationship has suggested,
perhaps not surprisingly, that doctors better understand their
patients’ health beliefs when patients actively participate in
the consultation by asking questions and sharing concerns
and also that physicians are poorer judges of their patients’
attitudes when patients are of a different race or culture than
the physician. 10
THE CANCER SETTING
Patients confronting a cancer diagnosis—no matter what
stage—immediately perceive its life-threatening nature. High
levels of fear and anxiety often result in correspondingly high,
VOLUME 9, NUMBER 2 � MARCH/APRIL 2011 www.SupportiveOncology.net 45