Managing Problems

8/18/2019 Managing Problems

1/11

rejection by the doctor. W e believe that

this problem of medical care in cancer

is not insurmountable, and can be

largely resolved through analysis and

study. This impression is being con

firmed in the course of a study which

has been in progress at the M assachu

setts General Hospital. In this study

emotional factors involved in the care

of a series of well over sixty cancer pa

ti en ts h av e b ee n i nv es tig ate d.

The Study The m aterial form ing the

basis of the study was gathered by the

psychiatrist and social worker in nu

merous interviews on a group of m ore

than sixty unselected patients at the

Tum or Clinic and in the M edical and

Surgical Services of the M assachusetts

General H ospital. In this series of

twenty-four men and forty-eight

women interviewed by the social

worker, twelve had chronic nonm alig

nant tumors of which just over one

third represented tumors of the breast.

Twenty-eight of the cases were first

seen before the diagnosis had been es

tablished and in repeated interviews

during treatment, and ten terminal

cases w ere follow ed. In her interview s,

the social worker avoided intensive

probing, but gave the patients a chance

to talk. In many cases she also inter

viewed the families. In eleven of the

cases, the em otional problems were ex

plored m ore intensively by the psychia

trist. Usually the patient s treatment

was planned by a single internist or

F ro mm ith e D ep artm ent of N eu ro lo gy a nd P sy

c hia try , H arv ard M ed ic al S ch oo l, a nd th e d ep art

m en ts o f P sych ia try an d S ocia l S erv ice , M assa

chuse tt s General Hosp it al , Bost on , Massachuse tt s.

@Schoolof M ed icine , U niversity o f M aryla nd,

Ba lt imo re , Ma ry land.

T his p ro je ct w as sup po rted b y a gran t fro m the

Amm ie ric an C an ce r Soc ie ty Ma ss ac hu se tt s D iv i

s io n ), i nc .

There are some aspects of the m an

agement and treatm ent of patients with

cancer that are often lost sight of under

the pressure of our busy lives as doc

tors. Since they relate prim arily to em o

tional and interpersonal factors in

chronic disease, these matters would

appear to be within the province of the

psychiatrist. But in the practice of com

prehensive medicine they are and m ust

be dealt with in great m easure, if not

exclusively, by the surgeon and the in

ternist. To our know ledge, there is no

well-grounded evidence to show that

em otional factors play a role in the pro

duction of neoplasms. Yet in the area

of effective therapy in cancer we can

expect em otional factors to be impor

tant. Results accum ulating from stud

ies in other illnesses offer strong evi

dence that em otional conflicts can

block or hinder therapy and that these

conflicts must be taken into account by

the doctor in his efforts to help patients

utilize the best available methods of

treatment. It is our im pression that this

will be found to apply also to patients

with cancer. In this disease effective

treatm ent m ust be prom pt treat

ment.11 Delay in coming for treat

m ent or the rejection of treatment for

emotional reasons, may make it im pos

sible for m any a patient to avail him

self of w hatever treatm ent is available.

The job of the doctor also includes

the alleviation and control of the dis

tress and suffering of the patient and

his fam ily. Unfortunately the distress

of the cancer patient affects his physi

cian or his surgeon, with the tragic re

sult that the doctor tends to avoid the

patient, even while doing his best to

m odify the course of the disease. This

avoidance compounds the patient s dis

tress and is often interpreted by him as

19

Managing the Emotional Problems

of the Cancer Patient

Ja co b E . F in esin ger M .D . Ha rley C . S ha nds M .D .

and Ruth D . Abrams M .S.


2/11

surgeon whom the patient saw on the

f ir st c li ni c a pp oi nt m en t.

The purpose of this survey was to

appraise the personality and em otional

difficulties confronting patients with

cancer of various types in various parts

of the body. It was our plan to study

the emotional factors operating in the

treatment of these patients, and to de

termine how these factors can be con

trolled to enable the patient to utilize

the best available care. W e hoped that

the study would throw light on the atti

tudes of patients and doctors to cancer

and on the special factors that charac

terize the doctor-patient relation in

cancer.

T his study offers striking evidence of

the concern that the patients felt about

their illness. T his inform ation w as read

ily elicited often in the very first inter

view . Special probing for this inform a

tion was not needed. The patient s con

cern was shown in the expression of

emotions: fear in almost every case;

gu ilt, â€ œ¿ ts m y fault I have a cancer; I

m ust have done something wrong,â€• in

about two thirds of the patients; and

fee lin gs o f in ferio rity. It w as im pre ssive

how many of the patients indicated in

the interview that they were preoccu

pied with the idea of cancer. Forty of

the patients, at the first interview , used

the w ord directly in connection with

the possible implication of their sym p

tom s, and eleven others referred to can

cer indirectly as having caused the

death of a friend or spoke of their

symptoms as indicating a possibly dan

gerous tumor. Som e of these patients

had not yet been definitely diagnosed.

U pon subsequent interview , w hen diag

nosis had been established, at least

fifty indicated that they knew they had

a cancer and used the word in describ

ing the sym ptoms for which they had

treatment.

In spite of these obviously expressed

fears and ideas, the behavior in at least

two thirds of the cases showed clear

evidence of avoiding facing their prob

lem realistically. This reaction was

seen in the periods of delay of from

one month to more than five years that

occurred between awareness of their

symptom s and appearing for m edical

help in more than one third of the

cases. A few (five patients) actually de

nied that they had a cancer, attributing

their symptom s to other causes. M any

others (twenty-six) denied the gravity

of their situation by displaying an un

natural lack of concern: â€œ¿ toesn t

b ot he r m e .â €•â €œ ¿ave no pain.â€•Thus, in

the same patients fear and denial were

se en , in dic atin g a c onflict.

In the interviews, the patients re

ferred to â€œ¿m yo cto r,â€ • b y w hich th ey

usually m eant the physician or surgeon

with whom they had had their first

clinic appointm ent. T hirty-eight of the

patients w ere seen regularly by four

teen doctors; although they referred to

their doctors with respect, and with a

somewhat unrealistic feeling of the

doctor s omnipotence, they never re

fe rre d to th eir d octo rs as u nd ersta nd in g

their problem s. They were aware that

their doctors were busy m en, an idea

that was reinforced by the nurses. A

few of these patients expressed the feel

ing that they were imposing on the doc

tor by com ing to him with symptoms

that m ight be trivial. They stated that

their doctors did not discuss their diag

noses with them . There was evidence

in this group that the doctors some

times had trouble in getting their pa

tients to undertake treatment, even

though they spent considerable time

urging their patients to do so. This

group seem ed to need the social worker

for support and advice in their prob

Jem s, although they were not referred

to the social worker for this purpose.

At the sam e tim e these patients com

m unicated less about pertinent prob

lem s than did the other group of twen

ty-tw o patients. The rem aining tw enty

two patients were treated by a single

doctor. In their interviews, these pa

tients referred to their doctor s under

standing and to his interest in every

thing that troubled them . From their

reports it seem ed that he frequently

let patients know and express the truth

20


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about their diagnoses. He appeared to

be available and in the tim e he gave

them was unhurried. Characteristic of

this group was that they did not display

need for dependence on the social

worker, and that they seem ed ready to

make realistic plans, even though this

group of patients had, on the whole, a

r ela ti ve ly p oo r p ro gn os is .

These data indicate that emotional

problem s are important in cancer pa

tients and must be taken into account

for com prehensive treatment. W e

should like to discuss the material in

g re ate r d eta il .

In studying the patients carefully,

one observes a variety of ways that pa

tients use in reacting to the threat of an

incurable, ominous disease. Som e of

these reactions can be seen readily,

whereas detailed study is required to

learn about other of the m ore com plex

mechanism s used. Some patients react

with obvious fear, which they may

discuss with the doctor if he gives them

a chance. M any patients react with

anxiety from w hich they flee in a va

riety of ways â€”¿by the avoidance of

anything to do with cancer, especially

treatm ent or com ing for help. They

m ay have difficulty in articulating their

anxiety and fears, feeling that it is

wrong to do so, that it indicates an in

ability to handle their own problems.

Others deal with anxiety by denial or

by suppressing itâ€”pushing the prob

lem out of their minds. Still other pa

tients express their anxiety by dem ands

for repeated exam inations, m ore roent

genogram s, and m ore advice. These are

som e of the common personality reac

tions we found. For example, a 17-

year-old boy with a melanoma, refer

ring to cancer said: â€œ¿Thathing I al

w ay s d re ad ed .â €• â €œ ¿Thatord I can t say

it .â€• â€œ¿Thatdreadful six-letter w ord.â€•

â€œ¿Thathing my aunt died of.â€•A 42-

year-old woman w ith cancer of the

c erv ix states , â€ œ¿ave been bleeding for

the past four or five m onths and have

not told anyone until tw o months ago

I think I am going to dieâ€”people die

of excessive bleeding. I had a friend

who died. She died of cancer. I am

afraid I have cancer.â€• A 50-year-old

patient with cancer of the breast with

m etastasis said before and during treat

m ent, â€œ ¿m so afraid that I have not

asked the doctors to give me a report

of their findings. I ask no questions;

one m ust have faith.â€•

W e have been im pressed by the fact

that many patients have feelings of

guilt2 about this illness, as it they

assume that a m alignant disease repre

sents some form of punishment for

wrongdoing in the past. These ideas are

accom panied by feelings of inferiority

and being no good. This type of reac

tion often is described by the patient

with surprising ease. In m any cancer

patients the punishm ent theme is ap

parent from the outset.

T hese feelings of guiltâ€”it is m y fault

that I have cancer; I must have done

som ething w rongâ€”occurred in every

one of our patients. M any patients re

act to cancer as they w ould to venereal

diseaseâ€”â€•ltis foul,â€•â€œ¿m ashamed to

h av e i t, â€ •â €œ ¿m ashamed to talk about

it.â€• In our series, sexual guilt alm ost

routinely occurs in patients w ith lesions

of the cervix. A further fact in this con

nection is that pre-existent venereal dis

ease is frequently felt to be a causative

factor. These patients and relatives

want a professional person with w hom

they can talk out their difficulties and

in many instances obtain great relief

from these discussions. The patients

w ith g uilt e sp ec ially d re ad re je ctio n.

T o illu strate : A 56 -y ear-o ld w om an

with inoperable cancer of the breast

mentioned the word â€œ¿cancerâ€•n dis

cussing her worries. The doctor com

mented by saying, â€œ¿Howo you feel

ab ou t c an ce r?â €• S he sa id , â€ œ¿ t so t lik e

heart trouble because it is such a dirty

d is ea seâ €”so u ncle an â€ ”rep elle nt. In th e

end there is an odorâ€”often there is de

form ity. People fear contagion. They

don t like to be with cancer patients.

You can not know how awful it is. In

the past when I had known people had

cancer, I always felt so badly for them.

Heart disease is not unclean. People

T ext co ntinu es o n pa ge 2 4.


4/11

don t object to being with these people.

It s all my fault too. I must have done

som ething to deserve all this.â€•

A 65-year-old woman with lym ph

om a said, â€œ ¿m very worried because I

don t know whether the trouble I have

now is caused by the infectionâ€”ve

n er ea l i nf ec ti on .â €•

A very com mon reaction was that of

avoidance. Often the patient is clearly

conscious of the fact that he prefers to

avoid seeing the doctor, or taking the

doctor s advice, or carrying out other

aspects of the treatm ent. M any patients

who are fully aware of the conse

quences of delay find them selves unable

to go to the doctor or to the clinic; at

the same tim e they realize that it is the

right thing to do. They hesitate to come

for examination, procrastinating and

p uttin g o ff th e in ev ita ble . In su bseq ue nt

interv iew s the se p atien ts h av e d esc rib ed

feelings of hesitation and inhibition in

regard to finding out what their diffi

culty m ight be. Just as these patients

avoid coming to see the doctor and in

itiating treatm ent, they sim ilarly avoid

carrying through treatm ent and find a

variety of rationalizations to keep them

from carrying out the advice of the

doctor. It is this mechanism of avoid

ance that in many ways tends to undo

the effect of cancer education cam

paigns. W e are inclined to rate this as

the most significantmotionalfactor

acting to prevent patients from getting

help. It is avoidance rather than igno

rance, we believe, that leads to the sur

prising gaps in information that one

encounters.

Several other m echanism s are closely

related to that of avoidance. In some

patientsne findsthattheirfirsteac

tionupon learninghattheyhavea can

cer is a flat denial of such a possibility.

As the illness progresses and as the

signs and sym ptoms becom e more

marked, even then one finds some

people still denying the fact that they

have a L ..ancer. T hese patients attribute

their sym ptoms to a variety of other

causes. One sees the sam e mechanism

in the families of these patients. The

mechanism of denial is related to that

of suppression, that is, the attem pt to

push out of one s mind the fact that

one has a serious illness and needs

treatment. It is our im pression that

pushing the problem out of one s mind

in no way solves the problem. W e

would like to emphasize this m echa

nism , because it is one that the doctor

often fosters in the patient. Doctors

often encourage patients to push ideas

out of their minds, believing it to be

desirable to encourage the patient to

dismiss and forget about ideas that are

unpleasant and disturbing. A ctually, by

doing so, they reinforce the patient in

his use of a m echanism the end result

of which is to keep him from obtaining

treatment as quickly as possible. This

point is illustrated in our study by in

stances in which the doctor spends con

siderable tim e urging the patient to ac

cept treatment without going into the

reasons for the patient s reluctance.

One doctor fterpendingwentymin

utes with the patient who had a cancer

of the esophagus, said, â€œ¿on t know

what is the matter with this patient. For

som e reason she is scared.â€•

Our discussion of the data m ay be

sum marized as follows: The cancer pa

tient is usually preoccupied in a dis

turbing way with ideas about his sick

ness, whether he tells the doctor so or

not. Secondly, he reacts to the danger

and uncertainty of his sickness with

conflicting emotions, which m ay crit

ically affect his capacity for accepting

m edical help and for m aking an op

tim al adjustment. Even an exception

ally w ell organized individual needs the

help of the doctor in adjusting to the

acute and chronic threat of cancer.

It is evidence of this kind that makes

us conclude that adequate treatm ent in

cancer must involve treatment of the

patient as well as of the lesion, with

em phasis on developing a good sustain

ing d octo r-pa tien t relatio n.

W e should like to present som e of

th e facto rs th at w e con sid er im po rtan t

for m aintaining a good doctor-patient

relationship. In all contacts with the

24


5/11

patient, w hether it be in history taking,

physical examination, during the

course of treatm ent, and in after care,

we believe it important to convey an

interest in the patient as a hum an being

W e wish to indicate our recognition of

the difficulties of the patient and our

desire to help. At the same tim e we

want to show the patient that we are

reliable, sound doctors who take our

responsibilities seriously. W e want to

be nonjudgm ental and give the patient

a feeling of acceptance and an attitude

of friendliness. W armth gives support

in the development and m aintenance of

the relationship; coldness and aloof

ness m ay defeat the therapeutic aim .

Yet warmth does not imply the over

em phasis of a purely conventional so

cial interest and prem ature comm it

ments and promises. These attitudes

are rarely expressed to the patient in

wordsâ€”they are comm unicated as a

rule nonverbally by our behavior. W e

indicate our interest in the patient by

keeping appointm ents and by giving

time free from interruption and hurry.

Even though w e. have only five m inutes

for a patient, we want to recognize that

this is his time. W e show interest in the

patient s problem s and needs by giving

him a chance to talk about them. By

the use of appropriately tim ed words,

com ments, and questions we help the

patient to bring out topics of impor

tance to him especially dealing w ith the

w orries and preoccupations associated

with his illness. W e convey to the pa

tient that we are reliable and sound by

taking a careful history, doing a careful

physical exam ination, and assisting him

wherever possible within the confines

of a professionalelationship.ut

above all, we want to keep open the

channels of comm unication w ith the

patient through which we develop and

use the relation to further our thera

peutic goals. W hat the doctor says and

does is im portant for the success of the

relationship. It is our belief that much

can be Jone toward developing pro

cedures that will promote a good doc

tor-pati(:nt relationship. A s criteria of

TABLE 1

Docto r Pa tient Re la ti on in Cancer

D if fic ult ie s o f P at ie nt B lo ck in g

Communication

Fears related to nature of cancer

F at al w as ti ng d is ea se

Treatment

Mutilating

Hopeless

F am i ly d is tr es s

P eo ple w ill a void m e

E mo tio ns re la ted to u nrea listic id ea s

G u il tâ €” ca nc er i s p un is hm e nt

Anxiety

R ea ct io ns to fa nta si es

Fears related to doctor

C annot help m e

W ill not talk about m y illness

â€œ¿Muchd o a bo ut n oth in gâ €•

W ill rejec t m e

a good working relation we set up:

Can the patient comm unicate freely

w ith his doctor about his illness and his

problems?

Does the patient co-operate in the

doctor s therapeutic plans?

W he n w e c ons id er the d octo r-p atien t

relationship in the treatm ent of cancer,

w e becom e aw are of special difficulties

in the im portant area of comm unica

tion.

TABLE 2

Doctor Pa ti en t Re la tion in Cancer

D iffic ultie s of D octo r in C om m un ic atin g

w it h P at ie nt

Doctor doesn t know w hat to say

H ow m uch should patient be told

W on t patient go to pieces if told the

truth

P hilo so ph y of â€ œ¿Lete ll e no ug h

aloneâ€•

Doctor doesn t know w hat to do

Frustration of therapeutic motive

m in im iz es v alu e o f s us ta in in g co n

tact

D octor s feelings block com tnunication

D istres s th rou gh sy mp ath y an d id en t

ification

D is co mfo rt in situ atio n in vo lv in g

double-talk

G uilt due to inadequacy of therapy

R es ult o f d iffi cu lti es

D oc to r a vo id s p ati en t

D o ct or r ej ec ts p at ie nt

25


6/11

Many patientshen theyreali zehat

they have a cancer find that they can

not talk about it, they cannot com muni

cate. V ery often the doctor too has the

s am e d if fi cu lt y.

W e have found repeated instances in

which the doctor has difficulty in deal

ing with patients because he knows the

patient has cancer, yet does not know

whattodo anddoesnotknow whatto

say. A barrier often exists between the

doctor and the patient and after the

diagnosis is fully established the doctor

tends to avoid the patient in a variety

of ways. This is done not generally be

cause such behavior is indicated but be

cause the doctor is trying to handle a

dilem ma. The result is that the patient

is seen less frequently and every visit

becomes an ordeal for the doctor as

well.

U ltim ately this change in the doc

tor s behavior and attitude is picked up

by the patient and is usually interpreted

as a rejection by the doctor. Often a

little more time, a little m ore under

standing, a little more planning, a little

more support, and an attempt to get

the patient to com municate do m ir

acles in developing a sustaining and

helpful doctor-patient relationship. W e

believe that m any tragedies and m uch

heartache can be avoided by the doc

tor s greater awareness and more pre

cise planning as to what he says and

does w ith the patient.

Very guardedly we should like to

glance at the m aterial in our study from

the point of view of the effectiveness of

the relationetweenthe doctorsand

their patients, recognizing that subjec

tive judgments in this area are not free

from distortions. W e have referred to

the group of twenty-two of the patients

who showed relativelyittleifficulty

in discussing their illness and diagnosis

with the social worker. Although as a

group they had a relatively poor prog

nosis, these patients im pressed us with

their realistic adjustm ent and m arked

therapeutic cooperativeness. As m en

tioned previously, they were all under

the care of a single doctor. They told

the social worker that he let them talk

to him about their problems and illness

a nd sh ow ed g rea t u nd ers ta nd in g.

W e are thus prom pted to stress the

importance of a good doctor-patient re

lation in the treatm ent of cancer, be

lieving that once the channels of com

m unication between the patient and the

doctor have been opened, many of the

perplexities confronting the patient can

be discussed. This works advanta

geously for both the patient and the

doctor. It gives the patient a feeling of

being accepted and understood and it

opens new areas in which the doctor

can work. The doctor can participate

in the discussions and m anagement of

the patient s difficult life situations and

can lend his support in planning for the

patient and the patient s family. W hen

adequate com munication is established

we find that it is possible to have the

patient discuss his illness. This often

leads to a discussion by the patient of

his fears and worries as to whether his

illness is cancer. In som e instances the

patient is aware of the fact that he has

cancer and m erely awaits the confirm

ing nod of the doctor.

It is our opinion that w ith know ledge

and practice the doctor can control his

procedures as the problem demands.

Let us then consider the operational

approach to the problem of handling

the doctor-patient relation in cancer.

W e can approach the problem in term s

of what the cancer specialist â€”¿who

may disclaim any special insight into

the handling of em otional m atters â€”¿

can do and say.

As a first step let us assum e that the

doctor is familiar with what we con

sider to be important factors in any

good doctor-patient relation. H e recog

nizes as his goals the maintenance of a

warm professional relation, in which

the patient is assured of the doctor s in

terest in him and in his illness and per

sonal problems. To this end the doctor

tries to be unhurried and uninterrupted

when he examines the patient and even

during brief subsequent contacts for

therapy or check up. He tries to get the

26


7/11

patiento talkâ€”noty probingwith

directpointedquestionsut starting

with a generalquestion ncourages

the patiento talkabouth imselfand

hisillnessispastreactionsoillness

and hisworriesnd fears.he method

of focussing the talk into these perti

nent topics will be encouragement at

appropriate tim es largely by nodding,

briefquestioningomments always

with signsof friendlynterestnd

avoidingndicationsf disapprovalr

shockedsurprise.e willwatch his

ow n behavior and observe how the pa

tient responds to it. He will plan and

controlthe management of the case

taking into consideration such factors

as the patient s type of personal re

a ction s, d ep en de ncy or ag gres siv ene ss,

and hisfamilyand work problems.

In dealingwith the cancerpatient

thedoctorproceedsinmuch thesame

way exceptinghathe isalerto the

special difficulties that tend to block

communicat ionbetwe en patientand

doctor. He is alert to any indication

that the patient may offer as to fears or

other emotions, such as guilt and a

sense of inferiority in connection with

hisillnessr withcoming to seethe

doctor.e showsinterestnany ideas

howeverfantastichatthepatientay

want to communicateinregardto the

sickness. A lw ays avoiding censure and

withfriendlyesturesnd expressions

duringexaminationr treatment e

tries to focus the patient s talk on his

past sickness, to gauge how he is re

ac tin g to h is p resen t sick ness, w heth er

he showsareasof conflictingearand

denial, such as are not unusual in pa

tients who are aware that they have or

m ay have an incurable sickness. He

trieso detec twhat the patient stti

tude to doctors m ay beâ€”w hether hos

tile, o r o ve rd ocile , o r d irect an d realis

tic.

If, by this procedure, he has suc

ceeded in breaking down some of the

barriers to comm unication that block

the developm ent of a good therapeutic

relationn cancer he may even ina

first interview have found that his pa

tient has direct or masked fear about

hisdiagn osis.e may be awarethathis

patientuspects cancerbuthesit ates

to sayso openly.Whetheror notthe

diagnosishas been established e

wantsto end theinterviewn sucha

way thatthepatientsconfidenthat

his doctor is planning for his care and

is interested in his welfare. He will

throughout the interview have guarded

himself from filling in gaps of em bar

â€ ¢¿ a ssm en tby o ver-rea ssu ran ce o r lo ng

explanations. He has made no state

m ents that will have to be taken back

later.

By thismeans thedoctormay have

been able to develop a relationship w ith

his patient in which the patient returns

for treatm ent, is co-operative in follow

ing directions, and com municates free

ly with the doctor in regard to his sick

ness and problems. Then if the patient

indicatespenlythathe thinkshe has

a cancer and asks for a direct answer,

thedoctorshouldprobablybe ableto

answer him simply and directly, ex

plaining to him at first only what he

seem s anxious to know regarding the

d ia gn os is an d the tre atm ent.

This leads us to a few comments

about one of the m ost difficult problem s

confronting w orkers in this fieldâ€”how

m uch should patients be told?

There is considerable difference of

opinion among cancer specialists on

this issue. Som e believe that every pa

tient should be told; others feel that pa

tients should be spared the misery of

knowing theirdiagnosis.e do not

k no w th e a ns we r to th is q ue stio n, w hic h

is a major problem for research in this

field. O ur ow n em phasis is operational.

W e evaluate a procedure in term s of

whetheritworks.Hence we arein

cline dto hold thatthe patie nthould

have enough informationo thathis

treatm ent progresses w ith the m inim um

of personal discom fort. In our opinion,

the m ain goal of therapy is not to in

form or educatepatientsuttocure

them and alleviateheiruffering.tis

onlywhen thegivingf informations

pertinento the cure alleviationr

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TABLE

Communication wi th Cancer Patien t

B reaking D ow n B arriers. I

L ett in g p at ie nt d is cu ss h is p ro ble mn s

D evelop relation w ith w arm sustain

ing interes t

G ive patient a chance to talk

F ocus patient s talk on pertinent top

ic s

R ea cti on s to h is s ic kn es s

Id eas a bou t ca nc er

Fantasies

Fears

W h at t op ic s?

C ap ac ity f or r ea lis tic a dj us tm en t

P as t c ri se s

Neuroses

P resen t d isturbance

A tti tu de t o d oc to rs

Show im mediate interest in perti

nent topics by m eans of:

Encouraging gestures and ex

pressions

B ri ef v er ba l c om m en ts , p ro mp ts ,

o r q ue st io ns

prevention of illness that it m ay be

com e the im mediate task of the doctor.

In treating cancer it is difficult to gen

eralize about the exact am ount of in

form ation to be given the patient. Ob

viously this depends upon what the pa

tient already know s. This the doctoi

c an a sc er ta in .

In the first place, it is im portant to

know, so far as possible, what the pa

tient has found out about the nature of

his disease, and what he has done with

the inform ation. It is easy to under

estimate or ignore how much the can

cer patient know s, and indeed this often

seem s to be routine practice on ward

rounds. There is considerable differ

ence between what a patient picks up

from his contacts with hospital per

sonnel and what he will admit he

knows. W hen a patient comes to a

clinic, the routine list of individuals

with whom he makes contact includes

adm itting nurse, clinic secretary, clinic

doctor, tum or-clinic secretary, tum or

clinic doctors, m edical student, nurse,

social w orker, and various technicians.

Ifhe entershehospitalortreatment

he runs the gamut of another series of

i nd iv id ua ls , in clu di ng n on pr of es si on al

personnel. A t each point in these series,

there is the possibility of acquiring

knowledge directly and through innu

endo. The individuals with whom he

com es in contact may not be aware of

the possible impressions w hich the pa

tient may pick up. W hen one adds to

this the conversations betw een doctors

that the patient m ay overhear and the

conversation with other patients that

go on during the long waiting periods

before the patient is seen, it is surpris

ing that not every patient is fully aware

of his diagnosis. Even so we cannot

take for granted that the patient know s.

In each case it is im portant to find out

through personal com munication how

much the patient does know.

The diagnostic period gives the doc

tor time and opportunity to develop

methods of com municating with the

patient. It enables him to obtain infor

mation which is highly pertinent to the

treatm ent. T his inform ation deals w ith

the patient s reactions to cancerâ€”his

ideas, fears, and even phantasies, and

his capacity for realistic adjustm ent

(Table 3). During this period, if the

patient introduces the word â€œ¿cancerâ€•

or asks for information about the dis

ease, the doctor will not hesitate to

show interest in the subject or even to

give the patient some brief general in

form ation as to benign or m alignant

tumors, as he seems to need it. During

the diagnostic period, the doctor can

pave the way for future comm unica

tion in regard to cancer. The relation

ship between doctor and patient will

be more comfortable and secure if the

w ord â€œ ¿cancerâ€•s no longer taboo and

need not be avoided. And it is our ex

perience that in m ost cases the patient

will provide the needed cue. W e have

already mentioned that in this study

almost every patient referred in some

way to cancer in the initial interview .

If the patient has in no way indicated

a concern about tum ors or cancer, it

may be best to postpone a discussion

until the diagnosis is confirm ed. Should

the patient specifically question the

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docto rabouthisdiagn osishedoctor

tells him that the diagnosis is not estab

lished, reassuring him that as soon as

the diagnosis is established they will

discuss it together in detail.

Once the presence of cancer is es

tablished, preferably by biopsy exam

ination, the doctor m ay then focus on

a discussion of the diagnosis. W e be

lieve that where the patient is a ma

ture, w ell-integrated individual, w ith

out neurotic tendencies or symptoms,

who has reacted reasonably well to past

crises, the doctor can proceed more

directly tow ard opening the discussion

of the diagnosis. Should the patient ask

for the diagnosis at this point, we be

lieve that the truth can be told. H ow

ever, the statem ent of truth should

immediately be followed by telling the

patient as simply and clearly as pos

sible w hat treatm ents are available and

indicated. The patient should have the

opportunity of talking over his ideas

and feelings about the diagnosis, as

well as his plans for the future. Our

experience indicates that a single dis

cussion m ay not be sufficient to enable

the patientto communicate freely.

During the course of treatm ent it m ay

be helpful for the doctor to create fre

quent opportunities for the patient to

talk about his treatment, and even

about the diagnosis itself, and the pa

tient s reaction to it. T hese discussions

need not be lengthy. They should indi

cate the doctor s concern and contin

ued interest in the patient. The most

helpful elem ents in com munication are

oftenthe non-verbalehaviorof the

doctorinlisteningngivinghepatient

tim e, in being concerned with the pa

tient s welfare and the welfare of his

fam ily. The doctor may also utilize

other personnel and resources such as

social service, nurses, and above all the

famil yin helpi ngthepatie nteather

this crisis and adjust in as useful a way

as possible. In the case of the patient

who is not so well adjusted, we believe

that the sam e procedures m ay be car

ried out. The tempo may be slower,

and the doctor may have to lean m ore

TABLE

Communication wi th Cancer Patien t

B reaking D ow n B arriers. II

Letting patient discuss his cancer

W hy fo cu s o n d ia gn os is?

M ost cancer patients w orry about

diagnosis

E vasion of topic blocks com muni

cation

W hen to fo cu s o n d iag no sis?

A f te r d ia gn os is i s e st ab li sh ed

A fter learning patient s ideas and

problems

A fter pa tie nt m ention s c an cer

A fter h e ask s fo r d ia gn os is

H ow to focus on diagnosis?

Preferably draw it out of patient

himself

Clar ify misconcep tions

U se sim ple clear statem ents â€”¿

S upp orted b y sig ns of in tere st

Frequent brief discussion during

c ou rs e o f th er ap y

W hat to avoid?

Overexplanation

Over-reassurance

Unnecessa ry c ircumlocu tion

U n tr ut hs â€ ”t ha t b lo ck c om m u ni ca

ti on a nd u nd er mi ne r el at io ns hi p

M ai nt ain w ar m s us ta in in g re la tio n

heavily on the support of a warm, help

ful relationship. In these patients, the

doctor and the social w orker may need

to give the patient more tim e, and see

him more frequently, until he has ad

justed to his sickness. In no case do we

feelthatany statementshouldbe

made brusquelynd hurriedlynd with

finality. To be avoided also are over

explanation, over-reassurance, unnec

essary circum locution that m ay convey

the doctor s em barrassment or in

security in this m ost difficult role. Eva

sion of this crucial topic blocks com

munication with the patient and may

underminethedoctor-patientelation.

Should the doctoralwaystellthe

c an cer p atie nt th e tru th ?9 â€ •3 16W e h ave

tried to answer this from our data.

M any patients regret that at som e

point or other doctors have told them

untruths in regard to their diagnosis

and in regard to their prognosis. W hen

the patient finds outâ€”as he does in

m ost instancesâ€”that the doctor has not

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b een tru th fu l, h e fin ds it diffic ult to b e

lieveor trustany otherstatementsf

the doctor.Our experienceith psy

choneurotic patients is the same, and

w e are forced to conclude that the tell

ing of untruthsâ€”no m atter w hat the

doctor s intentions happen to beâ€”just

as the divulging of confidence, is an

idealway of underminingthedoctor

p atie nt re la tio nsh ip . F urth er, th e h ed g

ing and avoidance of topics necessary

to preserve the lie blocks the doctor s

capacity to comm unicate. To the pa

tient it m ay mark the end of a thera

p eu tic d oc to r-p atie nt relation sh ip .

Besidesthesepracticalonsidera

tionsthereare even more basicones

that govern the doctor sbehavior;

namely thosedeali ngiththedoctor s

values.7 he values which we as

civilizedoctorscceptnduponwhich

m uch of our operation depends, in

clude m any, such as giving our patient

th e b est m ed ical care ava ilab le o r lea v

ing no stone unturned in our quest for

inform ation to relieve hum an suffer

ing. Telling the truth is still another.

These values w e believe are not arbi

trary, but are the result of the evolu

tio n of civ ilized m an .

How much of thetruthshouldwe

tell? From the strict operational point

of view the answer would be all that is

necessaryo achievethegoalof ther

apy. In som e patients m ore inform a

tion is necessary than in others. W e

have foundthisoperationaluleuseful

in m any difficult problems. O ur job is

not to make psychiatristssycholo

gists, pathologists, or surgeons of our

patients. It is to supply them with

enough practicalnformationo help

them utilizehebestavailableherapy

withtheminimalpersonalisturbance.

We need nottellhewholetruthbut

whatever we say should be truthful.

Indiscussionsboutthistopic ome

physiciansave mentionedthatocca

sionally they tell a lie to help a patient

handle an insurmountable crisis. This

has not been the case in our own pro

fessional experience and in that of

m an y p hysician s an d su rg eo ns sp ecial

izing in cancer. It is conceivable that a

lie may be necessary, but we should

like to recognize that it is counter to

our value judgm ent and to efficient

practice. A s soon as possible, w e should

like to straighten matters out with the

patient with am ple explanation of our

reasons.

W e should like to conclude with a

few words about another problem

which comes to the fore in working

with patients. This is the inevitable

problem of meeting death. For this we

obviously have no formula. Our obser

vations in cancer patients have im

pressed us w ith the capacity of patients

to face death realistically. M uch to our

surprise these patients show little fa

tigue, little depression, little going to

pieces. An occasional patient refers to

taking a fatal dose of m edicine, but in

this series no suicide occurred among

the patients who knew they had can

cer. In brief, we are of the opinion that

these patients, in contrast to a group of

psychoneurotic patients, show great ca

pacity for sublim ation. W e have also

noticed m arked tendencies on their

part to accept the inevitable, and to

m ake the best of it, to live for the day,

to engage in activities within their ca

pacity and interest. It is our im pression

that the patient is freer when he knows

h is s ta tu sâ €”d iag nos is a nd p rog no sis

which is another reason for free com

munication.

M any doctors have reported that,

once the decks are cleared, patients

seem to take a new lease on life, having

accepted their condition as another

crisis that has been surmounted. Hans

Zinsser has given us an account of this

reaction in his autobiography in which

he portrays his own state of mind

thus a most authentic example of subli

mation. I should like to quote som e

com ments from a letter of an eminent

psychiatrist 4 in reporting his activities

just before his death. â€œ¿Well,hat s

how it is now with m e. I am able to

see som e patients and, since my son

is m y very devoted and self-sacrificing

assistant and partner, I am getting

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along very w ell. I spend about eighteen

ho urs o f eve ry day in o r n ear the

bed, three days a week I am entirely

inbed.I suffero realfearâ€”Iaveno

fear. I find to my great joy that I am

really the philosopher that I hoped I

wasâ€”that I am serene and reconciled

to the very limited life I lead and to

the nearness of D eath. I need no sym

pathy or pity, and I am at times really

happy and I am writing a book, a sort

of last will and testament, with zest and

diligence and, I hope, with some in

References

spiration. I read a great deal, I am as

interested in m y work as I ever was,

but I do not find in m yself any opti

mism about life which makes me want

to cling to it. M y mind is as clear as

ever. I feel a profound pity for the

human raceâ€”and have rejected all

absolutes and all religions after re

examining all the theories of philos

o ph er s a nd th eo lo gia ns .â €•

I, for one, should like to achieve

s uc h a n a dj us tm en t.

1. Abram s, R. D.: Social casework w ith can

c er p atie nts . S oc ia l C as ew ork 3 2: 4 25 -4 32 , 1 95 1.

2. A bram s, R. D ., and Finesinger, J. E .: G uilt

reactions in patients w ith cancer. Cancer 6: In

press.

3. Cockerill, E . E.: The cancer patient as a

person; his needs and problems. Pub. Health

N ur sin g 4 0: 7 8- 83 , 1 94 8.

4. F ine sin ger, I. E .: P sychiatric inte rview in g.

1 . S ome p rin cip le s a nd p ro ce du re s in in sig ht th er

a py . A rt.. J . P hy ch ia t. 1 05 : 1 87 -1 95 , 1 94 8-4 9.

5. Finesinger, I. E .: T he doctor-patient rela

ti on sh ip â€ ”a n o pe ra ti on al a pp ro ac h. I n p re ss .

6. F inesinger, I. E .: A discussion of psycho

therapy and the doctor-patient relationship.

N eu ro ps yc hia tr y 1 : 4 3- 63 , 1 95 1.

7. F inesinger, 3. E.: Concerning values in

m ed icin e. B ull. S ch oo l M ed . U niv. M arylan d 36 :

163-170 , 1951 .

8. Finesinger, I. E .: Shands, H. C ., and

Abra,ns, R . D .: Managing the emotional prob

lems of the cancer patient. In Anon.: Clinical

P ro ble mn s in C an ce r R es ea rc h; S lo an -K ette rin g

Institu te S em in ar 1 94 8-19 49. N ew Y ork. S lo an

K ette rin g In stitu te . 1 95 2; p p. 1 06 -1 21 .

9. G intherg, R.: S hould the elderly cancer pa

tie nt b e to ld ? G er ia tr ic s 4 : 1 01 -1 07 , 1 94 9.

10. Harms, C . R.; P laut, I. A., and Oughter

son, A. W .: Delay in the treatment of cancer.

J. A . M . A . 1 21: 3 35-3 38 , 1 94 3.

11. Leach, 3. E., and Robbins, G. F.: Delay

in the diagnosis of cancer. J. A. M . A. 135: 5-8,

1947.

12. Levin, A . G .: C ertain factors influencing

ca nc er cu ra bility. S ou th. M . J. 4 0: 2 59 -2 61 , 1 947 .

13. Lund, C. C.: The doctor, the patient, and

the truth. A nn. m t. M ed. 24: 955-959, 1946.

14. Myerson, A.: Excerpt of letter from Dr.

Abraham Myerson to Mr. M aurice Hexter, Feb.

14 , 1949 .

15. Reid, I. R ., and F inesinger, J. E.: Infer

e nc e te stin g in p sych othe ra py. A m, I. P sych ia t.

1 07: 894-900 , 1950 .

16. Seelig, M . G .: Should the cancer victim be

told the truth? J. M issouri M . A . 40: 33-35, 1943;

Also in W ashington Univ. M . Alumni Quart. 6:

137-142 , 1943.

17. S hands, H. C.; Finesinger, I. E .; C obb, S .,

and A bram s, R . D .: Psychological m echanism s

in p at ie nts w it h c an ce r. C an ce r 4 :1 15 9- 11 70 , 1 95 1.

1 8. Z ilb oo rg , G .: F ea r o f d ea th . P sy ch oa na ly t.

Q ua rt . 1 2: 4 65 -4 75 , 1 94 3.

19. Z insser, H.: As I Remember Him ; the

Biography of R . S. Boston. Little, Brown Co.

1940.

I N ALL of his m inistrations to people the physician encounters no

sharper, m ore com pelling challenge to dem onstrate his skill as

scientist and artist than comes from the patient with advanced can

cer.

The physician, by example, often determ ines the behavior and atti

tude of nurse and family during the usually protracted, weary course of

term inal cancer. Let us act with authority and with a full sense of re

sponsibility. But also let us act with compassion and understanding and

restrained, subtle sympathy. A cheerful demeanor, patient attention to

minor as well as major complaints, careful and detailed directions to

nurse and family regarding the treatm ent of symptom s, the avoidance

before the patient of either a hopeless attitude or of indifference regard

ing sm all item s of procedure, encouragem ent by attitude and indirection

â€”¿ hese are of the essence. They support and sustain the spirit of its

battleâ€”a battle which m ay be won even though the body is doomed to

failure.

Morgan H. I.:The care of thepatientwith terminalcancer.Rocky Mountain M. 1.45:

116 119 1948.

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