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When a patient's health care team determines that the cancer can no longer be controlled, medical testing and cancer treatment often stop. But the patient's care continues. The care focuses on making the patient comfortable. The patient receives medications and treatments to control pain and other symptoms, such as constipation, nausea, and shortness of breath. Some patients remain at home during this time, while others enter a hospital or other facility. Either way, services are available to help patients and their families with the medical, psychological, and spiritual issues surrounding dying. A hospice often provides such services.
The time at the end of life is different for each person. Each individual has unique needs for information and support. The patient's and family's questions and concerns about the end of life should be discussed with the health care team as they arise.
The following information can help answer some of the questions that many patients, their family members, and caregivers have about the end of life.
How long is the patient expected to live?
Patients and their family members often want to know how long a person is expected to live. This is a hard question to answer. Factors such as where the cancer is located and whether the patient has other illnesses can affect what will happen. Although doctors may be able to make an estimate based on what they know about the patient, they might be hesitant to do so. Doctors may be concerned about over- or under-estimating the patient's life span. They also might be fearful of instilling false hope or destroying a person's hope.
When caring for the patient at home, when should the caregiver call for professional help?
When caring for a patient at home, there may be times when the caregiver needs assistance from the patient's health care team. A caregiver can contact the patient's doctor or nurse for help in any of the following situations:
- The patient is in pain that is not relieved by the prescribed dose of pain medication;
- The patient shows discomfort, such as grimacing or moaning;
- The patient is having trouble breathing and seems upset;
- The patient is unable to urinate or empty the bowels;
- The patient has fallen;
- The patient is very depressed or talking about committing suicide;
- The caregiver has difficulty giving medication to the patient;
- The caregiver is overwhelmed by caring for the patient, or is too grieved or afraid to be with the patient; or
- At any time the caregiver does not know how to handle a situation.
Our field is at a moment of great excitement, opportunity and risk. Faced with the reality that resources for treatment have limits, a revolution in funding of mental health benefits has begun. In order to contain costs new strategies are emerging, like capitation, case rates, case management and utilization review, that closely limit or oversee treatment provided and/or ask providers to bear the financial risk of treatment. The attention of psychiatrists has been powerfully drawn to the financial arena, where the introduction of close management of benefits has introduced a sometimes dizzying array of hoops through which a clinician must leap, dragging the patient behind, in order to persuade a case manager or utilization reviewer that a particular treatment is indicated. Quality is in danger of falling by the wayside in favor of cost containment as the watchword by which clinicians practice their art.
The impact of managed care on psychiatry has the potential for positive effects through better resource management, but the turning of psychiatrists' attention away from quality to cost containment is worrisome if it means only minimal treatment will be authorized for patients. A recent Rand Corporation study of prepaid versus fee for service mental health benefits showed that depressed outpatients in prepaid plans were more likely to acquire new limitations in role or in their physical functioning than those treated in a fee for service model (1). The authors suggest that the presence of Axis II disorders may account for the finding. The shift to new reimbursement strategies is here to stay, but we ought to pay attention to the clinical consequences. One danger, which may explain some of the Rand Corporation study findings, is the way many of the new reimbursement strategies leave the patient out of the terribly important negotiations around the treatment plan and its funding. The crucial clinical and financial dialogues about treatment have increasingly been reassigned to the doctor or other clinician and case manager, without the patient's true participation. This has the potential to leave the patient in the position of being a passive recipient of treatment, rather than an active agent in it (2).
Developmental psychologists have been interested in how parents influence the development of children’s social and instrumental competence since at least the 1920s. One of the most robust approaches to this area is the study of what has been called "parenting style." This Digest defines parenting style, explores four types, and discusses the consequences of the different styles for children. Parenting Style Defined Parenting is a complex activity that includes many specific behaviors that work individually and together to influence child outcomes. Although specific parenting behaviors, such as spanking or reading aloud, may influence child development, looking at any specific behavior in isolation may be misleading. Many writers have noted that specific parenting practices are less important in predicting child well-being than is the broad pattern of parenting. Most researchers who attempt to describe this broad parental milieu rely on Diana Baumrind’s concept of parenting style. The construct of parenting style is used to capture normal variations in parents’ attempts to control and socialize their children (Baumrind, 1991). Two points are critical in understanding this definition. First, parenting style is meant to describe normal variations in parenting. In other words, the parenting style typology Baumrind developed should not be understood to include deviant parenting, such as might be observed in abusive or neglectful homes. Second, Baumrind assumes that normal parenting revolves around issues of control. Although parents may differ in how they try to control or socialize their children and the extent to which they do so, it is assumed that the primary role of all parents is to influence, teach, and control their children. Parenting style captures two important elements of parenting: parental responsiveness and parental demandingness (Maccoby & Martin, 1983). Parental responsiveness (also referred to as parental warmth or supportiveness) refers to "the extent to which parents intentionally foster individuality, self-regulation, and self-assertion by being attuned, supportive, and acquiescent to children’s special needs and demands" (Baumrind, 1991, p. 62). Parental demandingness (also referred to as behavioral control) refers to "the claims parents make on children to become integrated into the family whole, by their maturity demands, supervision, disciplinary efforts and willingness to confront the child who disobeys" (Baumrind, 1991, pp. 61-62).
Panic attacks in and of themselves are powerful agents for eroding confidence. Suddenly, you feel unable to do all sorts of things you used to do, all sorts of things “normal” people do. On top of that, you feel as though you’ve lost control of your own body, something so basic to your sense of self that you probably never even gave it a second thought before the attacks hit.
Panic sufferers often describe themselves as “people-pleasers” who find it extremely painful to risk others’ dislike or disapproval. They may agree to others’ requests, suppress their own opinions, and put the needs of others before their own – sometimes to the point that they almost lose touch with their own wishes and feelings. As one woman put it, “I’ll turn myself inside out for you if it will get you to say just one nice thing about me.”
There are many reasons why people find it difficult to assert themselves. One important reason relates to fears of loss: you may feel you’ll put a relationship at risk if you assert yourself too forcefully. Or you may lack the confidence and self-esteem to express your own wishes, perhaps seeing them as unimportant.
Maybe you’re so tender-hearted that you can’t bear to refuse anyone anything. Or you may have become so accustomed to the role of “giver” in your family of origin that it scarcely occurs to you to refuse.
For many years, depression and other disorders of mood were thought to be afflictions of only adults. Within the past three decades, however, it has become evident that mood disorders are common among children and adolescents. Population studies reveal that between 10% and 15% of the child and adolescent population exhibit some symptoms of depression (U. S. Department of Health and Human Services [USDHHS], 2000).
In children and adolescents, the most frequently diagnosed mood disorders are major depressive disorder, dysthymic disorder, and bipolar disorder. This digest focuses on these three disorders as they are exhibited in childhood and adolescence - their symptoms, causal factors, and treatment.
Major Depressive Disorder
Major depressive disorder is a serious condition characterized by one or more major depressive episodes. In children and adolescents, an episode lasts an average of seven to nine months (Birmaher et al., 1996a, 1996b). Depressed children are sad and lose interest in activities they used to enjoy. They feel unloved, pessimistic, or even hopeless; they think that life is not worth living; and they may think about or threaten suicide. They are often irritable, which may lead to disruptive or aggressive behavior. They may be indecisive, have problems concentrating, and lack energy or motivation. They may neglect appearance and hygiene, and their normal eating and sleeping patterns may be disturbed (USDHHS, 2000).
Dysthymic Disorder
Dysthymic disorder has fewer symptoms, but is more persistent. The child or adolescent is depressed for most of the day on most days, and symptoms may continue for several years, the average dysthymic period being approximately four years. Seventy percent of children and adolescents with dysthymia eventually experience an episode of major depression. When this combination of major depression and dysthymia occurs, the condition is referred to as double depression (USDHHS, 2000).
Bipolar Disorder
In bipolar disorder, episodes of depression alternate with episodes of mania. The depressive episode usually comes first, with the first manic features becoming evident months or even years later. Adolescents with mania feel energetic and confident; may have difficulty sleeping but do not tire; and talk a great deal, often speaking very loudly or rapidly. They may complain of racing thoughts. They may do schoolwork quickly and creatively, but in a chaotic, disorganized way. In the manic stage, they may have exaggerated or even delusional ideas about their capabilities and importance, become overconfident, and be uninhibited with others. They may engage in reckless behavior (e. g., fast driving or unsafe sex). Sexual preoccupations are increased and may be associated with promiscuous behavior (USDHHS, 2000).
Other Disabilities Associated With Depressive Disorders
Approximately two-thirds of children and adolescents with major depressive disorder also have another mental disorder, such as anxiety disorder, conduct disorder, oppositional defiant disorder, psychoactive substance abuse or dependence, or phobias (Anderson & McGee, 1994). Authorities have also noted that children with medical problems often face extreme and/or chronic stress, which places them at risk for depression. Estimates of depression among youngsters with medical problems range from 7% in general medical patients to 23% in orthopedic patients (Guetzloe, 1991). Depression has also been linked to a variety of other medical conditions, including endocrinopathies and metabolic disorders (e.g., diabetes and hypoglycemia), viral infections (e.g., influenza, viral hepatitis, and viral pneumonia), rheumatoid arthritis, cancer, central nervous system disorders, metal intoxications, and disabling diseases of all kinds. Some of these conditions may be temporary, but some may be diagnosed as primary disabilities in youngsters with health impairments.
