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.