Denial in cancer patients

Coping styles as predictors for quality of life and prognosis in patients at risk for or with a diagnosis of heart failure: Results from the observational DIAST-CHF study

OBJECTIVE

Patients with heart failure often experience impaired health-related quality of life (HRQOL) and have an increased risk of cardiovascular and cerebrovascular events. The aim of this study was to investigate the predictive role of different coping styles on outcome.

METHODS

This longitudinal study included 1536 participants who either had cardiovascular risk factors or were diagnosed with heart failure. Follow-ups took place one, two, five and ten years after recruitment. Coping and HRQOL were investigated using self-assessment questionnaires (Freiburg Questionnaire for Coping with Illness, Short Form-36 Health Survey). Somatic outcome was quantified by incidence of major adverse cardiac and cerebrovascular events (MACCE) and 6-min-walking-distance.

RESULTS

Pearson correlation and multiple linear regression analysis showed significant associations between the coping styles used at the first three time points and HRQOL after five years. After adjusting for baseline HRQOL, minimization and wishful thinking predicted worse mental HRQOL (β = -0.106; p = 0.006), while depressive coping predicted worse mental (β = -0.197; p < 0.001) and physical HRQOL (β = -0.085; p = 0.03; n = 613). Active problem-oriented coping could not significantly predict HRQOL. Only minimization and wishful thinking was significantly associated with an increased 10-year-risk for MACCE (hazard ratio = 1.06; 95% confidence interval: 1.01-1.11; p = 0.02; n = 1444) and reduction in 6-min-walking-distance at 5 years (β = -0.119; p = 0.004; n = 817) in adjusted analyses.

CONCLUSIONS

Depressive coping and minimization and wishful thinking were associated with worse quality of life in patients at risk for or with diagnosed heart failure. Minimization and wishful thinking also predicted worse somatic outcome. Therefore, patients using those coping styles might benefit from early psychosocial interventions.

Evaluation of the quality of the information received during head and neck cancer announcement: Prospective two-center study

BACKGROUND

Providing patient with cancer with appropriate information following the disclosure of a cancer diagnosis has multiple benefits. The objective was to evaluate the quality of the information received during an announcement for head and neck cancer and to determine predictive factors.

METHODS

We conducted a prospective two-center study using self-questionnaires to assess the patient's perception of the quality of the announcement.

RESULTS

Satisfaction scores on the information provided about the overall disease were 7.7/10. The main positive predictors of quality were a satisfactory consultation setting (P = .004), assessment of pain by a physician (P = .04), physician availability (P = .003), accurate information about tumor stage, quality of information regarding the type (P < .0001) and purpose (P = .001) of treatment and its side effects (P = .006), and the interview with the oncology nurse coordinator (P < .05).

CONCLUSIONS

Patients who received the announcement of head and neck cancer perceived the information received during the pretherapeutic period as satisfactory.

What Is Missing for You to Be Happy? Comparison of the Pursuit of Happiness Among Cancer Patients, Informal Caregivers, and Healthy Individuals

CONTEXT

After cancer diagnosis, personal value priorities may change in a way that would transform such values and how life is perceived by cancer patients and their caregivers, including happiness and its pursuit.

OBJECTIVES

The objective of the study was to analyze and compare what cancer patients, informal caregivers, and healthy population believe that would make them happy.

METHODS

A qualitative content analysis was performed on the responses to a single question: "What is missing for you to be happy?" Narratives of cancer patients (n = 242, face-to-face interview), informal caregivers (n = 125, face-to-face interview), and healthy participants (n = 1,671, recruited through social media, online survey) were analyzed. Word clouds were created for each group of participants. Contents were identified and frequencies were compared among participants by means of chi-square and Fisher's exact tests.

RESULTS

Overall, participants were pursuing better health (n = 288, 14.1%), better interpersonal relationships (n = 456, 22.4%), money (n = 412, 20.2%), and work-related aspects (n = 481, 23.6%). Cancer patients and informal caregivers sought better health and cure more often than when compared to healthy people (P < 0.001). Among cancer patients, survivors' profile tended to be similar to that of the healthy population concerning what they need to be happy. Unexpectedly, "cure" (22.7%) was more frequent among participants with incurable cancer.

CONCLUSION

Regardless of the group they were in, participants sought happiness in what they considered to be important to their lives, but it was something they did not have at the time of the interview. Psychoeducational and cognitive-behavioral strategies focused on how to deal with life expectations among people facing cancer are awaited.

Death anxiety in patients with myocardial infarction or cancer

OBJECTIVE

The aim of this study was to find out the level of death anxiety among 3 groups: patients with acute myocardial infarction, patients with cancer and healthy individuals in two training and research hospitals; also to evaluate its relationship with several sociodemographic and clinical variables.

MATERIALS AND METHOD

This study was conducted with one hundred and eighty persons (108 male, 72 female) who have been referred to cardiology or oncology departments and the healthy individuals. Participants completed sociodemographic and clinical data form, State and Trait Anxiety Inventory (STAI-I, STAI-II), Thorson Powell Death Anxiety Scale (TPDAS), Death Depression Scale (DDS).

RESULTS

Participants included in the present study were 40% female with an average age of 53.48 for whole group. The mean TPDAS score for patients with AMI was 51.60 ± 16.40, for patients with cancer 37.10 ± 10.23 and for healthy individuals 43.40 ± 13.35. In AMI group there were positive correlations between STAI-I and TPDAS, DDS scores and also between STAI-II and DDS. In cancer group positive correlations were between STAI-I, II and TPDAS, DDS. TPDAS and DDS were positively correlated in all three groups. Women and participants who were unemployed scored higher on DDS.

CONCLUSION

In this study patients with AMI had higher death anxiety than patients with cancer or healthy individuals. Generally death anxiety was related with education, employment and socioeconomic status. Prospective studies carefully searching for different variables in different medical groups would reveal and help us to understand the importance of death anxiety and its impact on courses of physical and mental disorders.

Inter- and Intrapersonal Barriers to Living Donor Kidney Transplant among Black Recipients and Donors

CONTEXT

End-stage renal disease (ESRD) is more common among Blacks, but Blacks are less likely to receive a live donor kidney transplant (LDKT).

OBJECTIVE

The objective of this study is to identify barriers and coping mechanisms that Black LDKT recipients and donors experienced while receiving or donating a kidney.

DESIGN

A qualitative study was conducted using structured interviews. Thematic analysis was used for data interpretation.

PARTICIPANTS

All 20 participants identified as Black, with two participants identifying themselves as multiracial. The mean age for the 14 recipients was 60, and the average age for the 6 living donors was 47.

RESULTS

Themes emerging from the data suggest both recipients and donors faced barriers in the LDKT experience. Recipients faced barriers associated with their denial and avoidance of the severity of their ESRD, their desire to maintain the privacy of their health status, and their refusal to approach potential donors. Donors encountered negative responses from others about the donors' desire to donate and the initial refusal of recipients to accept a LDKT offer. Recipients identified faith as a coping mechanism, while donors identified normalization of donation as their method of coping. Various types of social support helped donors and recipients navigate the transplant process.

CONCLUSION

Black LDKT recipients and donors must overcome barriers prior to receiving or donating a kidney. Most of these barriers arise from communication and interactions with others that are either lacking or undesirable. Future interventions to promote LDKT among Blacks may benefit by specifically targeting these barriers.

Patients' understanding of treatment goals and disease course and their relationship with optimism, hope, and quality of life: a preliminary study among advanced breast cancer outpatients before receiving palliative treatment

PURPOSE

The aims of this study were to explore advanced breast cancer patients' knowledge of treatment intent and expectation of illness course and to evaluate their relationship with optimism, hope, and quality of life (QoL).

METHODS

Patients with advanced breast cancer (n = 55) who were treated in the ambulatory clinic of the University of Hacettepe were included in the study. They completed Life Orientation Scale, The Hope Scale, and the European Organization for Research and Treatment of Cancer Quality of Life questionnaires. The data regarding the knowledge of illness progression and the perceptions of therapy intent were assessed using self-administered open-ended questionnaires that were answered by the patients.

RESULTS

The data revealed that 58.2 % of the patients had an inaccurate perception of treatment intent, believing the aim of treatment was cure, whereas only 38.2 % of the patients had a realistic expectation that their disease may remain stable or may progress over a year. In addition, the awareness of disease progression and perception of goals of treatment was significantly related to hope and optimism scores but not to QoL.

CONCLUSIONS

A large proportion of patients diagnosed with advanced breast cancer believed that their treatment was "curative", and they would improve within a year. Findings of our study suggest that patients with inaccurate perception of treatment intent and unrealistic expectation of prognosis have higher hope and optimism scores than those who do not, but there were no significant differences in terms of global health status.

Newcomers to Al-Anon family groups: Who stays and who drops out?

Al-Anon Family Groups (Al-Anon), a 12-step mutual-help program for people concerned about another's drinking, is the most widely used form of help for concerned others (COs) in the US. This study assessed the prevalence of dropout, and predictors of dropout, in the six months following newcomers' initial attendance at Al-Anon meetings. Al-Anon's World Service Office mailed a random sample of groups, which subsequently yielded a sample of 251 newcomers who completed surveys at baseline and 6 months later. At the 6-month follow-up, 57% of newcomers at baseline had dropped out (had not attended any Al-Anon meetings during the past month). At baseline, individuals who later dropped out of Al-Anon were less likely to have been referred to Al-Anon by their drinker's health care provider, and reported less severe problems than individuals who continued to attend, but dropouts were more often concerned about their drinker's psychological health; newcomers with these concerns may have found them incompatible with Al-Anon's philosophy. Dropouts reported high rates of problems, suggesting that COs who drop out of Al-Anon would benefit from ongoing help and support.

Understanding barriers to Malaysian women with breast cancer seeking help

Delay in help-seeking behaviour which is potentially preventable has a major effect on the prognosis and survival of patients with breast cancer. The objective of this study was to explore reasons for delay in seeking help among patients with breast cancer from the East Coast of peninsular Malaysia. A qualitative study using face- to-face in-depth interview was carried out involving 12 breast cancer patients who had been histo-pathologically confirmed and were symptomatic on presentation. Respondents were selected purposely based on their history of delayed consultation, diagnosis or treatment. All were of Malay ethnicity and the age range was 26-67 years. Three were in stage ll, seven in stage lll and two in stage lV. At the time of interview, all except one respondent had accepted treatment. The range of consultation time was 0.2-72.2 months with a median of 1.7 months, diagnosis time was 1.4-95.8 months( median 5.4 months )and treatment time was 0-33.3 months (median 1.2 months). The themes derived from the study were poor knowledge or awareness of breast cancer, fear of cancer consequences, beliefs in complementary alternative medicine, sanction by others, other priorities, denial of disease, attitude of wait and see and health care system weakness. Help-seeking behaviour was influenced by a complex interaction of cognitive, environmental, beliefs, culture and psycho-social factors. Breast cancer awareness and psychological counselling are recommended for all patients with breast symptoms to prevent delay in seeking clinical help.

Coping with a diagnosis of breast cancer among Omani women

The aim of this study was to identify coping strategies experienced by Omani women after breast cancer diagnosis. Individual semistructured interviews were conducted with 19 women diagnosed with breast cancer. Several coping strategies were identified including denial, optimism, withdrawal, Islamic beliefs and practices, and the support of family members and health-care providers, but Islamic beliefs and practices were the commonest. Health-care professionals should be aware of and respect women's coping strategies and encourage them to use to reduce the psychological symptoms. They should also make family members and friends aware of their role in supporting and encouraging coping strategies.

Defensive coping and health-related quality of life in chronic kidney disease: a cross-sectional study

Background

Coping with the stresses of chronic disease is considered as a key factor in the perceived impairment of health related quality of life (HRQL). Little is known though about these associations in chronic kidney disease (CKD). The present study aimed to investigate the relationship of defensive coping and HRQL among patients in different CKD stages, after adjusting for psychological distress, sociodemographic and disease-related variables.

Methods

The sample consisted of 98 CKD patients, attending a university nephrology department. Seventy-nine (79) pre-dialysis patients of disease stages 3 to 4 and 19 dialysis patients were included. HRQL was assessed by the 36-item Short-Form health survey (SF-36), defensive coping by the Rationality/Emotional Defensiveness (R/ED) scale of the Lifestyle Defense Mechanism Inventory (LDMI) and psychological distress by the depression and anxiety scales of the revised Hopkins Symptom CheckList (SCL-90-R). Regression analyses were carried out to examine the association between SF-36 dimensions and defensive coping style.

Results

Patients on dialysis had worse scores on SF-36 scales measuring physical aspects of HRQL. In the fully adjusted analysis, a higher defensive coping score was significantly associated with a lower score on the mental component summary (MCS) scale of the SF-36 (worse mental health). In contrast, a higher defensive score showed a small positive association with the physical component summary (PCS) scale of the SF-36 (better health), but this was marginally significant.

Conclusions

The results provided evidence that emotional defensiveness as a coping style tends to differentially affect the mental and the physical component of HRQL in CKD. Clinicians should be aware of the effects of long-term denial and could examine the possibility of screening for defensive coping and depression in recently diagnosed CKD patients with the aim to improve both physical and mental health.

Nurse Perceptions and Experiences of Patient Health Assets in Oncology Care: A Qualitative Study

Health assets, a term that refers to patients’ strengths and potentials, has emerged as an important aspect of health care. A conceptual analysis of health assets revealed five core dimensions: mobilization, motivational, relational, volitional, and protective strengths. How nurses experience and use patients’ health assets, however, is unknown. In this qualitative study, 26 expert nurses in cancer care participated in focus group interviews. The nurses had a large repertoire of experiences with cancer patients’ health assets. When the data were subjected to thematic analysis, three new core dimensions were revealed: cognitive, emotional, and physical strengths. Balancing processes within and among health assets—identified as an overriding theme—appeared to be affected by individual and contextual variations. The nurses realized that patients’ health assets could be better used and voiced a need for the clinical and organizational support to do so. New issues about health assets raised in this study may be caused by its novel context (e.g., expert nurses in oncology care). More research is needed on health assets in other contexts, such as patients with different health problems, and of possible strategies to support nurses’ use of health assets.

Delayed treatment and continued growth of nonmelanoma skin cancer

BACKGROUND

Patients may delay treatment for skin cancer for various reasons. Prior research on treatment delay has focused on melanoma rather than nonmelanoma skin cancer (NMSC), which is much more common.

OBJECTIVE

We sought to clarify the reasons for delay in the presentation for diagnosis and treatment of NMSC.

METHODS

This was a prospective cohort study in a Mohs micrographic surgery private practice in an urban setting. Eligible subjects were 982 consecutive patients presenting for Mohs micrographic surgery for NMSC between March and December 2005. No enrolled subjects were withdrawn for adverse effects. The survey was a 4-page written self-administered questionnaire, eliciting patient medical history, skin cancer history, demographic information, initial and subsequent lesion size, and reasons for delay in presentation for evaluation and management. Outcome analyses addressed the: (1) frequency of specific reasons for delayed presentation, as provided by self-report; (2) association between reasons for delay with demographic or other patient-specific factors; and (3) change in lesion diameter from the time of detection by the patient to the time of presentation to the doctor.

RESULTS

Among the reasons for waiting, denial (including: thought it would go away, thought it wasn't important, too busy, thought they could self-treat, afraid it might be something dangerous) was the most frequent, accounting for 71% of cases; difficulty scheduling was associated with 10% of the instances of delay. Older patients (age >64 years) were more likely to wait to seek care than younger patients (odd ratio [OR] = 0.5; 95% confidence interval [CI] 0.4-0.7). Patients with a prior skin cancer were more likely to wait (OR = 1.4; 95% CI 1.1-2.0), as were patients with major life problems (OR = 2.6; 95% CI 1.6-4.3) and patients with a history of any cancer (OR = 1.8; 95% CI 1.3-2.4). Weighted kappa analysis comparing tumor size at the two time points yielded a kappa of 0.72 (SE = .02; 95% CI 0.68-0.77). When the data were separated into two groups, one including those tumors that had decreased in size or remained the same (698 patients), and those that had increased in size (120 patients), the median delay-to-presentation intervals associated with these two groups (2.5 vs 6.0 months, respectively) were found to be significantly different (P < .0001).

LIMITATIONS

This study may have limited generalizability to the extent that it reflects the characteristics only of the subpopulation of patients with skin cancer who eventually received treatment at a referral-based, urban, dermatology private practice. Overall, these patients may have been better insured and be more affluent than the general population.

CONCLUSIONS

Denial is the most common patient-specific factor accounting for delayed presentation for NMSC diagnosis and treatment. Patients younger than 65 years, with a skin cancer history, with major life problems, and with a history of any cancer were most likely to wait to see a doctor. There was a significant increase in tumor size from the time when tumors were noticed by patients to the time when patients presented to a physician. Increased delay was associated with increased tumor growth.

Coping styles in heart failure patients with depressive symptoms

OBJECTIVE

Elevated depressive symptoms have been linked to poorer prognosis in heart failure (HF) patients. Our objective was to identify coping styles associated with depressive symptoms in HF patients.

METHODS

A total of 222 stable HF patients (32.75% female, 45.4% non-Hispanic black) completed multiple questionnaires. Beck Depression Inventory (BDI) assessed depressive symptoms, Life Orientation Test (LOT-R) assessed optimism, ENRICHD Social Support Inventory (ESSI) and Perceived Social Support Scale (PSSS) assessed social support, and COPE assessed coping styles. Linear regression analyses were employed to assess the association of coping styles with continuous BDI scores. Logistic regression analyses were performed using BDI scores dichotomized into BDI<10 vs. BDI> or =10, to identify coping styles accompanying clinically significant depressive symptoms.

RESULTS

In linear regression models, higher BDI scores were associated with lower scores on the acceptance (beta=-.14), humor (beta=-.15), planning (beta=-.15), and emotional support (beta=-.14) subscales of the COPE, and higher scores on the behavioral disengagement (beta=.41), denial (beta=.33), venting (beta=.25), and mental disengagement (beta=.22) subscales. Higher PSSS and ESSI scores were associated with lower BDI scores (beta=-.32 and -.25, respectively). Higher LOT-R scores were associated with higher BDI scores (beta=.39, P<.001). In logistical regression models, BDI> or =10 was associated with greater likelihood of behavioral disengagement (OR=1.3), denial (OR=1.2), mental disengagement (OR=1.3), venting (OR=1.2), and pessimism (OR=1.2), and lower perceived social support measured by PSSS (OR=.92) and ESSI (OR=.92).

CONCLUSION

Depressive symptoms in HF patients are associated with avoidant coping, lower perceived social support, and pessimism. Results raise the possibility that interventions designed to improve coping may reduce depressive symptoms.

“Nothing is Wrong, Doctor”: Understanding and Managing Denial in Patients with Cancer

From a psychological perspective, denial is the process by which the mind defends itself against painful or threatening thoughts, feelings, perceptions, or information and may manifest in healthy or sick persons as well as in patients or those who care for them. For someone with a possible cancer diagnosis, there are several individual steps involved in the denial process, as the threatened meaning of one or more symptoms is sculpted into a more acceptable reality. Although most often felt to be a dysfunctional response, denial of illness is widespread and may serve an important adaptive or coping function, especially in a person facing the challenge of cancer. It may help a person cope with the various stages of their illness and treatment by allowing them time to process distressing information at a manageable rate. However, denial may also be dysfunctional, especially if it causes delay in seeking treatment for symptoms that present in the context of a true malignancy. Many clinicians misdiagnose denial when avoidance, disavowal, or another coping mechanism is invoked or when cognitive impairment or sensory deficits adversely affect perception. This article discusses denial in the context of cancer diagnosis, treatment, and prognosis and strategies for managing this common condition.

Denial of Chronic Illness and Disability

Denial has been an integral part of the psychological and disability literature for more than 100 years. Yet, denial is an elusive concept and has been associated with mixed, indeed conflicting, theoretical perspectives, clinical strategies, and empirical findings. In this two-part article, the author provides an overview of the existing literature on denial that addresses the most prominent and rehabilitation-relevant features of it. Part I provides a generic yet clinically based discussion of denial and focuses on the following: historical perspective of denial, the definitions of denial, the types or forms of denial most often encountered in the literature, the functions served by denial, the indicators or markers most frequently associated with denial, the dynamics and processes inherent in the operation of denial, and the costs and benefits of denial.

Concept analysis of symptom disclosure in the context of cancer

Although symptoms suggestive of cancer are the most common reason that people seek healthcare, the process undertaken to disclose the symptoms is unclear. The purpose of this article is to critically analyze the concept of symptom disclosure in the context of cancer. Rodgers' evolutionary approach was applied to analyze the concept of symptom disclosure. Concept analysis indicates that symptom disclosure is a decision-making process in which a person chooses to tell significant others and a healthcare provider about self-identified symptoms. Characteristics of the concept include symptom interpretation, weighing the risks and benefits of disclosure, and taking action. Influencing factors are knowledge, cancer risk perception, personal or family history of cancer, socioeconomic and cultural factors, and access to care. The concept analysis of symptom disclosure provides guidance for developing strategies to promote healthcare-seeking behavior in practice and suggest areas for future research.

Psychological Factors Affecting Medical Condition: A New Proposal for DSM-V

The DSM category of "psychological factors affecting medical condition" had virtually no impact on clinical practice. However, several clinically relevant psychosomatic syndromes have been described in the literature: disease phobia, persistent somatization, conversion symptoms, illness denial, demoralization, and irritable mood. These syndromes, in addition to the DSM definition of hypochondriasis, can yield clinical specification in the category of "psychological factors affecting medical condition" and eliminate the need for the highly criticized DSM classification of somatoform disorders. This new classification is supported by a growing body of research evidence and is in line with psychosomatic medicine as a recognized subspecialty.

Understanding Denial

PURPOSE/OBJECTIVES

To explore the adaptive and maladaptive uses of denial while developing a clearer understanding of denial.

DATA SOURCES

Nursing and psychological periodicals and textbooks.

DATA SYNTHESIS

Oncology nurses tend to have too broad a definition of denial because they overgeneralize similar patient responses and label them as denial. Because of the uncertainty as to its value, denial is viewed as a negative, fixed response to a crisis and can strain the nurse-patient relationship.

CONCLUSION

Denial is a fluid, interpersonal experience that can affect patients during many points of the cancer experience. By experiencing a clearer understanding of denial and recognizing its adaptive value, nurses can provide more effective patient care.

IMPLICATIONS FOR NURSING

Clinicians should not underestimate the value of the nurse-patient relationship when a patient is in denial. Patience, understanding, and self-awareness are crucial for providing a safe, trusting environment for patients who are experiencing denial.

Avoiding iatrogenic harm to patient and family while discussing goals of care near the end of life

BACKGROUND

Treatment of suffering is a core mission of medicine. Communication about treatment planning with the patient and family, called the goals of care discussion, offers the opportunity to provide effective relief. Such communication is particularly important near the end of life, because many medical decisions are determined then by emotional considerations and personal values.

OBJECTIVE

To define common unintended clinician behaviors, which impair discussion about goals of care near the end of life. To discuss the relationship between: (1) the medical decision-making responsibilities of patient and family, (2) clinician communication, (3) iatrogenic suffering, (4) the impact on medical decision-making, and (5) patient and family outcomes.

DESIGN

Thematic literature review.

RESULTS

The authors discuss how omission of the integral emotional and social elements of the goals of care discussion are reflected in five unintended clinician behaviors, each of which may impair medical decision-making and unknowingly induce patient and family suffering. We posit that such impaired decision-making and suffering may contribute to demands for ineffective, life-sustaining interventions made by the patient and family or, conversely, to requests for hastened death.

CONCLUSIONS

Understanding the challenges in the discussion about goals of care near the end of life will facilitate the development of more effective approaches to communication and shared decision-making. The authors hypothesize how decreased suffering through improved communication should diminish the occurrence of depression, anxiety disorders, and complicated grief in the patient and survivors, potentially improving medical outcomes. Proposed experiments to test this hypothesis will address important public health goals.

Appraisal and coping processes among chronic low back pain patients

OBJECTIVES

Appraisals and coping play important roles in musculoskeletal disorders, but how these aspects develop over time remains unknown. The aim of the current study was to examine the development of pain-related appraisals, coping and well behaviours among chronic low back pain (CLBP) patients.

METHODS

Twenty-two outpatients (15 women, 7 men) of working age were interviewed about past and present experiences of CLBP. The interviews were analysed using Grounded theory.

RESULTS

The majority of the participants used disregarding processes in response to CLBP. The disregarding process developed from a psychological defence into a conscious coping strategy, the transition mediated by a crisis. This defence seemed to protect the participants' self-concept and reduce emotional discomfort, although it did not promote rehabilitation. The disregarding strategy was usually employed in later phases of the disorder and was consistent with active attempts at changing pain-related behaviours. Study limitation: Most of the participants had experienced CLBP for several years, thus the risk of memory bias cannot be ruled out. Furthermore, the sample was composed of relatively healthy subjects, thus the findings may not apply to chronic low back patients in general.

CONCLUSION

Acceptance of CLBP favoured rehabilitation and helped participants change pain-related behaviours.

Outcome and quality of life in medicine: a conceptual framework to put quality of life research into practice

It is rather counterproductive to get caught up in never ending discussions on what quality of life (QOL) is and whether it can be assessed. This article is based on the idea that it is much more important to improve the conceptual frameworks that allow the use of the QOL concept in clinical practice. Survival of the QOL concept within the medical community will depend on its contributions to a better understanding of patients and to improving patient care. It is important to accept that QOL should not be viewed in isolation but in synopsis, with other psychologic concepts and clinical data. We propose a profile format that presents QOL data in a way that is easily accessible for clinicians, allowing action to be taken immediately. QOL profiles are never a substitute but a starting point for a patient-doctor interaction. A profile driven interaction has the potential to be structured, efficient, and leading to action.

Patients with haematological malignancies show a restricted body image focusing on function and emotion

The diagnosis of cancer threatens the psychological and bodily integrity. Based on this assumption, we aimed to explore how newly diagnosed patients cope with special regard to the body image (BI). In total, 40 patients (32 haematological malignancies) were assessed by questionnaires on mood, complaints, self-regulation and quality of life (QOL). The BI was assessed by the 'Body Grid' which reveals the constructs patients choose to characterize the body. The constructs were categorized using a model of six predefined categories comprising: emotion, control, activity, strength, function and appearance. Tinnitus sufferers and medical students served as comparison groups. Cancer patients showed significantly more anxious depression and a significantly lower QOL than controls. Their BI was restricted, focusing the functional status of body organs (e.g. opposing healthy vs. ill organs) as well as emotional aspects (e.g. trust vs. fear). The data convey fundamental psychological distress in newly diagnosed cancer patients. Restriction of BI and use of functional constructs may help to buffer the threat to body integrity. The emotional constructs reflect the existential impact. The data give a clear indication for the need for early psychosocial support which should aim at stabilizing the psychological and bodily integrity of the patient.

Differences in attitudes between patients with primary colorectal cancer and patients with secondary colorectal cancer: is it reflected in their willingness to participate in drug trials?

Recruitment of patients into drug trials is essential in order to evaluate new treatments. Knowing why patients enter drug trials and their fears regarding them can be used in future research to ensure good recruitment and provide a supportive atmosphere for patients. Forty patients with colorectal cancer and 30 patients with colorectal liver metastases were asked to participate in a drug trial involving the oral consumption of a diet-derived agent of unknown therapeutic action. All patients agreeing or refusing to participate were asked to complete a short questionnaire with a series of options detailing the reasons behind their decision. Patients with colorectal hepatic metastases were motivated by altruism in entering the trial (e.g. helping others, helping the investigator) and displayed a realistic expectation that the drug would give little direct benefit to them. Patients with primary colorectal tumours were motivated by more 'selfish' reasons such as helping themselves and displayed an unrealistic expectation concerning any therapeutic benefit from the trial drug. Over 90% of all patients polled stated that their decision was made after reading the patient information leaflet. Patients with different stages of the same disease have very different fears and anticipations of drug trials, which need to be addressed specifically. The importance of the initial contact is demonstrated. Unrealistic expectations regarding the trial drug are common despite clear information to the contrary.

Dysphagic independent feeders' justifications for noncompliance with recommendations by a speech-language pathologist

The purpose of this study was to examine the various ways in which independent-feeding patients with dysphagia justified their noncompliance with swallowing recommendations suggested by a speech-language pathologist (SLP). Sixty-three independent-feeding dysphagia patients between the ages of 65 and 100 years who had been identified by the SLP or staff as noncompliant with SLP recommendations were interviewed about their reasons for noncompliance. Reasons were classified into 8 categories: (a) denial of a swallowing problem, (b) dissatisfaction with the preparations such as thickened liquids or pureed foods, (c) assuming a calculated risk for noncompliant behaviors, (d) rationalizing their noncompliance in the face of contradictory evidence, (e) minimization of the severity of their problem, (f) verbal accommodation while maintaining noncompliance, (g) projection of blame toward the SLP, and (h) deflection of noncompliance by referring to an external authority. Reasons for noncompliance were discussed in light of theory and research on denial, coping mechanisms, and the social-cognitive transition model. Implications were drawn for SLP practice in dealing with noncompliant independent-feeding patients with dysphagia.

Fear, Anxiety, Worry, and Breast Cancer Screening Behavior: A Critical Review

Anxiety, fear, and worry are variously described as facilitators and barriers of breast cancer screening. However, several contradictions are evident in this research. A review article described the literature regarding the relations among fear, anxiety, and worry, along with emotion regulatory styles, and breast cancer screening behaviors before critiquing it in an attempt to uncover preliminary explanations for these discrepancies. Three main conclusions are drawn. First, it is suggested that researchers need to clearly define the components of cancer and the screening process that women are afraid of as each may bear a different relation to screening behavior. Second, greater care needs to be taken to employ psychometrically valid and reliable measures of fear and anxiety. Third, studies need to more systematically test findings across the minority and ethnic groups at greatest risk. A framework is presented and suggestions regarding the continued development of this promising area of research are made.

Hypnosis and existential psychotherapy with end-stage terminally ill patients

Existential Psychological Theory was employed as a conceptual and theoretical foundation for the use of hypnotically facilitated therapy in the management of intractable pain, nausea, and vomiting in 3 end-stage, terminally ill cancer patients. The existential principles of death anxiety, existential isolation, and existential meaninglessness were addressed with a combination of classic and Ericksonian techniques. The intractable nature of the presenting physical symptoms was conceptualized as a possible manifestation of the impact of the terminal prognosis. Direct hypnotic suggestions for the management of pain, nausea and vomiting were avoided. It was hypothesized that, as the existential conflicts associated with the patients' terminal status resolved, the physiological symptoms would become responsive to medication. After 6 sessions grounded in the principles of Existential Psychotherapy, the intractable status of the physical symptomatology remitted, and the patients responded to medical management. This paper addresses the usefulness of Existential Psychotherapy in hypnotic interventions for mediating somatic and psychosomatic symptomatology.

Symptomatic distress, hopelessness, and the desire for hastened death in hospitalized cancer patients

OBJECTIVE

This study evaluated the desire for hastened death (DHD) in cancer patients at varying stages of disease to determine its frequency and relationship to physical and psychological distress.

METHODS

Two hundred twenty-four inpatients at Princess Margaret Hospital completed questionnaires assessing pain, physical symptoms, depression, hopelessness, and DHD.

RESULTS

There was significant physical and psychological distress in this sample with a mean of nine physical symptoms reported by each subject. Seven percent reported moderate DHD on the Schedule of Attitudes Towards Hastened Death (SAHD) and 2% reported high DHD. Hopelessness and stage of disease were the only significant independent predictors of DHD and their interaction was associated with increased DHD. Hopelessness and, less so, depression both mediated the pathways between illness-related factors and DHD.

CONCLUSIONS

Findings suggest that DHD is significantly related to hopelessness and advancing disease. Assessment of this phenomenon prior to the end of life may provide opportunities for intervention.

Evaluation of an oncology outpatient orientation program: patient satisfaction and outcomes

A person's first visit to an outpatient cancer center is typically marked by considerable stress and negative emotion. Thus, innovative support interventions that aim to ameliorate such stress and emotion are warranted. This study evaluated one such intervention--a new-patient orientation program in a cancer center. The program is designed to: (1) provide patients with information about the center's facilities and procedures, (2) give them an opportunity to ask questions and discuss personal concerns, (3) provide them with detailed information concerning support services available in both the community and the cancer center, and (4) provide them with access to a support care practitioner for follow-up contact. Following the orientation program, 213 participants completed a mailed questionnaire designed to measure their level of satisfaction with various aspects of the orientation program and the effect of the program on their emotional state. The results showed that participants were extremely satisfied with the program, it helped them deal more effectively with their first visit to the center, and it increased their feelings of relaxation and comfort and reduced their feelings of fear and anxiety. These results support the use of informational and support interventions as an effective means of improving cancer care.

Prognosis Communication in Serious Illness: Perceptions of Older Patients, Caregivers, and Clinicians

OBJECTIVES

To examine agreement between patients, caregivers, and clinicians regarding prognosis communication and to examine patients' and caregivers' desire for prognostic information.

DESIGN

Cross-sectional survey.

SETTING

Participants' homes.

PARTICIPANTS

Two hundred fourteen persons aged 60 and older with a limited life expectancy secondary to cancer, congestive heart failure, or chronic obstructive pulmonary disease; caregivers; and clinicians.

MEASUREMENTS

Patient-clinician and caregiver-clinician agreement about the occurrence of prognosis discussions and patient and caregiver desire for prognostic information.

RESULTS

In 46% of patient/clinician and 34% of caregiver/clinician pairs, the clinician reported saying that the patient could die of the underlying disease, whereas the patient or caregiver reported no discussion. In 23% of patient/clinician and 30% of patient/caregiver pairs, the clinician reported discussing an approximate life expectancy, whereas the patient or caregiver reported no discussion. Of 205 patients who reported no life expectancy discussion, 40% did not want this discussion. Whereas 83% of those believing they had 1 year or less to live wanted to discuss prognosis, 79% of those believing they had 1 to 2 years, 53% of those believing they had 2 to 5 years, and 50% of those believing they had more than 5 years or who were unwilling to answer wanted this discussion (P=.007).

CONCLUSION

Although clinicians report that they are discussing prognosis, patients and caregivers frequently do not corroborate these reports. Furthermore, many patients do not want prognostic information. Despite previous reports concluding that patients want full disclosure about their illness, many seriously ill older persons and caregivers may not be ready or able to receive prognostic information.

A review of the role of illness models in severe mental illness

The ways in which people think about illness experiences have been associated with a variety of important behaviours and emotional responses in patients, carers, and professionals. Some of these responses have been shown to be related to outcome. Explicit models such as the self-regulation model (SRM) [Leventhal, H., Nerenz, D. R., & Steele, D. F. (1984). Illness representations and coping with health threats. In A. Baum & J. Singer (Eds.), A handbook of psychology and health. Hillsdale, NJ: Erlbaum, 219-252.] have been shown to be useful in highlighting key beliefs across a wide range of different physical illnesses. The specific beliefs about mental illness that have been assessed have been varied and largely without a common theoretical framework. This has resulted in a literature from which it is difficult to draw firm conclusions. The central aim of this paper is to assess the applicability of the SRM to mental illness. To this end, we review studies to date that have examined the beliefs that people with a mental illness have about their experiences. In addition, we review studies that have examined the beliefs of relatives of people with a mental illness and professionals who work with this population. We assess to what extent these studies are consistent with the SRM before suggesting ways in which the model could be further developed and tested. The SRM is presented as a useful framework for more advanced investigations into the function of beliefs about mental illness and how these can be modified in order to effect outcome. Developing psychological theories common to both physical and mental health may eventually result in an integrated approach in which mental illness becomes less stigmatised within the treatment setting.

Quality of life profile: from measurement to clinical application

Quality of life (QoL) can be assessed in an accurate, valid and reliable way by means of standardized QoL questionnaires and is an important endpoint in clinical trials today. The aim of this study is to implement quality of life as a diagnostic tool for problem-oriented follow-up care of cancer patients. This is done in the framework of an intervention study in the area of regional health care research using qualitative analysis and the methodological concept of barrier analysis. We developed the diagnostic tool by generating individual, graphic QoL profiles based on patients' responses to the EORTC QLQ-C30 and the corresponding disease-specific modules BR23 for breast cancer and CR38 for rectal cancer. The clinical application is investigated by assessing physicians' responses. The QoL profile is judged as a useful diagnostic tool by all participating physicians. It enables physicians to assess the QoL of the patient and incorporate the knowledge they gain in their daily practice. Especially in breast cancer follow-up care QoL profiles give added value to both patients and doctors. The next implementation steps have to extend the concept of QoL to larger groups of patients and physicians by overcoming the restraining factors as identified in the barrier analysis.

Knowledge and beliefs among brothers and sons of men with prostate cancer

OBJECTIVES

To describe prostate cancer knowledge and beliefs, important predictors of screening behavior, in first-degree relatives of men with prostate cancer and to compare the knowledge with beliefs about familial risk.

METHODS

We sent a letter to 837 men with prostate cancer to invite their brothers and/or sons aged 40 to 70 years to participate in the study. Their first-degree relatives who responded received a survey to explore their prostate cancer family history, prostate cancer knowledge, self-efficacy, barriers to screening, perceived benefits, perceived vulnerability, social support, and sociodemographic and medical characteristics.

RESULTS

Of 139 participants (age 53 +/- 9 years), 92% were white, and 27% had more than one relative with prostate cancer. Ninety-eight percent of men answered at least one half of the knowledge questions correctly. Older men responded correctly more often than did younger men. Physician recommendations did not appear to be associated with better knowledge about familial risk. Among the 105 subjects (76%) who knew about familial risk, only 65 (62%) believed they themselves were at higher risk of prostate cancer than the average American man. Most of the beliefs were favorable to screening.

CONCLUSIONS

Prostate cancer knowledge appeared high, although, surprisingly, familial risk was not the best understood domain. Physician recommendations were not associated with better knowledge about familial risk. Many men underestimated their own risk of developing prostate cancer, even among those with good knowledge about familial risk.