Monday, January 5, 2009

'Between utter despair and essential hope'

Journal of Clinical Oncology has an 'Art of Oncology' piece about denial and hope. It starts as a discussion of 'denial' (framing it as a normal coping mechanism in the initial aftermath of hearing life-altering news):

Patients tend to perceive a diagnosis of cancer as if they were in a movie. Professional experience educates: it is most often of no use to try to drag patients, or their family members, out of this movie. Psychologists and doctors conscientiously have to know that, although the diagnosis and facts may be explained more than once, even then patients often do not accept the facts. Patients with a cognitive escape-avoidance coping were reported to have a longer survival than other patients with localized melanoma. At some time, the patient will get over this state of shock. The time for a first psychic consolidation of reality awareness will come.
It then goes on to discuss patients moving from denial to other stages - using the 'Renz model of maturation' - and describes in somewhat spiritual terms this process:
The third stage consists of nothing less than transformation. What happens is more than just being able to accept. It is a gift of grace beyond human endeavor and power. It is here where the spiritual dimension comes in, so that patients momentarily, or for a while, feel different. There is happiness and well-being in the midst of illness. In the course of the dying process, spiritual experiences of such intensity often happen more than just once. After a shorter or longer struggle, patients reach a new mental state, just as a gift of grace.
Ok, well, not somewhat spiritual terms but explicitly spiritual terms. What struck me about this was not that I don't know what the authors are talking about. We all see amazing things every day in this line of work - life-transformations, patients in unbelievably horrible circumstances coping with truly humbling serenity and generativity, etc. - and I'll be the first to admit that I find this a 'mysterious' process. Why it happens with some patients/families and not others? If clinicians actually have some power over it (to foster it, to help cause these 'positive' transformations, etc.)?

That said, and with all acknowlegments to the critical importance of faith, religion, and/or spirituality in our patients' lives, I still am hesitant for us as a community to use spiritual language to describe such events. "It is a gift of grace beyond human endeavor and power" strikes me as an incredibly therapeutic nihilistic statement: both our patients and us as clinicians are passive witnesses to this, as how could we have an impact on something beyond our power? The fact that the process appears mysterious does not mean it is describable/understandable in spiritual terms alone, and doing so takes it out of the realm of inquiry, understanding, and intervention. I am probably over-reacting, but language is important....

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