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Handling collusion, anger and denial in Palliative care
- 1. Handling Collusion, Denial and Anger Dr Ruparna Khurana MBBS, DNB(RT), Ex-SR PM AIIMS Consultant Palliative Medicine, HOPE oncology
- 2. • Respect the time frame provided to me • Don’t want to overburden you with information blast • Retain time for reflecting what you have understood • Questions /doubts/confusions • Understood anything/something/nothing!
- 7. Handling Collusion, Denial and Anger
- 8. Etymology • Latin word ‘colludere’ • Col : together • Ludere : to play "to play together,“ • Collusion early 16th century • Situations in which individuals entered into secret agreements.
- 10. In PC.. • Patient family • Family + health care tram • Patient plus health care team • Patients generally know…
- 11. Reasons for colluding • Patient will lose hope • Depression • Hastens progression death • Suicide • Psychological pain • Unawareness amongst caregivers • Denial • Conflict
- 12. Problems of not telling the truth • No open discussions possible • Patient will remain unaware of the gravity of the situation • Conspiracy of silence • May hinder treatment • Unsettled/ unresolved issues • Lack of trust in family members and the healthcare team • Patient will not be able to plan ahead / Unfinished business
- 13. Benefits of breaking the collusion • Open discussions • Patients will be at peace and accept • Restore trust in healthcare system • Adhere to treatment • Plan ahead • Good deatrh
- 14. Handling • Acknowledge – act of love - need to protect • Explore – understanding and reasons - cost to colluders • Empathise • Discuss the pros/cons
- 15. • Has the patient expressed a wish to know • What if they were the patient • Assure the family that diagnosis will not be revealed if patient is not willing • Arrange to talk again and raise possibility of all being aware of reality.
- 16. • Gently break the collusion • Breaking the bad news
- 18. • Elisabeth Kubler Ross • Swiss American • Psychiatrist • 1969 Book – Death and Dying
- 20. Denial
- 21. Patients who appear not to acknowledge their diagnosis or its gravity, are said to be ‘in denial’
- 22. Denial • Patient's refusal to take on board the bad news • Not wanting to know the diagnosis • Not mentally prepared to handle the news • When a person finds the challenges too overwhelming
- 23. • Difficult emotional challenges at the EOL: Loss of control Loss of roles and responsibilities Anger Guilt Loneliness and isolation Spiritual crises
- 24. • Coping/ defense mechanism • Helps to avoid painful thoughts and feelings which are difficult to deal with • Serves a protective function by keeping at bay damaging thoughts
- 25. • Respect for the essentially protective nature of it. • Do not judge as “good” or “bad,” • Instead “Is this reaction/response helping the patient cope with his challenges?”
- 27. Subconscious disavowal • 71- year- old retired oncology nurse • Presented @ ED with abdominal pain • Large fungating chest wall lesion : advanced breast cancer • Investigations - chest wall invasion and liver metastasis • Her version : 20 years, not cancer, dermatitis • Nothing to worry about.
- 28. Handling denial 1) Recognise and confirm : misunderstanding/ misinformation/ neuropathology 2) Determine if its adaptive or maladaptive 3) Provide information tailored to patient’s needs 4) Explore emotional reactions and respond with empathy
- 29. Anger
- 30. Causes for anger in PC • Poorly controlled symptoms • Miscommunication / Lack of communication • Lack of trust on health care providers • Collusion, denial • Unresolved family conflicts • Frontal lobe disease/ Brain mets
- 31. Handling Anger • Invest some time • Dial up the empathy • Keep your cool • Mind your body language • Physically protect yourself • Legally protect yourself • Try and end the conversation on a positive / helpful note
- 32. BATHE technique • Background: active listening to understand the situation • Affect:/Acknowledge: Name and validate the emotion. Do NOT counter • Trouble: Ask what troubles / scares them • Handling: How are they handling the dying – are they making concrete plans about their finances, their things, their family? • Empathy: feel understood, less abandoned and alone. “..I can only imagine what you are going through…”
- 33. ANGER Effective Ineffective Acknowledge anger Dismiss anger Identify focus Refute focus Legitimise Defend actions of colleagues Encourage expression Anger increases Anger is diffused
- 34. Your thoughts
- 35. Thank you