Medical practice is eternally
fascinating because of its essential nature as both a science and an
art. This practice has roots in the priesthood and the classical
thinking of yester years, which confer on it an elitist and egalitarian
quality.
In comparison to and above all other
professions, doctors have the rare privilege of supervising the coming
to life of human beings and their taking the last breath as they battle
with the scourge of illness. In the process of engaging our clients, we
have access to information that no other person has about them, just as
we can come up with regulations that must be religiously adhered to,
irrespective of status.
Apart from the prestige, there is also
the responsibility that is demanded of this noble profession. One of
them is that of making a diagnosis, especially of illnesses that are
deemed terminal with no proven definitive remedy. The experience could
be as devastating to the doctor as it could be for the patient and his
relatives.
One of such is the diagnosis of cancer —
an illness that may not have a definitive care except for palliative
care, although for a good number of patients, early diagnosis and
intervention have proved very good in the final outcome. Any growth or
unusual symptom should be reported to the doctor, apart from undergoing
regular cervical pap smear and breast lump screening for women. This
guarantees prompt intervention before the cells become ubiquitous and
overwhelm the body systems.
One important aspect of care in this
group of patients involves dealing with psychological reactions
consequent upon the diagnosis. There is enormous mental health challenge
that attends this, which demands professional attention.
There is enough evidence that more than
47 per cent of patients with a diagnosis of cancer have symptoms of
fully established mental disorders. When there is a preexisting mental
illness in such patients, intervention may be more challenging.
The mental disorders arise from poor
adjustment to the illness, with anxious or depressed mood consisting of
about 68 per cent of them. Others may come down with depressive
disorders and, ultimately, delirium, as the disease advances.
The diagnosis of cancer for most people
results in a predictable psychological pattern of distress over several
weeks. The meaning of cancer is usually that of possible death, with
pain, possible disability or disfigurement from treatment, loss of
independence and self-esteem, and possible loss of significant
relationships due to changed appearance or disability.
This normal response is characterised by
three phases, namely, denial, which is characterised by an initial
disbelief in which the person doubts the diagnosis and questions that it
may be a mistake after all.
This is followed by a period of one or
two weeks of a turmoil phase characterised by intrusive thoughts about
death, poor concentration, irritability, anxious and depressed mood,
loss of appetite and inability to sleep. Activities of daily living may
be significantly interrupted, as there are major pre-occupations with
concerns of the future.
The third phase is one in which the
acute turmoil symptoms begin to diminish and the reality of illness
becomes more tolerable. Hope returns with beginning a treatment plan and
a clear course of action to deal with the disease.
This pattern of distress must be borne
in mind since it could be repeated at subsequent transitional points of
the illness; but with more profound depressive symptoms, especially in
learning of recurrence or progression of disease, in learning of
treatment failure and with news that no more treatment is possible. This
stage may require the involvement of mental health expert so that
patients do not abscond from treatment and escape into traditional or
religious alternatives that may worsen the outcome and make coping with
the disease more burdensome.
The ultimate experience of gradual loss
of health and well-being may confer depressive illness, usually
characterised by profound sadness, feelings of worthlessness, guilt,
extreme withdrawal from social interactions and preoccupations with
hopelessness and death. This may lead to thoughts of suicide that may
even be common at the early stages. Such patients view suicidal ideation
as a rational way of asserting ultimate control. Patients who are in
remission and who have a good prognosis should be evaluated for suicidal
ideation and promptly managed.
Depression, rather than pain, is the
greatest predictor of experiencing a wish for hastened death in this
group of patients. As palliative and end-of-life care becomes more
popular, quality of life assumes a central focus, especially in this
group of patients which definitely provoke ethical, cultural, religious,
and spiritual issues beyond their primary care of the disease.
The psychiatrist and other members of
the mental health care team definitely have a crucial role to play in
exploring all these issues professionally, especially when it comes to
suicidal ideation.
1 Comments
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