How does death vary by age, gender and socioeconomic status?
Highest deah rates in older groups
67% of death in 75+
Women on average live about 5 years longer
Less wealthy experience greater disease and earlier death
What are the 3 main patterns of dying?
Slow decline due to progressive disease
Death due to a sudden and unexpected event
Death in children and young adults due to accidents or illness
What is the typical initial reaction to news that you have a terminal illness?
Shock, numbness, disbelief and confusion
Hard to take in what is said
What are Kubler and Ross's stages of grief?
Give a brief description of each
"It's not true/Can't be happening to me"
Refusal to discuss illness/future
"Why me!" - Anger at illness
"The doctors are to blame!" - Anger at others
Search for alternative treatment?
"I'll go to church every day!" - Bargaining with god
"I'll do anything if you enter me into this clinicl trial" - Bargaining with doctors
Depression and hopelessness arise
Could be in response to reality finally sinking in
Patient accepts condition and plans for the future/moves on with the rest of their life
How must doctors respond to those in the Denial phase of grief?
Can be a coping mechanism
Must respect desire "Not to know"
Offer written information for patient to look at with family
Denial may be a barrier to care, make sure to review at a later time 'when ready'
A set of psychological and physical rections to bereavement
A normal reaction of overwhelming loss in which normal functioning ceases
Process of adapting to loss
E.g. Funeral rituals
Describe the grieving process
Disbeleif and shock
Everyone experiences this differently
Reassuring to know it is a normal thing and will pass
Common elements include Anger and blaming others
What are the effects of bereavement?
Particularly loss of spouse may increase risk of illness and mortality
Physical symptoms (SOB, palpitations, GI dysfunction, reduced immune function)
Behavioural symptoms (Insomnia, irritability, withdrawal)
Emotional symptoms (Depression, anxiety, anger, guilt)
Cognitive symptoms (Lack of concentration, memory loss, preoccupation, hopelessness, hallucinations)
Describe the resolution of grief
85% adjust to bereavement and experience minimal grief after 2 yrs
15% experience Chronic grief, Anxiety, depression, PTSD after 2 years
What are the risk factors for chronic grief?
Poor mental health
Type of loss (young person, nature of death, caring status)
Lack of social support, stress from other sources
Expression of grief discouraged
Ending of grief discouraged
How is medical practice often inconsistent with patient wishes regarding death?
Most people want to die at home, but instead die in hospitals
56% to 67% express wnating to die at home, but only 35% die at home or in a care home
Relatives are often unable to provide home care as they ack support and advice
What are the aims of palliative care?
Improve quality of life
Manage emotional and physical symptoms
Support patients to live productively
Give patients some control
How do physicians react to death?
How is coping with death best achieved by a physician?
Can have a serious impact:
- Feelings of failure, guilt, sadness, anger, reminder of mortality
- Risk of burnout
- Unsure how to express emotions
- Death not always a defeat
- Aknowledge loss with relatives, talk to colleagues/family
What are the stges of the sexual response cycle?
What are the sexual dysfunctions affecting men, women and both?
Lack/loss of sexual desire
Sexual aversion or lack of enjoyment
Dyspareunia (pain upon sexual intercourse)
Sexual arousal disorder
Vaginismus (tightening of outer vaginal muscles upon attempt to penetrate)
How does sexual dysfunction vary across individuals, couples and time/situation and cause?
Problems occur regardless of orientation
More than one problem can present in one person
Couples often both experience sexual dysfunction
Problems may be lifelong or acquired
May be generalised or situational
Due to physical or psychological difficulties
What are the overall prevalances of sexual dysfunction in men and women?
Men - 22%
Women - 40%
Likely to be underestimates
How does sexual dysfunction present?
Patient is direct about the problem
Patient only hints at dysfunction through speech or behaviour
E.g. Repeated negative investigations for pain or dyscharge or never being happy with offered methods of contraception
Stems from reluctance to raise the issue
Where might you refer a patient presenting with sexual dysfunction?
Ante or Post natal services
Pelvic pain clinic
What must be considered when discussing sexual issue with a patient?
Empathy and reassurance must be priority
Awareness of potential for embarrassment
Empathy for stigma and reassurance that it's ok to talk about
Privacy and confidentiality
Open and specific questions
Avoid labels and judgements
Terminology must be correct/understandable by all
Religious and cultural issues
Interview of partner (ask if you can)
What are the features of a structured clinical interview for sexual problems?
Detailed description of behavioural, cognitive and affective functioning
Relationship with partner
Releavant past relationships
Medical history and drug use
Mental health history
Family and psychosexual history (Repression, no intimacy as child)
Significant life events (Rape, sexual abuse)
Coping mechanisms and support networks
Why do people have sexual problems?
Cycle of failure and faer of failure enforcing further failure and problems
Predisposing factors to sexual 'failure':
False beliefs and concepts
Early sexual trauma
Precipitating factors for sexual 'failure':
Perpetuating factors (self):
Loss of confidence
Spectating (Hyper-selfconcious during sex)
Guilt and shame
Perpetuating factors (Partner):
Breakdown of communication
Pressure to perform
Critisism and blame
Guilt and self blame
Overall, Rarely a single factor
How were sexual problems historically viewed/treated?
Traditionally viewed as manifestations of deep seated psychological problems
Treated with long term psychotherapy
Masters & Johnson (1970s):
Introduced a behavioural approach to treatment focusing on immediate causes of dysfunction with short term target directed therapy
Basic assumption was that attitudes, ignorance and anxiety cause most sexual problems
What are the current main componenets of treatment of sexual dysfunction?
Educative counselling (Individual, couples)
Modification of attitudes/beliefs
Facilitation of communication/assertiveness
Specific directions for behaiour:
- Sensate focus - Focus on sensations not self
- Dilator therapy - Vaginismus
- Stop start - Erectile dysfunction
What physical treatments are available for males?
Oral therapy (Viagra, Cialis for ED)
Local therapy (EMLA cream)
Self injection therapy
Mechanical therapy (Pumps, rings to achieve erection)
Surgery (E.g. Inflatable penile implants)
What physical treatments for sexual dysfunction are available to women?
Testoserone (sexual drive increase)
Clitoral therapy device (increase arousal)
Zestra gel (improve sensation)