Anger: a common form of psychological distress ...

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many patients at the end of life (Cramer, 2000; ... ety regarding the end of life (Mystakidou et al, ..... Longing for ground in a ground(less) world: a qualitative.
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Anger: a common form of psychological distress among patients at the end of life Eileen O'Grady, Laura Dempsey, Carole Fabby

Abstract Psychological distress is common in palliative care patients and their families, and anger is a complex component of distress experienced by many patients at the end of life. Anger can be a form of tension release, as well as a coping mechanism for the patient and a way to disguise fear and anxiety.The interdisciplinary team are responsible for recognising psychological distress in patients, assessing their needs, and providing adequate psychological support. Although a certain level of psychological distress such as anger is expected in terminally ill patients owing to their situation, such responses may also be dysfunctional. This paper aims to highlight the challenges and complexities of adequately assessing and supporting palliative care patients who are presenting with psychological distress in the form of anger, in order to relieve their suffering and assist them in resolving their issues and improving their quality of life. Anger can be difficult to treat, and for some patients can be more distressing than some physical symptoms. Hence this paper also aims to offer anger management guidance to palliative care practitioners. Key words: Anger • Psychological distress • Communication 9 Collusion

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Eileen O'Grady is Staff Nurse, North West Hospice, Sligo, Ireland; Laura Dempsey is Lecturer, School of Nursing and Midwifery, National University of Ireland, Galway, Ireland; Carole Fabby is Clinical Nurse Manager, Galway Hospice, Ireland Correspondence to: Laura Dempsey [email protected]

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sychological distress can present in many ways, including anger, anxiety, fear, and denial (Block, 2006). Left unrecognised and untreated in a patient, it can amplify physical symptoms and have a negative effect on overall quality of life (QoL) (Burns et al, 2008). Cramer (2000) contends that patients may use aspects of psychological distress as a defence mechanism to protect themselves or their family. In this instance it is important that the communication of the interdisciplinary team is capable of building a therapeutic relationship with the patient and getting to the root of their distress (Ngo-Metzger et al, 2008). Avoidance in addressing the patient's psychological distress may lead to an unconstructive atmosphere between the patient, their family, and the interdisciplinary team (Thomas, 2003) and could potentially affect the formation of therapeutic relationships and care delivery.

Psychological distress is common in palliative care patients and their families, and anger is a complex component of distress experienced by many patients at the end of life (Cramer, 2000; Block, 2006). All palliative care patients require a comprehensive psychological, spiritual, and physical assessment, which enables a plan of care to be devised and aids collaboration with the patient and family (Block, 2006). Not only should this identify patients at higher risk of developing psychological distress, it should also allow every patient to receive the level of psychological support they require (Kelly et al, 2006). Palliative care also acknowledges the patient and family as a unit, and if the patient is suffering with psychological distress then the family may also be suffering (Strada and Breitbart, 2009). This paper aims to highlight the challenges and complexities of adequately assessing and supporting palliative care patients who are presenting with psychological distress in the form of anger, in order to relieve their suffering and assist them in resolving their issues and improving their QoL. Anger can be difficult to treat, and for some patients can be more distressing than some physical symptoms (Miller et al, 2005). Hence this paper also aims to offer anger management guidance to palliative care practitioners.

The experience of anger at tne end of life Although anger is seen as a common and justified reaction in palliative care patients, it often has a negative effect on a patient's QoL and their relationships with their family and the interdisciplinary team (Block, 2006; Philip et al, 2007). There has been minimal empirical research on palliative care patients who express anger due to their end-of-life situation; however, published studies that do exist such as Miller et al (2005) detail that patients may express anger toward themselves, their families, the interdisciplinary team, and their spirituality. International journal of Palliative Nursing 2012, Vol 18, No 12

Discussion

Anger can be a form of tension release as well as a coping mechanism for patients in palliative care and a way of disguising their fear and anxiety regarding the end of life (Mystakidou et al, 2008). Patients may feel unable to cope or come to terms with their terminal status and may express this through anger, often directed at health professionals (Beckstrand et al, 2009). Thomas (2003) posits that defensiveness from health professionals, although often a natural response, can only exacerbate the patient's anger and lead to avoidance of interaction between staff and patients. A more productive approach for health professionals is to listen to the patient and attempt to identify and understand the source of their anger (Zahaluk, 2004). Understanding the cause of a patient's anger is the first step to finding a solution (Haddad, 2004). If left unresolved, expressions of anger from the patient to others can have a huge impact not only on their QoL but also on the relationships they have with family and friends (Block, 2006).

Exploring the causes of patient anger As with all expressions of psychological distress, issues arise regarding how best to manage symptoms of anger and relieve patients from unnecessary suffering (Burns et al, 2008). Strada and Breitbart (2009) and Cramer (2000) suggest that some reasons for patients expressing anger can include feelings of loss, for example of independence, their role in the family, and of life itself. However, anger can also be seen as a consequence of a social and economic change, as patients expect a higher level of care and can use anger to place blame on medical staff for late diagnosis, poor prognosis, and insufficient care (Philip et al, 2007). Although the majority of the anger expressed by palliative care patients is seen as being justified and is short-lived, there are cases where the patient is angry owing to unrealistic expectations of the service provided to them (Breen and Greenberg, 2010). Zahaluk (2004) advocated that complaints policies should be made available to patients who wish to carry forward any issues they have with a service. In this instance quality documentation from the nurses is vital to their legal protection. However, it is also important that clinicians are able to admit mistakes and provide patients and families with sincere and genuine apologies (Breen and Greenberg, 2010). Another issue that should be explored with patients is their personal and previous experience of death, as this may be causing fear to be International journal of Palliative Nursing 2012, Vol 18, No 12

expressed through anger (Mystakidou et al, 2008). Patients with no previous experience of death may fear the unknown, whereas others may have had a negative experience of watching someone die. This can be a difficult subject to approach with a patient and so experienced staff should be involved, ensuring conversations about death and dying are approached at the patient's pace (Ngo-MetEger et al, 2008). Again, identifying the cause and providing patients with ways to discuss their anger lead to positive ways of dealing with their issues. An additional source of anger for patients and families is communication or, at times, a lack of communication from clinicians (Thomas, 2003). Patients and families require clear and concise information at each stage of their illness, especially when receiving bad news. The manner in which clinicians break bad news to patients can be detrimental to how the patient reacts (Vivian, 2006). Ngo-Metzger et al (2008) posit that ineffective communication of bad news can lead the patient to feel angry toward the clinician. When providing patients with information about their prognosis it is important to consider the ethical issues of giving and withholding information (Breen and Greenberg, 2010). Clinicians should promote patient autonomy but should also consider the principles of beneficence and non-maleficence.

^Although anger is seen as a common and justified reaction in palliative care patients, it often has a negative effect on a patient's quality of life and their relationships with their family and the interdisciplinary

team ...'

Collusion between the interdisciplinary team and families can be another source of anger for patients. As suggested by Vivian (2006), collusion should be avoided to ensure patients' wishes are respected. Health professionals working with palliative care patients require optimal communication skills and should be able to manage a situation in which the patient uses anger to express themselves, for example by helping them to find other ways of coping and encouraging relaxation (Ngo-Metzger et al, 2008).

Managing anger effectively When dealing with anger, both pharmacological and non-pharmacological interventions should be offered to the patient (Cramer, 2000). It should be remembered that allowing patients to express their anger can have a positive effect on them and assist their coping (Cramer, 2000). Philip et al (2007) developed a seven-step programme to assist health professionals in dealing with anger. The steps are preparation, listening to the patient, involving experienced clinicians, reconsidering approaches, acknowledging limits, supporting the team, and involving an independent advisor. Tools such as this are an invaluable asset for developing the clinician's ability to deal

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^Remaining calm when faced with patients or families expressing anger is an acquired skill that develops with time and exposure to such situations ...'

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with anger, with the aim of achieving positive outcomes for all involved. Enabling patients to talk openly and to feel they are being listened to without feeling judged provides holistic care and is a release for their emotions (Jones and Cutcliffe, 2009). Furthermore it may allow health professionals to understand the patient's reason for expressing anger and identify their needs. Time plays an important part in relieving patients' anger, as patients are more likely to feel they are being listened to if they are given uninterrupted time to talk about their feelings with health professionals (Kohr et al, 1998). Allowing such time may be more easily achieved in a hospice setting than a general ward setting owing to staffing levels (Breen and Greenberg, 2010). Family meetings are a useful tool for allowing uninterrupted time for patients and families to express their fears and concerns. Furthermore, they allow several disciplines to interact with patients and support each other in a safe environment (Kohr et al, 1998). Health professionals should also refrain from challenging a patient displaying anger as this has the potential to escalate the situation and may lead to further difficulty in resolving the problem and rebuilding rapport with the patient (Zahaluk, 2004). Although many patients may express their anger outwardly, e.g. by raising their voice, others express it passively (Burns et al, 2008). This can be even more difficult for health professionals to deal with (Cramer, 2000). Block (2006) advocates that palliative care clinicians remain professional and not take patients' anger personally. It is important to remember that patients facing the end of life do not always think or act in their usual manner owing to their traumatic situation. Although the health professional may find it difficult to care for the patient, they are still responsible for providing them with the highest level of care and should not decline to do so (Beckstrand et al, 2009). Unfortunately, health professionals can unconsciously disconnect from patients they find difficult and thereby not provide them with adequate care, instead providing only essential care (Smith and Hart, 1994). Another challenge for health professionals dealing with anger from patients or families is lack of experience or exposure to these situations. Breen and Greenberg (2010) suggest that junior staff should feel confident in involving senior and more experienced colleagues when caring for patients expressing anger. Senior staff might see anger as a positive emotion and assist the patient in redirecting that energy into other

positive emotions, whereas junior staff can feel vulnerable and intimidated (Smith and Hart, 1994). Experienced clinicians have the ability to respond accordingly to expressions of anger and have the skills to dissolve the situation through listening, understanding, and building relationships (Zahaluk, 2004). Remaining calm when faced with patients or families expressing anger is an acquired skill that develops with time and exposure to such situations (Breen and Greenberg, 2010). However, it is important that junior staff are involved and supported to develop confidence and competence for future situations. Reflecting on the situation with junior staff provides them with a learning opportunity and identifies areas that may have been dealt with differently (Thomas, 2003). Health professionals should also feel supported by management and colleagues through clinical supervision sessions implemented into practice (Beckstrand et al, 2009). Support for staff is critical for them to continue providing care for patients in difficult situations (Philip et al, 2007). Unfortunately, owing to staffing levels and time constraints, clinical supervision is not always a priority (Breen and Greenberg, 2010). An effective alternative to clinical supervision is clinical reflection within the team, which allows good team discussion of difficult cases and helps to support team members through self-assessment, facilitating the team to explore their individual and combined strengths and weaknesses (Racey, 2005). De-escalation techniques should also be used by health professionals dealing with patients expressing anger (Breen and Greenberg, 2010). Protocols should be in place at a local level to provide guidance to staff when dealing with difficult situations (National Institute for Health and Clinical Excellence. 2005). Health professionals should be aware of verbal and non-verbal responses they give to patients with feelings of anger, which may be a trigger if inappropriate (Thomas, 2003). These include eye contact, tone of voice, and body language. It is important that clinicians are aware of patients who may have predisposing factors that may influence their psychological reaction to a terminal illness, including psychiatric illnesses (Peteet et al, 2011). In this instance a psychiatric referral should be considered in order to meet the patient's psychological needs as part of providing holistic care (Kelly et al, 2006). Involvement of different professional disciplines, including social workers, counsellors, and psychologists, is advisable for patients who use anger to express their emotions (Beckstrand et al, 2009). Inlernational journal of Palliative Nursing 2012, Vol 18, No 12

Discussion

Another important aspect of care for patients expressing anger is spiritual care. This area should never be underestimated as often patients can express anger towards their spirituality, e.g. by asking 'Why is this happening to me?' or 'What have I done to deserve this?' (Bruce et al, 2011). A study by Miller et al (2005), who implemented an innovative group programme addressing spiritual, psychological, and relational aspects of living well at the end of life, reported that palliative care patients experienced fewer feelings of anger and anxiety on completion of the programme (Miller et al, 2005). Okon (2005) advocates that ensuring spirituality is explored with patients at an individual pace can help the patient express their feelings, including anger, and resolve issues that are leading to them feeling angry. However, it has been suggested that spiritual care can often be overlooked for palliative care patients, therefore patients are not receiving the holistic care they require (Miller et al, 2005). Gomplementary therapies, although not appealing to everyone, can offer a way of soothing both physical and psychological pain (Salmenperä et al, 2003). For example, aromatherapy has been found to have a positive effect on stress and anxiety levels of patients with metastatic cancer, which may reduce the likelihood of them expressing anger (Dunwoody et al, 2002). Greative activities such as art have the potential to increase relaxation levels, as well as providing non-verbal clues as to how the patient is feeling, and so should be offered to all patients (Devlin, 2006). Occupational therapists can also teach patients relaxation techniques through deep breathing exercises, massage, and music (Burns et al, 2008). Psychotherapy can also be of benefit to patients expressing anger, teaching them to divert their energy into more positive and productive emotions (Gramer, 2000). Unfortunately, complementary therapies are not widely available as part of palliative care services, and often patients are required to seek out these therapies themselves. This can be due to a lack of funding, a lack of time, and to the stigma that may be attached to the realistic benefits of complementary therapies (Salmenperä et al, 2003). However, many palliative care services are expanding to incorporate art, music, and relaxation techniques. Further services may also be available in connection with the palliative care services, and information leaflets on these should be provided for patients and families (Beckstrand et al, 2009). Nurses are ethically obliged to respect their patients and, although they may not agree with International journal of Palliative Nursing 2012, Vol 18, No 12

the anger the patient is expressing, it should not affect they care they deliver (Haddad, 2004). However, nurses also require respect from patients and families and should feel safe in their workplace (Thomas, 2003). Moreover, health professionals have an obligation to other patients and so, although it is important to assist the patient with their anger, it is also important to set boundaries to the patient's behaviour (Philip et al, 2007).

Conclusion To date, research regarding psychological distress in palliative care patients has helped to identify needs and provide support for patients and families fadng the end of life (Miller et al, 2005; Kelly et al, 2006). Further research is required, as the needs of patients and families are continuously changing. Research has been conducted on patients expressing anger in a psychiatric setting, but there is a dearth of research on palliative care patients who express anger owing to their endof-life situation. Kelly et al (2006) contend that additional research is required on how to deal with {>alliative patients who experience anger at the end of life in order to develop evidence-based guidelines at local and national level. Nurses need to support patients with anger and guide them through this difficult period (Kohr et al, 1998). On the whole, anger will be resolved once the patient is given time, continuity of care, and adequate clear information (Philip et al, 2007). Although often seen as a negative emotion, anger dealt with accordingly can assist patients in their journey and furthermore develop nurses' communication skills and ability to cope with difficult situations (Gramer, 2000). @J

*... anger dealt with accordingly can assist patients in their journey and furthermore develop nurses' communication skills and ability to cope

with difficult situations ...'

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