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Comment: Communication and cancer—A social psychiatrist's view
COMMENT:
COMMUNICATION PSYCHIATRIST’S
AND CANCER-A VIEW*
SOCIAL
COLIN MURRAY PARKES~
St. Christopher’s Hospice, Sydenham and Tavistock Institute of Human Relations
It is no good us beating about the bush, cancer is a nasty disease. If, as McIntosh indicates in the foregoing article, 66 per cent of those who develop it die, and it as Cartwright’s recent survey shows, 87 per cent have
pain (much of it very distressing) at some time during their terminal illness Cl]. we should not be surprised to find that everybody is frightened by the situation. This, of course, includes the doctors and nurses who are usually more aware of these facts and of the limits to the power of modern medicine than are the patients and relatives who seek their aid. And the more the professional cares about his patient and sees him as a human being like himself, the greater is his own distress likely to be when faced with the knowledge that this man has cancer. Doctors, nurses and relatives are, of course, fundamentally different from patients to the extent that they do not usually have the disease themselves, and this often leads them to assume that they are unaffected, iz their judgement and behaviour, by the strong emotions which the disease evokes. It is, therefore, a matter for annoyance, when some clever psychologist or sociologist demonstrates the extent to which irrational considerations influence clinical practice. In one of my own recent studies [2] I found that physicians, radiologists, general practitioners and nurses were all equally optimistic in their expectations of the length of survival of patients with known cancers and if we cannot be realistic to ourselves how much less realistic are our communications with our patients likely to be. I do not want to cause my patient unnecessary suffering so I naturally tend to “look on the bright side” and tell patients and relatives a version of the truth which places the situation in the best light possible. Since they too want to “look on the bright side” they are like]\ to reinterpret my optimistic message as being unduly pessimistic and by so doing. to widen the gap between expectation and actuality. Of course people vary in the extent to which they are able and willing to confront unwanted truths. Some doctors are more “open” than others, so are some * Comment on: Processes of communication, information seeking and control associated with cancer: a selective review of the literature by Jim McIntosh. Sot. Sci. & Med. 8. 167. 1974. t Social Psychiatrist. St. Christopher’s Hospice. Sydenham and Tavistock Institute of Human Relations.
nurses, some relatives and some patients. The work of Elisabeth Ross [3] indicates that, for the cancer patient, full realization takes time and that the length of time varies greatly. I have found a similar delay in realization among married women faced with the fact that their husbands have potentially fatal illnesses. In fact “grief’ has itself been described as a “process of realization”. This would seem to indicate that professionals who rely on a single interview in which to “break the news” are likely to find that communication has failed. It takes time to help the patient and his family to come to terms with the realities df illness. But I believe that such time is well spent. “Truth will out” and there is a tendency for patients who have been misinformed about their prognosis to feel let down and disillusioned when, eventually, the deterioration in their physical condition makes it obvious to all that they are on a dying trajectory. Is there evidence that any harm can be done by complete disclosure of the harsh facts as soon as they are known by the doctor? From clinical experience I would say that there are dangers in breaking bad news too abruptly, particularly if the patient is quite unprepared. Such early disclosure seems sometimes to precipitate uncontrollable anxiety or depression with panicky attempts to escape from an intolerable situation by seeking magical cures or avoiding further contact with the medical profession. I have known such fears to cause patients to discharge themselves from hospital and place the entire burden of cure on a relative who is not capable of providing it. Similarly sudden unexpected bereavements, where a young husband or wife has been given little or no warning of the coming death of his or her spouse, Kave been shown to be associated with lasting depression and disorganization when compared with expec$d bereavements [4]. So it seems important to break bad news in a manner which will allow the recipient, be he patient or spouse, to begin to prepare himself for the changes in his life which are implied by the new situation. This kind of tact is not to be confused with the forms of denial by which some doctors attempt to pretend to a patient that he has nothing to worry about. The patient whose doctor consistently tells him he looks better when he can see that he looks worse is likely to conclude, quite rightly, that his doctor is scared to tell 189
190
COLINMURRAYPARKES
him the truth. The message communicated is. therefore, the opposite of that which the doctor intended. If we are to help people to live until they die, we have to create an environment in which their fear of dying does not spoil their joy at living-a place in which it is literally “safe to die”. Paradoxical though this may sound, physicians such as C. M. Saunders have shown that for many patients this is perfectly possible [S]. What is needed is a mutually supportive therapeutic community in which the emotional needs of patients, relatives and staff are recognized and met. In such a setting communication about the illness is seen as an important matter, responsibility for which is shared by the staff team. Doctors and nurses keep each other informed of all discussions with the family (including the patient) concerning the illness. For instance it is recognized that a patient may ask questions of a nurse which he would not ask of a doctor because the patient can more easily disbelieve the nurse if she tells him facts about his illness which he is not ready to know. But it is important for this patient’s doctor to know what has passed between nurse and patient so that he can open the door to further communication if the patient is ready for it. Clearly the scientific investigation of such “defended” communications is very difficult and we should not be surprised at the disagreements and prejudices which creep into the literature. Even the investigator is going to die one day and it would be surprising if his own feelings on the matter did not obtrude.
In interpreting the literature, therefore. it is important to recognize any bias which is introduced by the investigator. Doctors find it hard to study their own behaviour and resent it when their behaviour is criticized by non-doctors. Sociologists and psychologists. lacking the doctor’s power to change the health care system, may be tempted to deal with their own sense of powerlessness by attacking the doctors rather than by recognizing that the doctor’s emotional needs should be treated with the same respect and understanding as those of their patients. It is not enough for scientists to take the lid off the health care system they must be prepared to get in among pain and death and grief and help to set things to rights.
REFERENCES 1. Cartwright A., Hockey L. and Anderson J. L. Life Before Death, p. 23. Routledge, Lond. and Boston, 1973. 2. Parkes C. M. Accuracy of predictions of survival in later
stages of cancer. Brit. Med. J. 29-3 1, 1972.
3. Ross E. K. On Death and Dying. Tavistock, Lond., Macmillan, N.Y., 1970.
4. Parkes C. M. Bereavement: Studies ofGriefin Adult Lijz, pp. 215-216. Tavistock, Lond., Internat. Univ. Press, N.Y., 1972. 5. Saunders C. M. The management of terminal illness. Hospital Medicine. Part I, December 1966. pp. 225-228; Part II, January 1967, pp. 317-320; Part III, February, 1967, pp. 433-436.
COMMUNICATION PSYCHIATRIST’S
AND CANCER-A VIEW*
SOCIAL
COLIN MURRAY PARKES~
St. Christopher’s Hospice, Sydenham and Tavistock Institute of Human Relations
It is no good us beating about the bush, cancer is a nasty disease. If, as McIntosh indicates in the foregoing article, 66 per cent of those who develop it die, and it as Cartwright’s recent survey shows, 87 per cent have
pain (much of it very distressing) at some time during their terminal illness Cl]. we should not be surprised to find that everybody is frightened by the situation. This, of course, includes the doctors and nurses who are usually more aware of these facts and of the limits to the power of modern medicine than are the patients and relatives who seek their aid. And the more the professional cares about his patient and sees him as a human being like himself, the greater is his own distress likely to be when faced with the knowledge that this man has cancer. Doctors, nurses and relatives are, of course, fundamentally different from patients to the extent that they do not usually have the disease themselves, and this often leads them to assume that they are unaffected, iz their judgement and behaviour, by the strong emotions which the disease evokes. It is, therefore, a matter for annoyance, when some clever psychologist or sociologist demonstrates the extent to which irrational considerations influence clinical practice. In one of my own recent studies [2] I found that physicians, radiologists, general practitioners and nurses were all equally optimistic in their expectations of the length of survival of patients with known cancers and if we cannot be realistic to ourselves how much less realistic are our communications with our patients likely to be. I do not want to cause my patient unnecessary suffering so I naturally tend to “look on the bright side” and tell patients and relatives a version of the truth which places the situation in the best light possible. Since they too want to “look on the bright side” they are like]\ to reinterpret my optimistic message as being unduly pessimistic and by so doing. to widen the gap between expectation and actuality. Of course people vary in the extent to which they are able and willing to confront unwanted truths. Some doctors are more “open” than others, so are some * Comment on: Processes of communication, information seeking and control associated with cancer: a selective review of the literature by Jim McIntosh. Sot. Sci. & Med. 8. 167. 1974. t Social Psychiatrist. St. Christopher’s Hospice. Sydenham and Tavistock Institute of Human Relations.
nurses, some relatives and some patients. The work of Elisabeth Ross [3] indicates that, for the cancer patient, full realization takes time and that the length of time varies greatly. I have found a similar delay in realization among married women faced with the fact that their husbands have potentially fatal illnesses. In fact “grief’ has itself been described as a “process of realization”. This would seem to indicate that professionals who rely on a single interview in which to “break the news” are likely to find that communication has failed. It takes time to help the patient and his family to come to terms with the realities df illness. But I believe that such time is well spent. “Truth will out” and there is a tendency for patients who have been misinformed about their prognosis to feel let down and disillusioned when, eventually, the deterioration in their physical condition makes it obvious to all that they are on a dying trajectory. Is there evidence that any harm can be done by complete disclosure of the harsh facts as soon as they are known by the doctor? From clinical experience I would say that there are dangers in breaking bad news too abruptly, particularly if the patient is quite unprepared. Such early disclosure seems sometimes to precipitate uncontrollable anxiety or depression with panicky attempts to escape from an intolerable situation by seeking magical cures or avoiding further contact with the medical profession. I have known such fears to cause patients to discharge themselves from hospital and place the entire burden of cure on a relative who is not capable of providing it. Similarly sudden unexpected bereavements, where a young husband or wife has been given little or no warning of the coming death of his or her spouse, Kave been shown to be associated with lasting depression and disorganization when compared with expec$d bereavements [4]. So it seems important to break bad news in a manner which will allow the recipient, be he patient or spouse, to begin to prepare himself for the changes in his life which are implied by the new situation. This kind of tact is not to be confused with the forms of denial by which some doctors attempt to pretend to a patient that he has nothing to worry about. The patient whose doctor consistently tells him he looks better when he can see that he looks worse is likely to conclude, quite rightly, that his doctor is scared to tell 189
190
COLINMURRAYPARKES
him the truth. The message communicated is. therefore, the opposite of that which the doctor intended. If we are to help people to live until they die, we have to create an environment in which their fear of dying does not spoil their joy at living-a place in which it is literally “safe to die”. Paradoxical though this may sound, physicians such as C. M. Saunders have shown that for many patients this is perfectly possible [S]. What is needed is a mutually supportive therapeutic community in which the emotional needs of patients, relatives and staff are recognized and met. In such a setting communication about the illness is seen as an important matter, responsibility for which is shared by the staff team. Doctors and nurses keep each other informed of all discussions with the family (including the patient) concerning the illness. For instance it is recognized that a patient may ask questions of a nurse which he would not ask of a doctor because the patient can more easily disbelieve the nurse if she tells him facts about his illness which he is not ready to know. But it is important for this patient’s doctor to know what has passed between nurse and patient so that he can open the door to further communication if the patient is ready for it. Clearly the scientific investigation of such “defended” communications is very difficult and we should not be surprised at the disagreements and prejudices which creep into the literature. Even the investigator is going to die one day and it would be surprising if his own feelings on the matter did not obtrude.
In interpreting the literature, therefore. it is important to recognize any bias which is introduced by the investigator. Doctors find it hard to study their own behaviour and resent it when their behaviour is criticized by non-doctors. Sociologists and psychologists. lacking the doctor’s power to change the health care system, may be tempted to deal with their own sense of powerlessness by attacking the doctors rather than by recognizing that the doctor’s emotional needs should be treated with the same respect and understanding as those of their patients. It is not enough for scientists to take the lid off the health care system they must be prepared to get in among pain and death and grief and help to set things to rights.
REFERENCES 1. Cartwright A., Hockey L. and Anderson J. L. Life Before Death, p. 23. Routledge, Lond. and Boston, 1973. 2. Parkes C. M. Accuracy of predictions of survival in later
stages of cancer. Brit. Med. J. 29-3 1, 1972.
3. Ross E. K. On Death and Dying. Tavistock, Lond., Macmillan, N.Y., 1970.
4. Parkes C. M. Bereavement: Studies ofGriefin Adult Lijz, pp. 215-216. Tavistock, Lond., Internat. Univ. Press, N.Y., 1972. 5. Saunders C. M. The management of terminal illness. Hospital Medicine. Part I, December 1966. pp. 225-228; Part II, January 1967, pp. 317-320; Part III, February, 1967, pp. 433-436.