ANGER ISSUES IN PALLIATIVE CARE

Anger is the strong emotion that one feels when he/she thinks that someone has behaved in an unfair, cruel or unacceptable way.

Anger is a strong feeling of annoyance, displeasure, or hostility.

Anger in patients and families is a common problem in the care of persons with advanced disease. Whereas it is widely accepted that anger may be a justifiable reaction to significant illness and loss, it frequently creates difficulties for the doctors involved in care. In particular, there is often a personal impact on the doctor at whom anger is directed.

Anger is a commonly encountered emotion in the cancer setting. Understanding its origin is vital but the practitioner needs to facilitate more than the ventilation of feelings; some change in attitude, the provision of social support and the promotion of adaptive coping need to be generated.

The perceived unfairness of illness and death commonly underpins anger in the patient with cancer.

Common sources of anger

Fear is probably the most common source of anger, especially in the dying and their families.

Fear of the unknown,
Being in pain or suffering,
The future well-being of family members,
Abandonment,
Leaving unfinished business,
Losing control of bodily functions or cognition,
Being a burden to the family, and dying alone.
A genuine insult – so called “rational anger” (e.g. Waiting six hours to see the doctor);
Organic pathology: frontal lobe mass, dementia or delirium; and
Personality style/disorder – the person whose approach to much of life is via anger or mistrust.

“BATHE” approach

Use the “BATHE” approach to create an empathic milieu (A person’s social environment). As with any difficult patient situation, communication techniques are especially important so that both the patient and physician do not become further embittered and frustrated.

Background: Use active listening to understand the story, the context, the patient’s situation.
Affect: Name the emotion; for instance, You seem very angry…. It is crucial to validate feelings so the angry person feels that you are listening. Attempting to defuse it, counter it with your own anger or ignore it, will be counter-productive. Acknowledging their right to be angry will help start the healing process and solidify the therapeutic relationship.
Troubles: Explore what scares or troubles them the most about their present and future. Just asking the question Tell me what frightens you? will help them to focus on circumstances they may not have considered.
Handling: Knowledge and positive action can help mitigate fears and reduce anger. How are they handling the dying – are they making concrete plans about their finances, their things, their family? Have they thought about formal counseling to help deal with depression and anger?
Empathy: By displaying empathy and concern you can help the person feel understood, less abandoned and alone. Avoid trite statements such as I know what you’re going through. Paraphrasing the patient’s comments is an effective way to convey that you heard and are seeking to understand: You feel like it’s so unfair that the cancer appeared out of nowhere after all these years.

Effective’s ways of managing anger.

Understand that it’s not easy being a patient or a family: trying to understand that it’s really not easy being a patient nor to be a relative whose loved one is in critical condition because no person would ever want to be stuck in the hospital for days, and to be taken care of by different strangers every eight to ten hours.
Show empathy: As a nurse, show empathy by focusing your attention on their feelings, expressions, and actions and show them that you are interested and that they are important.
Allow the patient to blow off some steam or ‘calm down: allowing patients to calm down first before you give them your explanation i.e. reminding yourself that they are not happy about being ill, so it’s best to just try your best to keep yourself cool while waiting for them to calm down.
Do not invade the patient’s personal space: Try not to get either too close or too far from them i.e. let them feel that they still have their own personal space that you wouldn’t be invading and that they are safe there.
Do not touch them: Let the patient speak their mind from a comfortable distance, but not too far that you’d have to shout at each other, or too near that you’d be uncomfortable to speak.
Be sensitive: Being sensitive to people’s feelings means accepting them and respecting them no matter what happens i.e. if a patient gets mad at you for something, don’t think that he is a bad patient or person rather think about how you would feel if you were in their shoes.
Be gentle: If you are to respond, do it in a calm and kind manner and if you want to make the situation better, try to avoid negativity. Instead, focus on something that you can do to help the person i.e. Think before you respond to anything the patient says because sometimes, people react too quickly without taking time to think about how their responses might affect others.
Do not argue: Being truthful of everything you say, and try not to think that you are always right. Communicating better and having a positive behavior towards any issue will solve anything.
Apologize for the inconvenience: Apologizing will not make you less of a person; it will only show that you are strong and brave enough to accept your mistakes. It could also lessen any tension that may occur between you and your patients (or their family members).
Settle the issues immediately: Of course, it is best to work on the complaint as soon as you can. The patient or family member is angry for a reason. Make sure to take note of the details of their complaint and find time to fix it.
Keep your promises: When dealing with patients, you tend to say things you do not mean, and more often than not, give promises that you cannot keep.
Set boundaries: Keep yourself safe but let them know that you are listening to them i.e. defuse situations before they even escalate e.g. a patient has the right to be involved in their medical decision-making, but they cannot use that right for any unreasonable demands.
Communicate: Being honest with everything you say to the patient and being available and responsive to your patients i.e. never let them feel that you are ignoring them.
Acknowledge the emotion that the patient is projecting: Validating the person’s feelings will help them feel understood i.e. let them feel that their feelings make sense, that you hear them and you understand them.
Listen: Active listening also means you should look at the problems from the other person’s point of view i.e. focus on what the person is saying to you before offering any help. Remember to take note of what they are saying, and try to retain the information.
Ask open-ended questions: Ask gentle, probing questions to learn more about what the other person think and feel i.e. ask clarifications if you don’t get what the patient is trying to say.

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