Sunday, November 22, 2009

Acceptance and well-being

JCO has a paper looking at prognostic acceptance in cancer patients, and its relationship with well-being. It's a Canadian study, involving 380 patients with advanced cancer (enrollment criteria including having an expected prognosis of under 6 months and being aware of the incurable nature of their cancer; this number is out of 920 who met enrollement criteria - the rest declined or died before the interview could occur; about 40% declined from the beginning and one wonders if these were disproportionately people who weren't doing well). They were interviewed about a lot of things, including whether they accepted their incurable cancer vs. not (based on answers to a question, in a semi-structured interview, of 'Do you feel you can accept your situation and come to terms with all that is happening?' They compared patients who endorsed acceptance (most of them; 74%) with those who didn't.

The results are relatively straight-forward. Non-acceptors were younger, were more likely to have above-high-school education, and were more likely to have (based on concurrent screening during the research interview) depression and/or anxiety. No surprises there (well, while the 'above high-school education finding has not been a strong trend in this sort of research it's not a shocking finding either).

More interesting is the semi-quantitative part of the paper, in which they describe how these patients discussed their coping (or lack of). It's a like a mini-primer of how our patients cope or struggle with facing their deaths. It mentions an aspect of this that I've been thinking about a lot lately based on several patient encounters - the role of having family members who also accept their illness in helping people cope. It's a uniquely lonely place - to know you're dying - and not to have anyone who you can even mention that reality to or discuss it in a straight-forward way. There are many flavors of this: loved ones too gobsmacked by their own grief to be able to engage with the patient him/herself about what's going on, loved ones whose only response is to say 'don't think about it,' 'keep positive,' 'you'll beat this you're a fighter,' 'pray.' All those strategies are part of a healthy coping package for most people of course, but aren't sufficient for those who Know and want to connect with loved ones about what this all will mean. This stuff, in isolation of any other space for discussion, seems like a kind of 'positive-only' form of emotional distancing, and I've had many patients complain to me about it. A similar thing can occur with clinicians as well - ignoring the elephant in the room (the fact that the patient is dying) and talking about the scan results, or the next treatment steps. I'm curious if readers often find themselves in this position - realizing you (the clinician) is (at least temporarily) the only individual with whom the patient is able to talk about what they actually want to talk about.

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