I work as a consultation psychiatrist in a large cancer hospital in Norway. My work varies on a continuum from having conversations about existential matters to handling complicated neuropsychiatric clinical cases related to the cancer itself or medical treatment. I also counsel health professionals on managing patients with existing mental health issues during cancer diagnosis and treatment. Meeting people who are faced with death draws attention to the significance of life itself.
I encounter both patients full of hope and patients who have lost hope. The course from losing hope to a depressive state of mind can be short. How can we help palliative cancer patients restoring a meaningful life when death is approaching? I will present a constructed case story and then share some reflections and experiences from my work.
Case - “Fred”
Fred, a 28-year-old man, has struggled with cancer on and off since he was 17 years and was diagnosed with osteosarcoma. Despite reduced physical function, he managed to get a part-time job he enjoyed, and he lived together with his girlfriend until they broke up two years ago.
When I met him, his cancer was metastatic and he received immunotherapy, but the prognosis was poor. However, no doctor could tell him how many months or years he had left in life. Physically he felt okay, but he was full of sorrow and anxiety of what lied in front of him. Sleeping was bad, and he admitted drinking too much alcohol. His friends wanted to meet him and the workplace was welcoming him back, but he saw no point of engaging with others as he would die soon.
Fred demonstrated both anxiety and depressive symptoms. He had lost hope in life, a state called demoralization in literature (1). He had sleeping problems, and his self-care was poor. I offered him consultations at our outpatient clinic, and I suggested trying out mirtazapine for better sleep, which he profited well from. He was very open in our conversations and had in many ways “accepted his fate”. He was not so afraid of dying but feared pain. I explained him about modern palliative medicine that could offer pain relief. We talked through his recent choices of withdrawing from social life. He said he wanted to quit drinking alcohol and asked me if he was “allowed” to try dating again – even if his life probably would be short. I motivated him to make plans for his life again. We agreed that the “worst case scenario” of making plans is the risk of having to change them (which we all do time to time).
I meet many patients in Fred’s situation. They stop making plans for their life, alluding to the fact that they will soon die. However, a life with no plans or goals can easily lead to depressive feelings and a sense of meaninglessness. I followed “Fred” for some months with a consultation every 2-3 weeks. I would best characterize my approach as some kind of “supportive psychotherapy”. His mood got better, and his anxiety diminished. He “took the risk” of starting to live his life again, of course with the same uncertainty about his future, but with the confidence that the opposite choice would do him no good. He wanted to make the most out of what he had left in life.
Cancer and death
Patients often tell me that the first thing they thought about when they were diagnosed with cancer was death. Historically, cancer mortality was high, and the relationship between cancer and an imminent death still live vividly in peoples’ minds. The success of modern cancer medicine has changed the scary scenario for many types of cancer. In Norway, nearly three out of four cancer patients these days have a life expectancy of five years or more after diagnosis (2).
Still, many patients get a reduced life span due to cancer. When I walk in the cancer wards and meet very sick patients going through some heavy cancer treatment (often with a lot of side-effects), I reflect on how much we are willing to fight to keep the death away, longing for some more good days in life.
Psychological reactions and adaptation
Severe somatic disease and the fear of a hastened death make a psychological impact on all of us. However, most cancer patients do not develop a clinical depression (3). What is more common is fluctuating depressive and anxiety symptoms in response to the different phases of the cancer trajectory. Somatic symptoms such as pain, nausea or dyspnea tend to aggravate psychological distress. Hence, it is important to treat underlying somatic symptoms and helping patients to sleep to reduce anxiety, depressive thoughts and demoralization.
Patients and their caregivers adapt to severe disease and a change in life expectancy in different ways. Howard Brody, a medical doctor and professor in medical humanities, has written about the narratives of the human life in his book Stories of Sickness (4, p.147). He suggests a parabolic curve as a visual metaphor of the life span. Severe cancer disease and early death alter the individual’s parabolic curve (on the right side of the curve). Factors such as personality traits, earlier life events and traumas, coping style and current life situation influence on the individual adaptation process to this “shift in curve”. Most difficult for us as health personnel is when patients in (late) palliative stage (or their caregivers) never comes to the point of “accepting” the situation. This may lead to family members losing their opportunity to have the good conversations with each other and to say farewell.
Care for the caregiver
Patients in palliative phase often worry about how their caregiver will handle the situation after their death. A 45-year-old woman, “Anna”, was referred to me with depressive symptoms. She had metastatic breast cancer and had been through all lines of medical cancer treatment. She disclosed to me that what she worried most about was her husband. They’ve had a very happy marriage, and she felt so sorry for him because he would soon be alone. She wanted him to pursue his life after her death. After she introduced this theme in a consultation, she decided to talk to her husband and give him permission to get a new girlfriend after she died. Next time I met her she told me that talking to her husband about these matters gave her peace and she felt relieved. Anna died 3 weeks later. □
References
Fava M, Sorg E, Jacobs JM, Leadbetter R, Guidi J. Distinguishing and treating demoralization syndrome in cancer: A review. Gen Hosp Psychiatry. 2023;85:185-190. https://doi.org/10.1016/j.genhosppsych.2023.10.004
Cancer registry of Norway. Cancer in Norway [internet]. Available from Cancer in Norway (kreftregisteret.no)
Caruso R, Nanni MG, Riba M, Sabato S, Mitchell AJ, Croce E, Grassi L. Depressive spectrum disorders in cancer: prevalence, risk factors and screening for depression: a critical review. Acta Oncol. 2017; 56:146-155. https://doi.org/10.1080/0284186x.2016.1266090
Brody, H. Stories of sickness. 1.ed. New Haven and London: Yale University Press; 1987. 192 p.