Evaluation of the psychological state of patients with advanced cancer and the impact of support on their emotional condition.

AIM OF THE STUDY: The aim of the study was to evaluate the patient's psychological state in the advanced stage of cancerous disease and to assess the effect of sustenance provided by the nursing personnel upon the emotional state of the patient.
MATERIAL AND METHODS: The study group comprised 46 subjects treated in palliative care medical wards in Łódź. The data were collected in accordance with the HADS-M questionnaire as well as a self-developed survey. The information obtained was analysed by means of Pearson χ(2) test.
RESULTS: The results obtained indicate that most subjects undergo mood aggravation. 76.2% of patients were diagnosed with depressive states. Only 19.6% of the population under investigation showed no signs of anxiety states. The study demonstrates irritation to be yet another unfavourable emotional state coupled with the advanced stage of cancerous disease with as few as 4.4% (4.2%) respondents claiming not to suffer any such symptoms. The patients highly prize the support they receive and it notably improved their well-being. Social support is essential in the advanced stage of the disease. Less severe mental disorders were noted in people who have received all kinds of support.

Introduction

The continuous rise in the number of cancer patients evokes concern over their present and future life quality, which is abated by the fact of diagnosis [1]. Cancerous disease triggers a spate of psychological difficulties in response to the predicament they are facing. The terminal stage of the disease in question involves both the aggravation of physiological functions of the organism and the growing painfulness which in turn leads to the patient's loss of interest in contacting the environment. These facts have been confirmed by many studies, according to which anxiety, depression, fatigue and pain are symptoms affecting quality of life [2]. Especially a low quality of life, both in the emotional and physical sphere, is observed in patients with advanced stage of disease [3]. The condition of the patients is difficult, not only for them, but also for their families and caregivers [4, 5]. The reality of the great suffering surrounds the patient and his/her immediate family members, embraces and permeates all aspects of their life. In the face of death the patient loses his/her family position and social position, which combines with changing values and ideals. Neither the patients nor their families are prepared for a new, hard life situation; therefore during patient care the psychological and emotional needs of immediate persons should not be forgotten [6, 7]. In the time of changes the family, as a stabilising factor, requires strengthening from the outside. This support exerts a significant impact on the functioning of the patient and his family and gives the satisfaction, hope and motivation to fight the disease [8]. Team work provides the opportunity to distribute the burden of care, responsibility, stress alleviation, and mutual support onto multiple parties. The nurses are the coordinators of the process of patient effective reassurance in all its aspects as they are in constant and intimate contact with the patients themselves, their families, volunteers as well as all other members of the therapeutic team. The support provided by the term may be differentiated, in terms of scope, into instrumental, emotional, appraisal, informational and tangible. The effective care programme requires one to see human health care problems in all their complexity and to consider not only biophysical changes but also those which are defined as psychosocial. One means of comforting the said patients features hospices that are set on ascertaining the optimal life quality in all the spheres of the patients’ functioning.

Aim of the study

The aim of the study is to furnish an answer to the following questions:

Which psychological difficulties are the most awkward to a patient in the terminal stage of cancerous disease?

What is the patients’ evaluation of the support provided by the nursing staff?

Is there a correlation between the support received and the psychological state of the patient?

Material and methods

The study was conducted in the palliative care medical wards in Łódź in 2009. For the purpose of psychological state evaluation the HADS-M questionnaire was implemented as adapted for Polish standards by M. Majkowicz, K. de Walden-Ga#x0142;uszko and G. Chojnacka-Szaw#x0142;owska. The survey consisted of three groups of questions. The first category contained questions about anxiety, the second related to the states of depression and the third examined states of irritation. Other data were assessed in accordance with a self-developed survey. The questionnaire of the survey included 38 questions: 22 questions related to physical symptoms attributable to cancer, 11 questions concerned forms of social support and its quality, the following questions related to nursing care and its impact on the quality of life, and the remaining questions determined demographic data. The research was conducted after obtaining the consent of the Bioethical Commission (no. RNN/404/08/KB). The influence of the support on emotional state of the patient was analysed by means of the non-parametric Pearson χ2. The statistical significance level was set at p < 0.05.

Results

The study group comprised 46 subjects treated in the palliative care medical wards in Łódź. The questionnaires were presented to patients with preserved verbal and logical contact. The subjects ranged in age from 30 to 65 years.

Over 50% of pollees were aged over 65 years. Young people constituted 13%. The distribution with regard to sex proved even. The percentage of males was 47.8% and females 52.2%. All subjects were urban residents.

In the first part of the study the focus was on the emotional state of the patients. The results of the analysis are presented in Figs. 1–3. The problem associated with the occurrence of anxiety was found in the majority of those investigated, which was very often accompanied by edginess, panic and fear. Depression is another accompanying symptom in the group of respondents. Patients pointed to the negative experiences associated with the disease as sadness and despondence.

Fig. 1

Anxiety states in subjects in the advanced stage of the disease

Fig. 3

Irritation states in subjects in the terminal stage of the disease

Depression-related states in subjects in the advanced stage of the disease

Because of the health status in more than half of the patients the loss of optimism and self-confidence was shown, which resulted in frequent outbursts of anger and irritation. The study points to the prevalence of depression out of all three considered states (anxiety, depression, irritation) in the investigated group. Anxiety was found to be the least frequently occurring.

Next to be investigated was the evaluation of appraisal support received from the nursing personnel and the patients’ expectations towards the professional group in question. The results obtained are shown in Figs. 4–8.

Fig. 8

Evaluation of medical support

Evaluation of emotional support as received from the nursing personnel

Evaluation of informational support as received from the nursing personnel

Evaluation of appraisal support as received from the nursing personnel

Evaluation of instrumental support

The respondents’ reactions indicate that the most numerous group of them were granted instrumental (71.7%) and emotional (65.2%) support. There was the least satisfaction with the level of informational support they received. In most cases, informational support proved to be low and superficial and thus failed to meet the patients’ expectations.

The majority of patients share the opinion that nursing care favourably affects their quality of life. The respondents’ reactions indicate that nursing care was helpful both in alleviating unpleasant physical ailments and in improving peace of mind. Only a marginal percentage endorsed a conviction to the contrary (Fig. 9). The majority of patients (87%) indicate a lowered psychical mood.

Fig. 9

Evaluation of the impact of nursing care upon the life quality in subjects in the terminal stage of the disease

In the last stage we attempted to answer the question whether there is a likelihood of the impact of support upon the emotional state of patients (Fig. 10).

Fig. 10

Evaluation of the psychical mood in subjects in the advanced stage of the disease

As may be inferred from the data collected in the Table 1, the types of support to have the most notable effect on all kinds of disorders include informational, emotional and appraisal support, which were those at the level p < 0.001. The percentage of people with anxiety and depression decreased as emotional support and appraisal support were provided. The statistical significance was shown to be at p > 0.001 between informational support and all kinds of disorders. Appraisal support was significant. A lower value of p < 0.05 was assumed between instrumental support and psychical state of those investigated. A statistically non-significant value was assumed between researched states and tangible support.

Table 1

The outcome of the statistical analysis of the impact of various types of support upon the emotional state of a patient in the terminal stage of disease

Type of support	Depression	Anxiety	Irritation
emotional	χ2 = 32.84	χ2 = 35.04	χ2 = 57.22
	df = 9	df = 9	df = 9
	p < 0.001	p < 0.001	p < 0.001
informational	χ2 = 28.22	χ2 = 33.51	χ2 = 90.99
	df = 9	df = 9	df = 9
	p < 0.001	p < 0.001	p < 0.001
instrumental	χ2 = 9.35	χ2 = 21.97	χ2 = 16.88
	df = 9	df = 9	df = 2
	p < 0.05	p < 0.05	p < 0.001
tangible	χ2 = 1.65	χ2 = 7.34	χ2 = 18.87
	df = 9	df = 9	df = 3
	p > 0.05	p > 0.05	p < 0.001
appraisal	χ2 = 46.09	χ2 = 27.12	χ2 = 76.89
	df = 6	df = 6	df = 9
	p < 0.001	p < 0.001	p < 0.001

It is for this reason that, having borne in mind the dissatisfaction of the patients with the level of informational support provided, greater pressure should be put on the conversation with the patient and responding to the patients’ queries in a clear, intelligible and anticipated manner.

Discussion

The fact of rescue and extension of life increases the number of people with chronic diseases, that determine many of the psychological stresses. Therefore modern medicine increasingly emphasises not only extension of patients’ life but also its quality. It creates the need to emphasise the appropriate psychosocial care, the purpose of which is to ensure the longest period of high quality before death. The most important is to provide medical care and emotional support to patients in the terminal stage of cancerous disease [10]. The needs of a patient in the terminal stage of cancerous disease are to be considered in tangible, emotional, social and spiritual terms [4]. The study presented here centres on the salience of the psychological dimension in the overall structure of the life quality in patients in the terminal stage of disease. According to K. de Walden-Gałuszko chronic disease gives rise to a number of emotional reactions. They predominantly comprise negative feelings such as anxiety, depression, anger, and melancholy [11]. Cancerous disease spurs variegated negative psychological responses to the predicament they are facing. The incidence of psychological disorders reaches over 60% of cases of patients in an advanced stage of cancerous disease [12]. Numerous different reasons may lead up to the development of unfavourable psychological conditions [13]. One consists in the diagnosis of cancerous disease and the concomitant lifestyle change, social role alteration, and concern with the future prosperity of the patient's family. Others concern the change in outside appearance, impairment of vital organ functions, the pain accompanying the disease as well as pharmacological therapy, diagnostic procedures performance and the prolonged hospitalization [14]. On the strength of the analysis of the heretofore gathered information it emerges that a decreased mood occurs in the majority of patients, irrespective of their age and disease duration. The negative outcome of the terminal stage of cancerous disease that takes the form of depression was observed in most subjects under study (76.2%). Similar effects were noted by Eleonora Mess et al. They reveal as many as 74% of patients to evince decreased mood and symptoms of depression and 92% to have been reluctant to come to terms with the disease and the consequent condition [15]. In the literature on the subject the findings diverge in respect of the size of the problem at hand, pointing to both small and large percentages. However, most authors point to percentages above 60% [11, 15–18].

In the advanced stage of cancerous disease depression may be accompanied by anxiety syndrome as an expression of the growing acuteness of the symptoms of the disease as well as the concerns over the patient's own life. According to Rogowicz the subject involved experiences emotions from distress, through anxiety, to terror [19]. Anxiety in the terminal stage of the disease stems from the prospective final analysis of one's life as well as the species survival instinct and the instinct for self-preservation that is associated with the feeling of terror [20]. Anxiety manifests itself on three planes – psychological, behavioural and vegetative-somatic. In psychological terms anxiety elicits tension, distress and the inability to relax. It may manifest through concentration disturbance or reduced intellectual capacities. Its behavioural expression consists in a range of symptoms from excitation to psycho-motor arrest. Immediate signs may include facial expression, timbre change as well as trembling of the hands.

Vegetative symptoms of anxiety involve the feeling of dryness in the mouth, excessive perspiration, heightened pulse and accelerated respiration, augmented arterial blood pressure, increased muscular tension, insomnia-related conditions as well as nightmares. Somatic effects may include abdominal pain, diarrhoea, and frequent urge to urinate. The research revealed anxiety states to occur in 58.7% of subjects enrolled in the study and borderline cases in 21.7%. Only a marginal percentage of 19.6% of the patients under investigation showed no distressing signs. Hopwood obtained slightly lower values with anxiety states present in 24% of patients and depression in 18%. In addition, he found anxiety to affect at least 1/3 of the families suffering from the terminal disease of immediate family members [21, 22].

Psychological support proves significant in the suppression of anxiety and depression in patients in the terminal stage [23]. Many authors point to the importance of support in care-giving [24-26]. The nurse is a companion and a guide in the hard process of merging own identity. The best method features conversation by virtue of which the origin of the anxiety that affects the subject may be traced back as well as various relaxation techniques aimed at removing tension and distress. The objective of the caregiver is to earn the patient's trust through constant charitable presence and patient listening to the patient's qualms. To cite de Walden-Galuszko's words, the fundamental method recommended in all states of emotional discomfort involves catharsis – a skilful encouragement towards ‘getting it off your chest’ or the method of ‘distraction’ – that is, diverting attention from the sorrowful feelings. In the available literature on the subject of psychological support such expressions may be encountered as ‘therapy through conversation’ [27]. Moreover, it is of vital importance to be ready to adjust to the dynamics of the patient's change of attitudes and reactions along with the observation of his/her behaviour and the readiness to bring comfort [28]. All mentioned procedures are targeted at securing the patient's feeling of safety, emotional calm and his/her preparation for the constant aggravation of their medical condition [29]. In the research as many as 71.7% of patients were found to be entirely satisfied with the emotional support provided by the nursing personnel. The statistical significance was shown to be at p < 0.001. The percentage of patients with anxiety and depression dropped in response to the emotional and appraisal support supplied. A strong statistical significance estimated at p > 0.001 was shown to hold for the interdependence of informational support and the above-mentioned syndromes. Appraisal support proved to be of considerable statistical significance as well. A less significant correlation of p < 0.05 was detected between instrumental support and the subjects’ psychological state. No statistical significance was found between the conditions in question and tangible support.

Irritation constitutes yet another symptom of cancerous disease. The analysis of research studies indicated that it affects 60.7% (60.1%) of subjects with a further 35.7% of patients manifesting borderline cases. In as few as 4.4% of respondents no such signs were observed. In this particular case all types of support proved to exert a beneficial influence on the psychological state of the patients. Irritation affected mostly those patients who were left alone. The said group of subjects complained about the brevity of time expended by the nursing care in showing support and that it falls below their expectations.

The replies to the questionnaire as furnished by the patients under study indicate that over half of the group examined (53.5%) hold nursing care in high regard and appreciate its favourable influence on their life quality. Authentic care for the patient has a beneficial effect – as the patients themselves confirm – on the patient's life quality. However, the results obtained are not satisfactory since the remainder of subjects see room for more nursing care in the health care giving process. The studies by other authors indicate that patients who receive support from a palliative care team obtain a much higher level of support as well as pain alleviation than patients who confine themselves to the services of the family physician and the community nurse [30, 31]. However, as Desmedt, Michel and Twycross state, most patients wish to die at home and avail themselves only of the assistance of the family physician and a community nurse with training in the field of palliative care [32, 33]. Currently, around the world the need to change care by adopting the integrated approach to identifying and responding to the psychosocial needs of patients in support is emphasised.

In conclusion: In more than half of subjects under investigation all three disorders were present, namely anxiety, depression and irritation. The patients highly rate the received instrumental and emotional support. Social support plays a key role in the terminal stage of cancerous disease. Milder psychological disorders were observed in subjects who received all kinds of support.