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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.
8/18/2019 Managing Problems
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, †œ¿ ts m y fault I have a cancer; I
m ust have done something wrong,― 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: “¿ toesn t
b ot he r m e .â €•â €œ ¿ave no pain.―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 “¿m yo cto r,†• 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
8/18/2019 Managing Problems
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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 —¿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 it—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: “¿Thathing I al
w ay s d re ad ed .â €• â €œ ¿Thatord I can t say
it .― “¿Thatdreadful six-letter w ord.―
“¿Thathing my aunt died of.―A 42-
year-old woman w ith cancer of the
c erv ix states , †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 die—people die
of excessive bleeding. I had a friend
who died. She died of cancer. I am
afraid I have cancer.― A 50-year-old
patient with cancer of the breast with
m etastasis said before and during treat
m ent, “ ¿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.―
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 guilt—it is m y fault
that I have cancer; I must have done
som ething w rong—occurred in every
one of our patients. M any patients re
act to cancer as they w ould to venereal
disease—―ltis foul,―“¿m ashamed to
h av e i t, †•â €œ ¿m ashamed to talk about
it.― 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 “¿cancer―n dis
cussing her worries. The doctor com
mented by saying, “¿Howo you feel
ab ou t c an ce r?â €• S he sa id , †œ¿ t so t lik e
heart trouble because it is such a dirty
d is ea seâ €”so u ncle an †”rep elle nt. In th e
end there is an odor—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.
8/18/2019 Managing Problems
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don t object to being with these people.
It s all my fault too. I must have done
som ething to deserve all this.―
A 65-year-old woman with lym ph
om a said, “ ¿m very worried because I
don t know whether the trouble I have
now is caused by the infection—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, “¿on t know
what is the matter with this patient. For
som e reason she is scared.―
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
8/18/2019 Managing Problems
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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
words—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
“¿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 †œ¿Lete ll e no ug h
alone―
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
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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 —¿who
may disclaim any special insight into
the handling of em otional m atters —¿
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
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patiento talk—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 be—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
†¢¿ 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 field—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 cancer—his
ideas, fears, and even phantasies, and
his capacity for realistic adjustm ent
(Table 3). During this period, if the
patient introduces the word “¿cancer―
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 “ ¿cancer―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 —¿
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 †”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 †•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 out—as he does in
m ost instances—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 untruths—no m atter w hat the
doctor s intentions happen to be—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. “¿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 realfear—Iaveno
fear. I find to my great joy that I am
really the philosopher that I hoped I
was—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 race—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
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3. Cockerill, E . E.: The cancer patient as a
person; his needs and problems. Pub. Health
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5. Finesinger, I. E .: T he doctor-patient rela
ti on sh ip †”a n o pe ra ti on al a pp ro ac h. I n p re ss .
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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
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son, A. W .: Delay in the treatment of cancer.
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and A bram s, R . D .: Psychological m echanism s
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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
—¿ hese are of the essence. They support and sustain the spirit of its
battle—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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