Inge B. Corless, PhD, RN, FAAN
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Well-being: Psychosocial Care
Introduction
• Psychological factors are
important facets of living and
dying
• Psychological factors may
influence outcomes of
physiological challenges
• Regardless of their impact on
survival, the presence or absence
of psychological factors have an
influence on quality of life
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Well-being: Psychosocial Care
Assumptions
• Psychosocial aspects of
care are critical to
enhancing a patient’s
quality of care at the end
of life
Mr. Williams
• Breaking bad news: patient and
family centered approach
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Well-being: Psychosocial Care
Related Terms
• Stressor: “Events that
•
have the capacity to
induce emotional
distress”
Stress: “The experience
of emotional distress”
• Nott’s model: How
stress may accelerate the
progression of HIV
Disease
Stressors
1
2
Maladaptive Functioning
2
Neuroendocrinological
3
Effects
4
Psychological
Effects
4
Immunological
Effects
Faster Progression in HIV Infection
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Well-being: Psychosocial Care
Psychological Effects
• The following have an
impact on psychological
well-being:
–
–
–
–
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Anxiety/fear
Depression
Loneliness
Suffering
Dependency/lack of
independence
– Decreased self-esteem/
self-respect
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– Guilt/anger
– Adjustment to the
disease/prognosis
– Satisfaction with care
– Despair
– Acceptance of Loss
– Denial/Acceptance
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Well-being: Psychosocial Care
Psychological Effects: Uncertainty
• Uncertainty:
– Will vary depending on the
phase of the illness trajectory
• Course of illness falls into
three phases
– Acute adjustment (around
diagnosis)
– Period of chronic illness
– Terminal phases (death is in
sight)
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(Forstein)
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Well-being: Psychosocial Care
Psychological Well-being
• Psychological Well-being:
(Ferrell, 1989):
– Seeking a sense of control in the
face of life-threatening illness.
• To promote psychological wellbeing, ask these three questions
(Scanlon, 1989):
– “What do they worry about?”
– “How do they cope?”
– “How can nurses help?”
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Well-being: Psychosocial Care
Case Example: Mr. Rosena
• Mr. Rosena’s story and your connection:
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–
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He is told by you that his cancer is progressing.
You learn that Mr. Rosena is afraid of pain more than death.
You reassure him that you’re committed to relieving any pain
You assess him frequently for pain / Offer round-the-clock pain service
• Positive result based on visit:
– A major concern is alleviated for Mr. Rosena.
Wong-Baker FACES Pain Rating Scale
NO HURT
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HURTS
LITTLE BIT
HURTS
LITTLE MORE
HURTS
EVEN MORE
HURTS
WHOLE LOT
HURTS
WORST
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Well-being: Psychosocial Care
What Do Patients Worry About?
• According to Scanlon patients
worry about:
– Further debilitation and dependency
– Pain and suffering
– Consequences for dependents and arranging
affairs
– An uncertain future
– Lingering
– Dying alone
– Loss of control
– Changing relationships
– Existential concerns
– Change in mental functioning
– Afterlife
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Well-being: Psychosocial Care
Coping with Far-Advanced Disease
• Approaches to coping can be
adaptive or maladaptive.
• Responses frequently observed
include:
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Denial
Fear
Anxiety
Depression
Withdrawal
Acceptance
Resignation
Anger
Mrs. Gregory
• Mrs. Gregory: “I’ll sign this
Power of Attorney thing, but
then I won’t discuss it any
more.”
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Well-being: Psychosocial Care
Denial
• Denial can be beneficial in the short term if
patient sustains integrity and personal freedom
• Negative aspect to denial:
– May interfere with the terminally ill person getting
his or her affairs in order.
• Under such circumstances, it will be
useful to work with the patient
along these lines:
– “What if you were not going to recover,
what would you need to do?”
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Well-being: Psychosocial Care
Case Example: Mrs. Gregory
• Mrs. Gregory is a 62-year-old woman who has
been a patient for many years at the office where
you work as a nurse. The past few months, she has
been complaining of increasing upper abdominal
pain and weight loss.
Mrs. Gregory
• Mrs. Gregory and her daughter, Gloria, react
to the bad news of her diagnosis.
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Well-being: Psychosocial Care
Fear & Anxiety
• Fear: The response to a perceived danger.
• Anxiety: A non-specific response.
• Other Aspects:
– Terminally ill persons may experience both of these
responses.
– Treat both fear and anxiety by exploring concerns of the
patient.
– A major concern: Being in pain without appropriate
medication (fear of suffering more than death)
– Children fear being alone, as well as pain. Children
blame themselves and feel guilty for disruption.
– Health care provider should meet with the patient, family,
and other team members to discuss the plan of care.
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Well-being: Psychosocial Care
Depression & Withdrawal
• Depression is the most frequently observed symptom in the
terminally ill
– Observed in 77% of persons with far-advanced cancer
• Suggested questions to assess depression:
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–
–
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“Can you describe your mood for me?”
“How long have you felt this way?”
“What is the feeling of depression like for you?”
“Have you noticed changes in your level of interest in
normal activities?”
– “How would you rate your feeling of depression on a 1-to-10 scale?”
• Suggested questions to ask children:
– Are you lonesome?
– What makes you feel sad?
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(Isaacs, 1998)
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Well-being: Psychosocial Care
Acceptance, Resignation &
Transcendence
• Acceptance:
– “Acknowledging the inevitable finality of human life,
though not necessarily liking it. For dying patients it is
a resignation with a quality of sadness.”
(Scanlon, 1989)
• The polar extremes of acceptance: Resignation and
transcendence:
– Resignation:
• The individual experiences a sense of hopelessness
to a situation that cannot be changed.
– Transcendence:
• Indicates acknowledging the situation, but rising
above it to achieve an integration on a higher level.
Transcendence integrates the psychosocial with the
spiritual aspects for the terminally ill person.
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Well-being: Psychosocial Care
Anger
• Anger:
– “Anger is a healthy and understandable response to
numerous and immeasurable losses: the loss of a future,
unfulfilled promises, shattered dreams, and ended
relationships.”
• Anger is healthy
– Expressing anger may be difficult for family members
and professional caregivers to accept.
– Reason for anger must be clear to family and caregivers
– Failure to convey reasons for anger isolates the
terminally ill.
• A positive nursing response: Demonstrate
respect and empathy.
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Well-being: Psychosocial Care
Summary of Psychological Care
• “Psychological care is analytic in nature.” (Grey)
• The purpose of psychological care:
– To help the patient attain a greater depth of understanding of him or
herself and his or her situation.
• Listening and probing:
– Understanding the patient’s world as she or he perceives it.
– Enables the nurse to explore possibilities that are in keeping with the
patient’s view of the world (even with children as young as 3 years old).
• Presence
– Bearing witness is helpful to the patient and family as they traverse this
difficult time in their lives. It is a role that is intrinsic to nursing.
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