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Dentist’s role in management of the cancer patient
Dentist's role in management of the cancer patient
Regina F. F lesch* Ph.D., Philadelphia
The dentist can help his patient with cancer by understanding the patient’ s emotional problems, by offering a con tinuing relation, by showing calm and enduring interest and effort on behalf of the patient, and by helping to alleviate anxiety and forestall depression when such feelings are related to dental care. The dentist should be aware of the com munity resources available to assist the cancer patient, and should not hesitate to help him obtain the necessary care and aid.
The following discussion of the dentist’s management o f the cancer patient will be more meaningful if, at the outset, the terms are defined. Here “ the cancer pa tient” refers to the patient whom the dentist definitely knows to Have cancer. It does not refer to the patient in whom the dentist merely suspects the disease, however strong his suspicions, nor to the patient who suffers from acute or chronic fear of cancer, that is, the cancerphobic patient. This discussion has relevance to the management of other groups of pa tients, but the emphasis is on understand ing the emotional problems inherent in the treatment of any patient whom the dentist knows to have cancer.
Underlying the discussion are two principles which should be made clear from the beginning and which will be amplified as it proceeds. These principles are, first, that by the time the dentist knows the patient has cancer, the patient also, either consciously or unconsciously, is aware of it.1 Second, when the dentist speaks of the psychological problems of the cancer patient, he in no way implies that a patient with a particular psy chological makeup has a predisposition toward the disease, nor does he imply that the emotional response to the dis ease is uniform or unchanging or that it can be considered unrelated to the patient’s changing environment. Even when a patient consults a den tist or physician for treatment of a quite different ailment, the patient can hardly be totally unaware of the cancer. H e may consciously dismiss it as unimportant or deny that it exists so that he appears sur prised when the doctor calls his attention to it. Nevertheless, the examining doc tor’s concern about the patient, the in sistence upon follow-up and the examina tion procedures will inevitably indicate to the patient that something is decidedly wrong. Many of the clinic patients at the University of Pennsylvania School of Dentistry are poorly educated and do not know what the word “ biopsy” means. However, because they sense what it im
FLESC H .. . V O L U M E 66, A P R IL 1963 • 35/467
plies, the clinic staff tries to avoid the word in the patient’s presence.2 This sub liminal or preconscious awareness con tributes to the problems of treating cancer patients, for it precipitates the acute anxi ety commonly seen in this group of patients. In instances where the patient himself does not have overt visual and tactile evidence of disease, the body can signal the mind of the danger. The body and mind function as a unit; no disembodied mind ever consulted a doctor. Much of the current discussion of psychosomatic medicine focuses on physical ailments, such as ulcers, resulting from emotional tensions. However, signals may run in the other direction as well, and mental anxi ety may be a response to physical mal functioning of which the patient has no conscious knowledge. For example, chil dren suffering from intestinal parasites, such as pinworms, often are troubled by disturbed sleep and nightmares. Psychi atric literature also records examples of patients whose dream content showed un conscious awareness of grave illness, al though at the time neither the patient nor the psychiatrist knew of the subse quently diagnosed malignancy.3 The anx iety manifest in such sleep disturbances is simply the psychic response to somatic invasion by a foreign substance, the re verse side of the familiar psychosomatic unity.4 The patient does not need to be con fronted with the information of malig nancy in order to develop awareness of his illness and profound disturbance about it. This brings into a new per spective the old question which has pre occupied many practitioners: “ whether the doctor should tell the patient that he has cancer.” Whether or not the patient is openly told of his condition, the gravity with which the illness is treated, the em phasis on continued care, the treatment— often surgery— all come as a shock to the patient. An individual patient’s reaction to this shock depends on his personality pattern and his customary response to
crises, his personal strength and his life situation.5 At one time the struggle for health may appear uppermost; at another time, denial and retreat from the crisis will prevail. Individuals vary not only among themselves but within themselves. In helping the patient meet the crisis, the doctor can have no better ally than his understanding of the emotional problems besetting the patient. N o rules apply to all patients at all times, but some common emotional constellations which create problems in the treatment of these pa tients can be isolated. When the dentist understands these problems, he is in a better position to help the patient meet them. S O M E E M O T IO N A L P R O B L E M S O F T H E C A N C E R P A T IE N T
The doctor treating a patient with a di agnosis o f malignancy should expect to encounter at least three emotional prob lems in his patient: an abnormal fear of dependency, irrational feelings of resent ment and envy directed toward healthy individuals in the environment, including the doctor, and heightened self-destruc tive impulses. Perhaps the most common problem is an abnormal degree of dependency and an accompanying flight from it or yield ing to it.6 The doctor need only recall here the almost universal attitude that accompanies a common cold: the desire to go to bed and be waited on. It has been suggested that the desire to be looked after during illness, as a child is looked after, is simply the psychological adaptation to the body’s weakness. In the normally independent and mature adult, this dependent adaptation facilitates the acceptance of rest and care, and thus can speed recovery. The patient who faces prolonged illness and surgery, however, faces debilitation or incapacitation, and possibly extensive rehabilitative work.7 A patient who has strong underlying de pendent needs can become unduly fearful of prolonged, if not permanent, incapaci
36/448 • T H E J O U R N A L O F T H E A M E R IC A N DEN T A L A S S O C IA T IO N
tation. In addition to this dependency, cancer itself implies to the patient that his body is being invaded and gradually taken over by an internal enemy against which he and m odem science are power less. The lay public often remembers from cancer education more about what cannot be done than what can be done. It is not surprising, therefore, that patients act like helpless, dependent and lost children, and take flight from the diagnosis, the doctor, and the possible help. It is paradoxical that dependence, which is a normal com ponent of illness and which generally cements the patient’s relationship to the doctor, to some dependent patients may have a terrifying undertone of permanent helplessness, which drives them away from care. The emotional return to the state of a dependent child means that the patient turns to the omnipotent doctor as a child does to an all-powerful parent.1 I f the doctor cannot gratify the patient’s wish for health, the patient may react as irra tionally as a child to a frustrating parent. Cancer patients often verbalize their feel ings that they have been cruelly treated by “ fate” or “ life,” and indicate that the disease has the unconscious meaning of punishment, deserved or undeserved. When the writer was a college student, she visited a friend whose older sister presumably was unaware that she had ad vanced leukemia. The friend had just bought her first pair of navy blue pumps and proudly displayed them for admira tion. The sister’s criticisms about her taste were so derogatory that the next day the shoes were returned to the store, and the friend did not dare buy another pair. Even an unsophisticated adolescent could perceive the lurking rage and envy that one sister should skip around in those shoes while the other lay beneath the earth. T o patients struggling with resent ment and envy, surgery, with attendant pain and possible mutilation, can be per ceived as further injury and punishment. The doctor who inflicts the wound can easily become a target for the resentment
and envy that these patients feel toward healthy persons. Again it is paradoxical that the cancer patient, needing help and goodwill from everyone in his environ ment, may alienate people by his irritabil ity, temper displays, unreasonable de mands, and stubborn lack of cooperation. In the consideration o f self-destructive impulses, this discussion need not go into the controversial question of the presence, in everyone, of an instinct toward death. The cultural emphasis on the dangers of cancer, and the common lay equating of cancer and death must be taken into ac count when it is said that malignancy mobilizes self-destructive impulses in pa tients.3 H ow many times has the doctor heard people say that if they knew they had cancer they would kill themselves? The suicide rate among cancer patients reputedly is high. It is easy to speculate that cancer patients commit suicide in order to avoid suffering or becoming a burden on their families. Such speculation may be partly valid. However, modem drugs eliminate much suffering, and natu ral death unquestionably is more accept able and easier for families than suicide. Another explanation may lie in the omi nous nature o f malignancy itself. T o the patient who feels that his body is being destroyed by uncontrollable evil forces, suicide may represent a voluntary, active curb to an otherwise inevitable course of events. Again it is a paradox that a pa tient’ s attempt to control a situation may lead to his self-destruction. However, even with patients who put up a strong fight for life, the doctor should be aware of the possible self-destructive tendencies which may sabotage treatment, if not lead to actual suicide. S U G G E ST E D T E C H N IC S F O R M E E T IN G T H E S E P R O B L E M S
The dentist is in a fortunate position to meet these emotional problems construc tively. The following specific technics, suggested to help the dentist in practical situations, at first may sound contradic
FLESC H . . . V O L U M E 66, A P R IL 1963 • 37/46»
tory. They are actually no more contra dictory than the emotional problems which they are designed to meet. Further more, the patient, in whom the struggle is raging, does not perceive such an ap proach as contradictory, but rather, as what he needs from the dentist to help him in his illness. Unlike the surgeon, the dentist can offer the patient a continuing relation on which to depend. A strong, secure, competent, comforting person to turn to and return to means everything to the dependent sick. With prosthetic patients, consultations, refittings and adjustments can fulfill real needs, and also show the patient that the dentist is available to help and com fort him. However, at the same time that the dentist shows calm and enduring interest and effort, he should show that he expects the patient to help himself. The dentist can create prostheses for the patient, but the task of using them is the patient’s, not the dentist’s. T o this end, the patient can be assigned small exercises or duties related to the use of the prosthesis. It is imma terial if the particular activity asked of the patient has little or no practical value. The important thing is to keep the pa tient from falling into helpless passivity or dependency because of his illness. In other words, the dentist should use any thing he can— exercises, duties, trips to the office— to keep the patient actively working on his problem, but at the same time, show him that he is with him every step of the way. Cancer patients can be expected to feel rage, either consciously or uncon sciously, toward the people from whom they seek help. Forewarned, the wise doc tor does not take personally the patient’s irritability, nor does he become defensive if the patient accuses him of neglect or incompetence.1 The prosthodontist’s en tire effort is toward the rehabilitation of the patient and toward the eradication of the evidence of illness or surgery. The prosthodontist, therefore, is in an excel lent position to avoid becoming the target
of irrational rage, and by his functioning he can help the patient again regard members of the health professions as heal ers, not injurers. In his contact with the patient, the prosthodontist should avoid any suggestion— by act or word— of the retaliation which the patient uncon sciously expects in return for his own hostility. Furthermore, the dentist, con tinuing with the patient, is in a good position to time his care, postponing un pleasant procedures until the patient has regained self-control or is not overtly hos tile. If the dentist finds that on a certain day he himself has less tolerance for the hostile or demanding patient, it may be easier for both and less time-consuming to ask if the patient would prefer to work on this problem another day when he feels less tense about it. Leaving a degree of control with the patient can be helpful in evading the patient’s latent resentment. Obviously, no unpleasant procedures should be scheduled immediately after a negative session, even if the dentist uses a placebo office visit between them. At the same time that the dentist maintains this objective, calm interest in his patient, he should convey that he expects the pa tient’s cooperation in the office and out side, no matter how the patient may feel occasionally. In other words, like a wise parent, the dentist rejects obstructive be havior, but accepts the patient himself. As in other situations, the setting o f limits keeps the patient related to reality so that he is less overwhelmed by fears of feelings, either his own or others. Although the dentist knows that cancer patients have a high mortality rate, he should behave as though he has every ex pectation that a particular patient will get well permanently. This attitude need not be verbalized; chances are that the pa tient would not believe the words any way. The attitude of confidence and hopefulness may be conveyed most ef fectively by the dentist’s continuing plans on the patient’s behalf.3 For example, the dentist can tell the patient that he expects
38/470 • T H E J O U R N A L O F T H E A M E R IC A N D ENTA L A S S O C IA T IO N
him to come for monthly checkups and adjustments for at least a year. The den tist can make this arrangement in an assured, confident manner, even though he knows that the patient has a limited life expectancy. Although the dentist nat urally shows that he thinks the patient’s illness is serious, at no time should he indicate that he feels he can do no more for the patient, or that this is the last prosthesis he expects to make for him. If the patient presses the dentist about life expectancy, the dentist can reply truthfully that no one can say with cer tainty that a disease cannot be arrested with proper care. Such actions and atti tudes on the part o f the dentist support the patient in his inner and outer struggle for life. It is o f inestimable value to the patient to have persons in his environ ment who never give up fighting for his life and comfort and who never despair. If the dentist has any question about the ethics of seemingly valueless consulta tions, he should remember that in this context, these consultations are a form of psychotherapy. Like the physician, the dentist has a responsibility to alleviate anxiety and to forestall depression wher ever these feelings are intimately related to his professional care. E N V IR O N M E N T A L S U P P O R T S
The cancer patient lives in a materially different environment than does the can cer free patient. Th e world of the cancer patient is one of physical treatment, dis comfort and anxiety, with the possibilities of impairment, disfigurement and death always in the background.8’ 8 This world o f real dangers prevents the cancer pa tient from seeing himself, his family, his physician and his dentist as he saw them before the dangers arose. Both patient and dentist need every avenue of support to keep the patient constructively related to his environment. Here, where the re sources of the individual are likely to be insufficient, it is important to remember that other resources are available. A l
though dentistry traditionally is practiced in relative isolation, the same resources are open to dentistry as to medicine or social work. These resources lie in the family, the community and the organized network of professional agencies which help serve people in trouble. Under normal circumstances, unless dealing with children, the practicing den tist does not consult other members of the patient’s family in arriving at a treat ment plan. With the cancer patient, even the most perceptive dentist must take into account the family constellation in assessing how much cooperation he can expect from the patient. Particularly in the early stages with a cancer patient, when preparing him for diagnosis and surgery, the dentist may find it profitable to rely on responsible members of the family to see that the patient takes the necessary steps. For example, with pan icky or defiant patients, rather than de bate whether to confront the patient with the possibility of cancer, the dentist can often work through family consultations to guide the patient indirectly to the de sired end. At any point during the pa tient’s treatment, the dentist can enlist the cooperation o f responsible family members to help him help the patient. The patient’s ability to cope with the dis ease may be related to those family mem bers on whom he can depend and to those who depend on him. Beyond the family is a wider commu nity containing lay and religious groups to which the patient can turn. The pa tient’s occupation and his employment affiliations are important in assessing and planning rehabilitation. Frequently, labor unions have funds and facilities for sick members and also can assist in rehabilita tion. It can be helpful to know the pa tient’ s religious affiliation and religious orientation, and such information can often be picked up in natural conversa tion.8 When other sources of help fail, church groups may assist in many differ ent ways. Certainly an understanding clergyman can do a great deal for the pa
FL ESC H . . . V O L U M E 66, A P R IL 1963 • 39/471
tient’ s morale, and, in my experience, in obtaining funds. Clubs and social groups, similarly, can help the dentist in rehabili tation work with his patient, and if the dentist knows o f such groups, he may sug gest them to the patient or the family. Also, the patient often can be helped greatly if his doctor is able to introduce him to patients who have had similar con ditions and have met them successfully, or to patients who have achieved a good result from prostheses or have led satisfy ing lives despite illness. Most important, other professions are devoted to serving the sick, and these pro fessions are at hand to help the dentist. Medical services need not be discussed because dentistry has a long history of close collaboration with medicine. A l though dentists as a rule take less advan tage of other professional services, they should remember that public health nurs ing services and social services can be helpful. These professional workers can take time, which is not available to the busy practitioner, to go into the home and establish contact with reluctant family members. For the management of crises, the services o f visiting nurses and social workers are invaluable. A home visit can provide a picture o f the family’s interac tion and its response to the patient. Where the dentist and the physician tra ditionally are reluctant to enter, the visit ing nurse and family caseworker know how to gain access to a home and family. Members o f these related professions can help the dentist meet the needs of the cancerphobic patient, as well as of the cancer patient, for these workers may follow up psychiatric referrals which the practicing dentist would find awkward or time-consuming. By enlisting the help of related health professions, the dentist can avoid the dilemma of “ to tell or not to tell the can
cer patient.” The dentist’s primary goal is not to give the patient information, but to help him obtain the necessary care. Even in the rare instances where the pa tient is told directly, the much discussed problem of “ who tells the patient” should resolve itself. In such instances the dentist serves the patient best by acting as a member of a health team. Important de cisions are made in consultation with other health workers who know different parts of the total picture, and responsi bilities are shared. The dentist who works with a patient within the suggested emo tional and environmental framework is in a better position to see his patient through the taxing steps to health or to death than is the dentist who attempts to work without this frame of reference. If the program outlined seems at first to be outside the traditional functions of dentistry, it still is in keeping with den tistry’s tradition of assuming increasing responsibilities for the patient’s health. By such broadening of its horizon and gradual enlarging of its sphere of activi ties, dentistry has gained the place it now holds among the health professions.
*Research associate, School of Dentistry, University of Pennsylvania. 1. Beliak, Leopold, editor. Psychology of physical illness. New York, Grune & Stratton Co., 1952, p. 27-43, 45-52, 52-73. 2. Bird, Brian. Talking with patients. Philadelphia, J. B. Lippincott Co., 1955. ^3. Eissler, Kurt R. The psychiatrist and the dying p a tient. New York, International Universities Press, 1955. 4. Bard, Morton. Psychological reactions to oral can cer. Oral Surg., O ral M ed. & Ora! Path. 12:922 Aug. 1959. 5. Lederer, Henry D. How the sick view their world, in Jaco, E. Gartly, Patients, physicians and illness. Glencoe, III., The Free Press, 1958, p. 247-256. 6. Raven, R. W . A handbook on cancer for nurses and health visitors. London, Butterworth & Co., Ltd., 1953. 7. Koos, E. L. The sociology of the patient: a text book for nurses. New York, M cG raw -Hill Book Co., Inc., 1950. 8. Harris, Edward G. Physician, clergyman and p a tient in terminal illness. Pennsylvania M . J. 54:541 June 1951.
Regina F. F lesch* Ph.D., Philadelphia
The dentist can help his patient with cancer by understanding the patient’ s emotional problems, by offering a con tinuing relation, by showing calm and enduring interest and effort on behalf of the patient, and by helping to alleviate anxiety and forestall depression when such feelings are related to dental care. The dentist should be aware of the com munity resources available to assist the cancer patient, and should not hesitate to help him obtain the necessary care and aid.
The following discussion of the dentist’s management o f the cancer patient will be more meaningful if, at the outset, the terms are defined. Here “ the cancer pa tient” refers to the patient whom the dentist definitely knows to Have cancer. It does not refer to the patient in whom the dentist merely suspects the disease, however strong his suspicions, nor to the patient who suffers from acute or chronic fear of cancer, that is, the cancerphobic patient. This discussion has relevance to the management of other groups of pa tients, but the emphasis is on understand ing the emotional problems inherent in the treatment of any patient whom the dentist knows to have cancer.
Underlying the discussion are two principles which should be made clear from the beginning and which will be amplified as it proceeds. These principles are, first, that by the time the dentist knows the patient has cancer, the patient also, either consciously or unconsciously, is aware of it.1 Second, when the dentist speaks of the psychological problems of the cancer patient, he in no way implies that a patient with a particular psy chological makeup has a predisposition toward the disease, nor does he imply that the emotional response to the dis ease is uniform or unchanging or that it can be considered unrelated to the patient’s changing environment. Even when a patient consults a den tist or physician for treatment of a quite different ailment, the patient can hardly be totally unaware of the cancer. H e may consciously dismiss it as unimportant or deny that it exists so that he appears sur prised when the doctor calls his attention to it. Nevertheless, the examining doc tor’s concern about the patient, the in sistence upon follow-up and the examina tion procedures will inevitably indicate to the patient that something is decidedly wrong. Many of the clinic patients at the University of Pennsylvania School of Dentistry are poorly educated and do not know what the word “ biopsy” means. However, because they sense what it im
FLESC H .. . V O L U M E 66, A P R IL 1963 • 35/467
plies, the clinic staff tries to avoid the word in the patient’s presence.2 This sub liminal or preconscious awareness con tributes to the problems of treating cancer patients, for it precipitates the acute anxi ety commonly seen in this group of patients. In instances where the patient himself does not have overt visual and tactile evidence of disease, the body can signal the mind of the danger. The body and mind function as a unit; no disembodied mind ever consulted a doctor. Much of the current discussion of psychosomatic medicine focuses on physical ailments, such as ulcers, resulting from emotional tensions. However, signals may run in the other direction as well, and mental anxi ety may be a response to physical mal functioning of which the patient has no conscious knowledge. For example, chil dren suffering from intestinal parasites, such as pinworms, often are troubled by disturbed sleep and nightmares. Psychi atric literature also records examples of patients whose dream content showed un conscious awareness of grave illness, al though at the time neither the patient nor the psychiatrist knew of the subse quently diagnosed malignancy.3 The anx iety manifest in such sleep disturbances is simply the psychic response to somatic invasion by a foreign substance, the re verse side of the familiar psychosomatic unity.4 The patient does not need to be con fronted with the information of malig nancy in order to develop awareness of his illness and profound disturbance about it. This brings into a new per spective the old question which has pre occupied many practitioners: “ whether the doctor should tell the patient that he has cancer.” Whether or not the patient is openly told of his condition, the gravity with which the illness is treated, the em phasis on continued care, the treatment— often surgery— all come as a shock to the patient. An individual patient’s reaction to this shock depends on his personality pattern and his customary response to
crises, his personal strength and his life situation.5 At one time the struggle for health may appear uppermost; at another time, denial and retreat from the crisis will prevail. Individuals vary not only among themselves but within themselves. In helping the patient meet the crisis, the doctor can have no better ally than his understanding of the emotional problems besetting the patient. N o rules apply to all patients at all times, but some common emotional constellations which create problems in the treatment of these pa tients can be isolated. When the dentist understands these problems, he is in a better position to help the patient meet them. S O M E E M O T IO N A L P R O B L E M S O F T H E C A N C E R P A T IE N T
The doctor treating a patient with a di agnosis o f malignancy should expect to encounter at least three emotional prob lems in his patient: an abnormal fear of dependency, irrational feelings of resent ment and envy directed toward healthy individuals in the environment, including the doctor, and heightened self-destruc tive impulses. Perhaps the most common problem is an abnormal degree of dependency and an accompanying flight from it or yield ing to it.6 The doctor need only recall here the almost universal attitude that accompanies a common cold: the desire to go to bed and be waited on. It has been suggested that the desire to be looked after during illness, as a child is looked after, is simply the psychological adaptation to the body’s weakness. In the normally independent and mature adult, this dependent adaptation facilitates the acceptance of rest and care, and thus can speed recovery. The patient who faces prolonged illness and surgery, however, faces debilitation or incapacitation, and possibly extensive rehabilitative work.7 A patient who has strong underlying de pendent needs can become unduly fearful of prolonged, if not permanent, incapaci
36/448 • T H E J O U R N A L O F T H E A M E R IC A N DEN T A L A S S O C IA T IO N
tation. In addition to this dependency, cancer itself implies to the patient that his body is being invaded and gradually taken over by an internal enemy against which he and m odem science are power less. The lay public often remembers from cancer education more about what cannot be done than what can be done. It is not surprising, therefore, that patients act like helpless, dependent and lost children, and take flight from the diagnosis, the doctor, and the possible help. It is paradoxical that dependence, which is a normal com ponent of illness and which generally cements the patient’s relationship to the doctor, to some dependent patients may have a terrifying undertone of permanent helplessness, which drives them away from care. The emotional return to the state of a dependent child means that the patient turns to the omnipotent doctor as a child does to an all-powerful parent.1 I f the doctor cannot gratify the patient’s wish for health, the patient may react as irra tionally as a child to a frustrating parent. Cancer patients often verbalize their feel ings that they have been cruelly treated by “ fate” or “ life,” and indicate that the disease has the unconscious meaning of punishment, deserved or undeserved. When the writer was a college student, she visited a friend whose older sister presumably was unaware that she had ad vanced leukemia. The friend had just bought her first pair of navy blue pumps and proudly displayed them for admira tion. The sister’s criticisms about her taste were so derogatory that the next day the shoes were returned to the store, and the friend did not dare buy another pair. Even an unsophisticated adolescent could perceive the lurking rage and envy that one sister should skip around in those shoes while the other lay beneath the earth. T o patients struggling with resent ment and envy, surgery, with attendant pain and possible mutilation, can be per ceived as further injury and punishment. The doctor who inflicts the wound can easily become a target for the resentment
and envy that these patients feel toward healthy persons. Again it is paradoxical that the cancer patient, needing help and goodwill from everyone in his environ ment, may alienate people by his irritabil ity, temper displays, unreasonable de mands, and stubborn lack of cooperation. In the consideration o f self-destructive impulses, this discussion need not go into the controversial question of the presence, in everyone, of an instinct toward death. The cultural emphasis on the dangers of cancer, and the common lay equating of cancer and death must be taken into ac count when it is said that malignancy mobilizes self-destructive impulses in pa tients.3 H ow many times has the doctor heard people say that if they knew they had cancer they would kill themselves? The suicide rate among cancer patients reputedly is high. It is easy to speculate that cancer patients commit suicide in order to avoid suffering or becoming a burden on their families. Such speculation may be partly valid. However, modem drugs eliminate much suffering, and natu ral death unquestionably is more accept able and easier for families than suicide. Another explanation may lie in the omi nous nature o f malignancy itself. T o the patient who feels that his body is being destroyed by uncontrollable evil forces, suicide may represent a voluntary, active curb to an otherwise inevitable course of events. Again it is a paradox that a pa tient’ s attempt to control a situation may lead to his self-destruction. However, even with patients who put up a strong fight for life, the doctor should be aware of the possible self-destructive tendencies which may sabotage treatment, if not lead to actual suicide. S U G G E ST E D T E C H N IC S F O R M E E T IN G T H E S E P R O B L E M S
The dentist is in a fortunate position to meet these emotional problems construc tively. The following specific technics, suggested to help the dentist in practical situations, at first may sound contradic
FLESC H . . . V O L U M E 66, A P R IL 1963 • 37/46»
tory. They are actually no more contra dictory than the emotional problems which they are designed to meet. Further more, the patient, in whom the struggle is raging, does not perceive such an ap proach as contradictory, but rather, as what he needs from the dentist to help him in his illness. Unlike the surgeon, the dentist can offer the patient a continuing relation on which to depend. A strong, secure, competent, comforting person to turn to and return to means everything to the dependent sick. With prosthetic patients, consultations, refittings and adjustments can fulfill real needs, and also show the patient that the dentist is available to help and com fort him. However, at the same time that the dentist shows calm and enduring interest and effort, he should show that he expects the patient to help himself. The dentist can create prostheses for the patient, but the task of using them is the patient’s, not the dentist’s. T o this end, the patient can be assigned small exercises or duties related to the use of the prosthesis. It is imma terial if the particular activity asked of the patient has little or no practical value. The important thing is to keep the pa tient from falling into helpless passivity or dependency because of his illness. In other words, the dentist should use any thing he can— exercises, duties, trips to the office— to keep the patient actively working on his problem, but at the same time, show him that he is with him every step of the way. Cancer patients can be expected to feel rage, either consciously or uncon sciously, toward the people from whom they seek help. Forewarned, the wise doc tor does not take personally the patient’s irritability, nor does he become defensive if the patient accuses him of neglect or incompetence.1 The prosthodontist’s en tire effort is toward the rehabilitation of the patient and toward the eradication of the evidence of illness or surgery. The prosthodontist, therefore, is in an excel lent position to avoid becoming the target
of irrational rage, and by his functioning he can help the patient again regard members of the health professions as heal ers, not injurers. In his contact with the patient, the prosthodontist should avoid any suggestion— by act or word— of the retaliation which the patient uncon sciously expects in return for his own hostility. Furthermore, the dentist, con tinuing with the patient, is in a good position to time his care, postponing un pleasant procedures until the patient has regained self-control or is not overtly hos tile. If the dentist finds that on a certain day he himself has less tolerance for the hostile or demanding patient, it may be easier for both and less time-consuming to ask if the patient would prefer to work on this problem another day when he feels less tense about it. Leaving a degree of control with the patient can be helpful in evading the patient’s latent resentment. Obviously, no unpleasant procedures should be scheduled immediately after a negative session, even if the dentist uses a placebo office visit between them. At the same time that the dentist maintains this objective, calm interest in his patient, he should convey that he expects the pa tient’s cooperation in the office and out side, no matter how the patient may feel occasionally. In other words, like a wise parent, the dentist rejects obstructive be havior, but accepts the patient himself. As in other situations, the setting o f limits keeps the patient related to reality so that he is less overwhelmed by fears of feelings, either his own or others. Although the dentist knows that cancer patients have a high mortality rate, he should behave as though he has every ex pectation that a particular patient will get well permanently. This attitude need not be verbalized; chances are that the pa tient would not believe the words any way. The attitude of confidence and hopefulness may be conveyed most ef fectively by the dentist’s continuing plans on the patient’s behalf.3 For example, the dentist can tell the patient that he expects
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him to come for monthly checkups and adjustments for at least a year. The den tist can make this arrangement in an assured, confident manner, even though he knows that the patient has a limited life expectancy. Although the dentist nat urally shows that he thinks the patient’s illness is serious, at no time should he indicate that he feels he can do no more for the patient, or that this is the last prosthesis he expects to make for him. If the patient presses the dentist about life expectancy, the dentist can reply truthfully that no one can say with cer tainty that a disease cannot be arrested with proper care. Such actions and atti tudes on the part o f the dentist support the patient in his inner and outer struggle for life. It is o f inestimable value to the patient to have persons in his environ ment who never give up fighting for his life and comfort and who never despair. If the dentist has any question about the ethics of seemingly valueless consulta tions, he should remember that in this context, these consultations are a form of psychotherapy. Like the physician, the dentist has a responsibility to alleviate anxiety and to forestall depression wher ever these feelings are intimately related to his professional care. E N V IR O N M E N T A L S U P P O R T S
The cancer patient lives in a materially different environment than does the can cer free patient. Th e world of the cancer patient is one of physical treatment, dis comfort and anxiety, with the possibilities of impairment, disfigurement and death always in the background.8’ 8 This world o f real dangers prevents the cancer pa tient from seeing himself, his family, his physician and his dentist as he saw them before the dangers arose. Both patient and dentist need every avenue of support to keep the patient constructively related to his environment. Here, where the re sources of the individual are likely to be insufficient, it is important to remember that other resources are available. A l
though dentistry traditionally is practiced in relative isolation, the same resources are open to dentistry as to medicine or social work. These resources lie in the family, the community and the organized network of professional agencies which help serve people in trouble. Under normal circumstances, unless dealing with children, the practicing den tist does not consult other members of the patient’s family in arriving at a treat ment plan. With the cancer patient, even the most perceptive dentist must take into account the family constellation in assessing how much cooperation he can expect from the patient. Particularly in the early stages with a cancer patient, when preparing him for diagnosis and surgery, the dentist may find it profitable to rely on responsible members of the family to see that the patient takes the necessary steps. For example, with pan icky or defiant patients, rather than de bate whether to confront the patient with the possibility of cancer, the dentist can often work through family consultations to guide the patient indirectly to the de sired end. At any point during the pa tient’s treatment, the dentist can enlist the cooperation o f responsible family members to help him help the patient. The patient’s ability to cope with the dis ease may be related to those family mem bers on whom he can depend and to those who depend on him. Beyond the family is a wider commu nity containing lay and religious groups to which the patient can turn. The pa tient’s occupation and his employment affiliations are important in assessing and planning rehabilitation. Frequently, labor unions have funds and facilities for sick members and also can assist in rehabilita tion. It can be helpful to know the pa tient’ s religious affiliation and religious orientation, and such information can often be picked up in natural conversa tion.8 When other sources of help fail, church groups may assist in many differ ent ways. Certainly an understanding clergyman can do a great deal for the pa
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tient’ s morale, and, in my experience, in obtaining funds. Clubs and social groups, similarly, can help the dentist in rehabili tation work with his patient, and if the dentist knows o f such groups, he may sug gest them to the patient or the family. Also, the patient often can be helped greatly if his doctor is able to introduce him to patients who have had similar con ditions and have met them successfully, or to patients who have achieved a good result from prostheses or have led satisfy ing lives despite illness. Most important, other professions are devoted to serving the sick, and these pro fessions are at hand to help the dentist. Medical services need not be discussed because dentistry has a long history of close collaboration with medicine. A l though dentists as a rule take less advan tage of other professional services, they should remember that public health nurs ing services and social services can be helpful. These professional workers can take time, which is not available to the busy practitioner, to go into the home and establish contact with reluctant family members. For the management of crises, the services o f visiting nurses and social workers are invaluable. A home visit can provide a picture o f the family’s interac tion and its response to the patient. Where the dentist and the physician tra ditionally are reluctant to enter, the visit ing nurse and family caseworker know how to gain access to a home and family. Members o f these related professions can help the dentist meet the needs of the cancerphobic patient, as well as of the cancer patient, for these workers may follow up psychiatric referrals which the practicing dentist would find awkward or time-consuming. By enlisting the help of related health professions, the dentist can avoid the dilemma of “ to tell or not to tell the can
cer patient.” The dentist’s primary goal is not to give the patient information, but to help him obtain the necessary care. Even in the rare instances where the pa tient is told directly, the much discussed problem of “ who tells the patient” should resolve itself. In such instances the dentist serves the patient best by acting as a member of a health team. Important de cisions are made in consultation with other health workers who know different parts of the total picture, and responsi bilities are shared. The dentist who works with a patient within the suggested emo tional and environmental framework is in a better position to see his patient through the taxing steps to health or to death than is the dentist who attempts to work without this frame of reference. If the program outlined seems at first to be outside the traditional functions of dentistry, it still is in keeping with den tistry’s tradition of assuming increasing responsibilities for the patient’s health. By such broadening of its horizon and gradual enlarging of its sphere of activi ties, dentistry has gained the place it now holds among the health professions.
*Research associate, School of Dentistry, University of Pennsylvania. 1. Beliak, Leopold, editor. Psychology of physical illness. New York, Grune & Stratton Co., 1952, p. 27-43, 45-52, 52-73. 2. Bird, Brian. Talking with patients. Philadelphia, J. B. Lippincott Co., 1955. ^3. Eissler, Kurt R. The psychiatrist and the dying p a tient. New York, International Universities Press, 1955. 4. Bard, Morton. Psychological reactions to oral can cer. Oral Surg., O ral M ed. & Ora! Path. 12:922 Aug. 1959. 5. Lederer, Henry D. How the sick view their world, in Jaco, E. Gartly, Patients, physicians and illness. Glencoe, III., The Free Press, 1958, p. 247-256. 6. Raven, R. W . A handbook on cancer for nurses and health visitors. London, Butterworth & Co., Ltd., 1953. 7. Koos, E. L. The sociology of the patient: a text book for nurses. New York, M cG raw -Hill Book Co., Inc., 1950. 8. Harris, Edward G. Physician, clergyman and p a tient in terminal illness. Pennsylvania M . J. 54:541 June 1951.