Session 8 Flashcards
(19 cards)
Describe Diversity in Dying
[*] England and Wales 2010 there were 49342 deaths, around 1350 per day (highest in the winter)
[*] Less experience of the realities of death in modern society due to
- Fewer people die at home
- Medicalisation of death (Illich 1990) (at time of death, common to experience symtpoms and receive medical attention)
[*] Death rates are falling in England and Wales as improvements in diet and medical advances lead to people living longer. Death rate of men fell by 22% in the last decade and by 18% for women.
[*] Diversity in death: Gender
- Women on average live longer
- UK life expectancy at birth (2009-2011)
Men 78.7
Women 82.6
[*] Diversity in death: Age
- Death rates highest in older age groups (2010: 67% of deaths were people aged 75+)
- But people can die at any age
- Death of child/young person can be particularly difficult to cope with
[*] Diversity in death: Socioeconomic differences
- Less wealthy on average experience poorer health and die sooner.
- Geographic inequalities (Glasgow City has lowest life expectancy in the UK)
What are the patterns of dying?
[*] 3 main patterns of dying (Clark & Seymour 1999)
- Gradual death with a slow decline in ability and health e.g. terminal cancer etc, can plan for end of life
- Catastrophic death through sudden and unexpected events
- Premature death in children and young adults through accidents or illness
But each death is different even when same underlying cause (e.g. heart failure, Gott et al 2007)
[*] NB: people are living longer but in poorer health and with poorer quality of life, particularly at end of life. We have a growing population of elderly with multiple health problems.
Describe the 5 stage grief model of adjusting to the idea of dying (Kubler-Ross 1969)
[*] Initial reactions to news of terminal illness
- Most people experience shock, numbness, disbelief and confusion
- Can be hard to take in what’s been said – difficult to come to terms with what has happened
[*] 5 Stages:
[*] Denial
It’s not true
It can’t be happening to me
Refusal to discuss illness/the future
[*] Anger
- Why me?
- Who is to blame? The doctors don’t know what they are doing! It’s their fault for not being to offer treatment or cure!
- Search for alternatives? Alternative medicine/research on internet/second opinion
[*] Bargaining
- I’ll go to church everyday if I can just live to see my grandchild
[*] Depression
- What’s the point? I can’t fight any longer
[*] Acceptance
- It’ll be OK
- I’m ready to make funeral arrangements – they accept their own mortality, that it’s inevitable and therefore can plan for their death.
Explain the potential positive and negative implications of denial, in coming to terms with a diagnosis of terminal illness
[*] Can be a coping mechanism
[*] Respect desire ‘not to know’
[*] Offer written information for patient to look at with family
[*] Denial can be barrier to good care
[*] Check and review over time – ‘when ready’
What is bereavement associated with?
[*] Loss, grief and mourning
[*] Grief:
- A set of psychological and physical reactions to bereavement
- A normal reaction to overwhelming loss, albeit a reaction in which normal functioning no longer holds – Parkes & Weiss (1983)
[*] Mourning
- Process of adapting to loss
- Role of funeral rituals (helps people see grief is normal, opportunity to celebrate person’s life, mark transition between now and the future)
What is the grieving process?
[*] The grieving process (Engel 1962)
- Disbelief and shock in early stages
- Developing awareness
- Resolution (acceptance; people are able to move on)
[*] Each person experiences stages differently
- But reassuring for people to know that grief passes through various stages and for most people grief will lessen and end
- Common elements e.g. anger, blame, guilt
Describe the symptoms of bereavement
[*] Bereavement is associated with stress, increased risk of illness and mortality (particularly older people who lose their spouse – loss of social support which is important for longevity)
[*] Symptoms of bereavement: it’s often reassuring for people to know these symptoms are common
- Physical e.g. shortness of breath and palpitations; fatigue; digestive symptoms; reduced immune function
- Behavioural: e.g. insomnia, irritability, crying, social withdrawal
- Emotional: e.g. depression, anxiety, anger, guilt, loneliness
- Cognitive: e.g. lack of concentration, memory loss, preoccupation, hopelessness, disturbance of identity, visual and auditory hallucinations
[*] Psychological interventions little help for grief except in high risk people – “there is no way round grief, only a way through” – Collick (1986)
[*] Within 2 years
- 85% adjusted to bereavement and experiencing minimal grief – sometimes they will have setbacks e.g. on birthdays or anniversaries.
- 15% experiencing chronic grief: anxiety, depression, PTSD
Identify the risk factors for chronic grief following bereavement
[*] Risk factors for poor outcome of bereavement (Sheldon 1998)
- Prior bereavements, mental health
- Type of loss (young person, nature of death (e.g. suicide, sudden), caring status e.g. mother or father)
- Lack of social support, stress from other crises
[*] Factors that lead to complications in grief process (Parkes & Weiss 1983)
- Expression of grief discouraged (people who feel they have to stay strong for others)
- Ending of grief discouraged (people feel guilty about moving on, starting new relationships)
Describe the aims of palliative care
[*] Most people die in hospital despite wanting to die at home
[*] Relatives often feel unable to provide home care – lack of support and advice, concerns about pain management
[*] Aims of palliative care
- Improve quality of life
- Manage emotional and physical symptoms
- Support patients to live productively in good health, avoid medicalization (intervention) of death
- Give patients some control
[*] Hospices provide palliative care, maximising quality of life and symptom control but there is bias towards patients with cancer (due to well known disease trajectory) – only 10% non-cancer
[*] Liverpool Care Pathway: end of life care pathway used in hospital with the aims of palliative care
Discuss reflecting on death of a patient
- Death should never be routine but more likely to seriously impact on health professional when patient is well known (Redinbaugh et al 2003), or is like us or like someone we are close to
- Feelings: failure, sadness, guilt, anger, reminder of mortality or own personal loss, right to express emotions when you are the doctor? Risk of burnout.
- Coping – need to protect yourself but important not to lose empathy
- Death not always a ‘defeat’
- Acknowledge loss with relatives, talk to colleagues/family
Describe the sexual response cycle and give examples of dysfunctions that can arise at each stage
[*] Sexual dysfunctions are characterised by a disturbance in sexual desire and in the psychophysiological changes that characterise the sexual response cycle and cause marked distress and interpersonal difficulty.
3 Stages:
[*] Desire
- Lack or loss of sexual desire e.g. de to PTSD, post childbirth.
- Excessive sexual desire – addiction (internet pornography etc)
[*] Arousal (increased blood pressure, increased respiratory rate)
- Erectile disorder in men
- Sexual disorder in women
[*] Organism (once arousal has reached peak intensity)
- Rapid ejaculation or inhibited orgasm (absent or takes a very long time) in men
- Orgasmic dysfunction in women (can be hyper or hypo, including permanent arousal)
Sexual aversion and lack of sexual enjoyment (can occur in both sexes) e.g. due to previous life events
Dyspareunia (painful during or after sexual intercourse, more common in women)
Vaginismus (in women – muscles around the vagina suddenly and painfully contract (tighten) upon penetration). Primary vaginismus = never been penetrated, secondary is after trauma, infection, childbirth etc
Give examples of the factors that can lead to sexual problems
[*] Problems occur irrespective of sexual orientation
[*] More than one problem can co-exist in the same individual e.g. vaginismus and loss of libido, rapid ejaculation and erectile failure
[*] Problems are often present in both partners e.g. vaginismus and erectile failure
[*] Problems may be lifelong or acquired
[*] Problems may be generalised or situational
[*] Problems may be due to physical and/or psychological difficulties
[*] Prevalence (NB: no current definitive data available)
A survey of 1512 GP attendees in London found that 40% of women and 22% of men received at least one diagnosis of sexual dysfunction – (Nazareth et al 2003 – these figures are likely to be a significant underestimate)
Describe how sexual problems may present and referral pathways
[*] Sexual problems may present overtly or covertly e.g.
- Repeated negative investigations for pain or discharge
- Never being happy with any offered method of contraception
- Reluctance to raise a sexual problem
- Increased individuals seeking help
[*] Referral Pathways
- GUM (Genitourinary Medicine)
- Gynaecology units
- Ante or postnatal services
- Family planning services
- Urology
- Oncology
- Psychiatry
- Pelvic pain clinic
- Voluntary sector
Points to consider when discussing sexual issues with a patient
- Empathy and reassurance
- Embarassment
- Stigma
- Privacy and confidentiality
- Open and specific questions
- Avoid labels and value judgements – do not make assumptions
- Terminology
- Religious and cultural issues
- Interview partner (if there is one)
- It gets easier with practice
Structural Clincial Interview for Sexual Health Problems
- Detailed description of the problem, its onset and progression. Include behavioural, affective and cognitive functioning
- Relationship with partner
- Relevant past relationships
- Medical history and drug use
- Mental health history
- Family and psychosexual history
- Significant life events
- Sexuality
- Cultural aspects
- Coping mechanisms and support networks
Why do people have sexual health problems?
Precipitating factors
- Physical e.g. after childbirth, operations, random failure incident
- Psychological e.g. mood, stress
- Life events
- Partner’s problems
Perpetuating factors (Self) (What keeps the sexual dysfunction going)
- Loss of confidence
- Spectating – feel like they’re outside their body and watching it “Am I doing it right?”
- Guilt and shame
- Anger and frustration
Predisposing factors
- False beliefs and concepts
- Unrealistic expectations
- Poor communication skills
- Physical vulnerability
- Early sexual trauma
Perpetuating factors (partner)
- Breakdown communication
- Pressure to perform
- Criticism and hostility
- Guilt and self blame
Sexual dysfunction is rarely caused by a single factor. Consider the relative physical and psychological contributions to a particular case.
Describe the main components of psychosexual therapy
[*] Treatment: traditionally sexual problems were viewed as manifestations of deep-seated psychological problems, treated with long-term individual psychotherapy/psychoanalysis.
[*] Main components of Psychosexual Therapy
- Educative counselling: individual/couple
- Modification of attitudes/ beliefs
- Facilitation of communication/assertiveness
- Helps build up trust between couples
- Specific directions for sexual behaviour – sensate focus/ dilator therapy / stop-start
- Sensate focus: patient learns where and how they like to be touched and in which situation “being in the moment”
- Dilator therapy: desensitization therapy used for vaginismus, teach them how to relax
- Stop start: desensitization therapy for premature ejaculation
Describe physical treatments for men
- Oral therapy e.g. Viagra, Cialis, testosterone, SSRIs – all used for premature ejaculation
- Local therapy e.g. EMLA cream – to decrease sensitivity
- Self injection therapy – used to inject base of penis => increase duration of erection
- Mechanical therapy e.g. pumps, rings
- Surgery e.g. penile implant
[*] An integrated approach incorporating physical and psychological treatments is likely to be more beneficial than a single approach.
Describe physical treatments for women
- Testosterone – used in post menopausal women with desire problems
- Lubricants
- Oestrogen (oestrogen deficiency affects response)
- Clitoral Therapy Device (EROS) - increases blood supply
- Zestra gel – increases pleasure
[*] An integrated approach incorporating physical and psychological treatments is likely to be more beneficial than a single approach.
