9. Managing Chronic & Terminal Illness

Question 1

9 Health Tips?

Answer 1

1. Blame will get you nowhere.
2. Your perception of your health is more important than your BP.
3. Support groups fight cancer, too.
4. Care for those who care for others.

Question 2

Chronic Conditions in Canada?
* Hypertension: 25%
* Osteoarthritis: 14%
* Mood / Anxiety Disorders: 13%
* Osteoporosis: 12%
* Diabetes: 11%
* Asthma: 11%
* COPD: 10%
* Ischemic Heart Disease: 8%
* Cancer: 8%
* Dementia: 7%

Answer 2

44% of adults (20+) have at least 1 of 10 common chronic conditions. (60% if we consider ALL chrinoic conditions)

Most of us are likely to develop at least one chronic condition that may lead to our death.

Chronic conditions account for 2/3 of Canada’s health spending

Chronic conditions are more common among lower-income Canadians, women, and seniors
-> Not inherent aspect of agining becuse they are largely determined by socioecomic facotrs which can be overcome

Question 3

What unique psychological / social challenges arise when the diagnosis is terminal?

/

And how do people adapt to the prospect of dying?

Answer 3

There is a huge different psychologically between these two. Certain things become worse as you have less time.

The psychological and social challenges people are confronted with differ.

Question 4

Adjusting to Chronic Illness, 3 main topics?

Answer 4

Coping, Adaptation, and Psychosocial Interventions

Question 5

Adjusting to Chronic Illness - Immediately after a chronic disease is diagnosed?

Answer 5

Patients are often in a state of crisis or shock -> an acute stress reaction.
- Stunned, bewildered, and behaving in an automatic & detached way.
-> not sustained over long-term

Question 6

Adjusting to Chronic Illness - Feeling Involved in The Initial Response?

Answer 6

Anxiety (nervousness, worry) and anger(“Why did this happen to me?” frustration, irritability, hostility) are also common.

Sense of control is lowered; secondary appraisal is common (especially in regards to social resources)
- The degree of social support can vary for the individual, a lot of people have no one to help them.
- A diagnosis can further isolate those who are already isolated.

Engage in more emotion-focused coping early on.

Denial: Inability to recognize, accept, or deal; plays mixed.
- Can be healthy early on, but becomes problematic long-term -> not consistent across all situations.

Question 7

Crisis Theory - Overlook? (one sentence)

Answer 7

Describes factors that influence how people
adjust/cope after first learning they have a chronic illness.

Question 8

Crisis Theory - Breakdown?

Answer 8

• Illness-related factors (difficultues walking)
• Background, personal factors (SOS, family history)
• Physical/social environments (School teaching, stigma)

->
Coping Process
- Appraisal of the diagnosis (determines how we cope with it)
- Adaptive Tasks (specific problems that have to be overcome)
- Coping Skills

->
Outcome of Crisis
- Adjustment

Question 9

Adaptive Tasks in Coping
People who are ill must address 2 types of adaptive tasks?

Answer 9

1. Tasks related to the illness or treatment.
   - Coping with the symptoms or disability of illness.
   - Adjusting to hospital environment, procedures, treatments (chemo-side effects).
   - Developing good relationships with practitioners.
2. Tasks related to general psychosocial functioning.
   - Controlling negative feelings, having positive outlook.
   - Maintaining satisfactory self‐image, sense of competence (body image, losing hair/gaining weight, amputations).
   - Preserving good relationships with family/friends.
   - Preparing for an uncertain future.

Question 10

Coping with Cancer over Time

Dunkel Schetter et al. (1992) Asked cancer patients to indicate the coping strategies they found most useful…? (5)

Answer 10

1. Social support/direct problem solving
   (“Talked with someone to find out more about the illness/situation”)
2. Distancing
   (“I didn’t let it get to me”)
3. Positive focus
   (“I learned something from this experince”)
4. Cognitive escape/avoidance
   (“I wished that the situation would go away”)
5. Behavioural escape/avoidance
   (e.g., eating, drinking, sleeping, etc.)

Question 11

Which coping strategies tend to be maladaptive over time?
1. 2. 3. Leads to…

Answer 11

Rumination:
Associated with exacerbation of symptoms.

Interpersonal withdrawal:
Associated with loneliness and low relationship satisfaction.

Avoidant coping (e.g., denial):
Associated with increased psychological distress and can exacerbate the disease process; leads to poor adjustment to illness. -> How?
- Not seeking care, following up on treatment plan, poor management of the disease

Question 12

Denial in Cancer Patients

In a review of research on denial in cancer patients…
* Denial of diagnosis ranged in 4 to 47% of patients.
* Denial of impact (outcomes) occurred in 8 to 70% of patients.
* Denial of emotions occurred in 18 to 42% of patients.

Answer 12

The impacts on physical and social functioning were inconsistent; the impact on psychological functioning depended on the form of denial.

Distractive strategies were found to reduce distress, whereas passive escape mechanisms turned out to decrease psychological well-being (maladaptive).

Question 13

Depression?
May delayed as patients…
The avarege person’s depression…

Answer 13

Depression: Feelings of sadness, despair, helplessness, hopelessness.

May be delayed as patients try to understand implications of condition; physically debilitating; direct impact on symptoms.
- The more people realize the nature of their diagnosis, more likely to feel helplessness -> lead to depression

The averge person deppression increases, over the long-term it oftem improves, but it varies. Long-term we see a negative emotional impact.

Question 14

How can depression complicate medical?

Answer 14

Overall asseesment, it is difficult to seperate the sympoms of the depression from the disease. Example, Fatigue

History of depression is associated with poorer adjustment to cancer and other chronic illnesses.

Question 15

Can depression impact cancer survivability?

Giese Davis et al. (2011, Journal of Clinical Oncology
Followed 101 women with metastatic breast cancer for 1 year.
* Monitored depression over the course of year; measured 3 X using Center for Epidemiology Studies Depression Scale (CES D), a leading measure of depression.
* Controlled for demographic & medical factors.

Answer 15

“Median survival time was 53.6 months for women with decreasing CES D scores over 1 year and 25.1 months for women with increasing CES D scores.”

Those who experienced decreasing depression in that one year, lived longer compared to those who experienced increases in depression.

Mental health may not save people from the diagnosis, but it can add years of survival.

Question 16

Social Challenges in Cancer
Cancer patients can experience challenges in relationships. Why?

Answer 16

Patients may have difficulty seeing family/friends due to illness or treatment. They may also feel socially awkward or embarrassed about their condition. Not wanting to be pitied or seen as weak.

Other people may begin to avoid the patient due to feelings of vulnerability. They may also worry they’ll say the wrong thing or break down emotionally.

Stigma (either imposed or internalized) also affects relationships.

Question 17

What are some ways that stigma can arise with cancer?

Answer 17

Contemporary literature suggests that cancer stigma depends on the extent to which an individual’s identity and sense of self are affected by the diagnosis.

Perceived controllability and visibility of cancer, and whether it interferes with daily functioning, are also main factors in cancer stigma.

Question 18

Effects of Cancer Stigma?

Answer 18

In people with cancer, stigma is associated with more problematic outcomes, e.g., depression.

Is there an impact on cancer screening?
Yes. In a community sample of adults, cancer stigma was correlated with reduced cancer screening for cervical, breast, and colorectal cancer.

Question 19

Adaptation, defintion?

Answer 19

The process of making changes in order to adjust constructively to life’s circumstances.

Question 20

As the focus of coping moves from the crisis stage to dealing with more permanent changes, successful adjustment to chronic conditions involves…?

Answer 20

…several major adaptive tasks that continue
indefinitely.

Including mastery of demands directly related to ongoing management of the disease, minimizing physical limitations and disability and preserving as much positive functioning as possible.

Question 21

Long-term cancer survivors have higher rates of…?

Answer 21

emotional distress, especially those of lower SES and those who are single and disabled.

Social relationships are impacted, especially for couples.

But most cancer patients display a remarkable amount of resilience.

Question 22

Evaluating Adjustment - Quality of Life (QoL)?

Answer 22

The degree of excellence people appraise their lives to contain.

Based on physical, psychological, vocational, and social functioning; includes disease or treatment-related symptoms.

Emphasis is placed on daily living

An important indicator of recovery from/adjustment to chronic illness.

Question 23

Evaluating Quality of Life?
An important aspect of quality of life is a person’s perceptions of their own health….

Answer 23

Can predict with great accuracy morbidity and mortality.

Health questionnaires/surveys with Likert response scales.
e.g., Would you rate your current health as…
(1) very poor, (2) poor, (3) fair, (4) good, or (5) excellent?

In research, we would refer to this as
self-reported/self-rated health (SRH) or subjective health.

Question 24

Medical Outcomes Short Form Health Survey (SF 36)

Answer 24

Test many different Health Concepts

Question 25

Is subjective health consistent with objective health?

Answer 25

YES: SRH is associated with prevalence of all diseases, onset of all diseases, and laboratory parameters of health.

One exception: Some studies have found a lack of association with cancer.
- Due to random chance, not always health behiours.

Question 26

Is subjective health predictive of mortality?

Answer 26

YES: SRH significantly predicts mortality in longitudinal research, often more than objective indices of physical health such as blood pressure etc.

Question 27

AND the predictive validity of self
reported health has increased
over time!

Answer 27

People are more accurate at assessing their own health.

• The public is becoming more sophisticated as assessing their own health.

Question 28

Satisfaction with Life Scale?

Answer 28

Indicate your agreement with each item using a scale of 1
(strongly disagree) to 7 (strongly
1. In most ways, my life is close to ideal.
2. The conditions of my life are excellent.
3. I am satisfied with my life.
4. So far, I have gotten the important things I want in life.
5. If I could live my life over, I would change almost nothing.

Question 29

Is life satisfaction predictive of morbidity?

Answer 29

YES: There is also a significant association between life satisfaction and onset of many chronic diseases (e.g., Feller et al., 2013).

• Not as reliable across conditions as self-reported health.

Question 30

Is life satisfaction predictive of mortality?

Answer 30

YES: Life satisfaction scores predict mortality.

• Not as reliable across conditions as self-reported health.

Question 31

Why is self-assessment of health more predictable than physical measurements?

And what mechanisms may be involved?

Answer 31

• People are better at taking into consideration multiple factors.
• People may be more optimistic of their health, so they engage in more health behaviours over time.
• People who are happier, live longer and healthier lives -> stay engage with good health habits,