How to deal with an apathetic patient who does not know how to cope with his current illness. Using a centripetal approach, the physician works with family dynamics collectively building patient's emotional and physical recovery.
(Fictional narrative by the doctor)
James Fleck, MD, PhD: Anticancerweb 21 (12), 2022
It was eleven o'clock on a Sunday night and a lady called me on my cell phone. She apologized for the inconvenience but said it was urgent. Her name was Heloise and she was very distressed. Her husband, Arthur, 71, was in deep depression. Two days ago, he had stopped communicating. He locked himself in his room, didn't eat and barely answered questions. She told me that Arthur had rectal bleeding last month and that two weeks ago a colonoscopy would have diagnosed a malignant tumor. She spoke to the doctor and insisted that nothing should be immediately reported to Arthur, given his current frail condition. The doctor was a gastroenterologist, who apparently agreed to keep the arrangement confidential, but would reassess the situation at Arthur's next appointment. Arthur had not asked about the result of the exam, showing progressive disinterest in life. He slowed down the pace of work. He spent most of his time sitting or lying down, watching TV, looking listless. He began to have a restless sleep, waking up several times during the night. Heloise tried to take Arthur to an appointment with the gastroenterologist, but he twice refused to attend. They have two children who are willing to collaborate, but Arthur's aloof and refractory attitude has paralyzed the family. Heloise had periodic check-ups with her cardiologist. He was my colleague at the University Hospital and upon learning of Arthur's situation, he advised Heloise to contact me.
I asked Heloise if Arthur had any previous psychiatric illness. She said no. She stated that until the rectal bleeding he was fine. He never had depression. He used to have enthusiasm for work and a good family relationship. She couldn't understand what was going on. I asked if she would like me to come over to her house for a face-to-face consultation. She said no. Arthur would have to agree. I was feeling the tension and ambivalence that dominated that family and made myself available to be contacted at any time. I suggested that she come see me in person the next day so we could come up with a plan to deal with the situation. I advised her to come with her children as they were probably distressed too. Heloise agreed.
The next day, Heloise and her two children came to the office. Heloise was 68 years old. She was a very thin woman, struggling with diabetes and coronary artery disease. Luis, the eldest son, was 42 years old. He was a lawyer and expressed himself in an excessively formal way. The daughter Martha, 38 years old, was calm, relaxed and communicative. Everyone was clearly apprehensive about Arthur's condition. The two children were married and Arthur had a great relationship with three small grandchildren. There were three preteen boys. Arthur enjoyed contact with nature and used to have fun on fishing and camping trips, as well as some walks along the seaside. He was very affectionate and his grandchildren called him Geronimo, an affectionate way of putting him in the position of head of an alleged indigenous tribe. Heloise took the initiative and commented that she was shocked by her husband's sudden change in behavior. Despite not doing preventive medical evaluations, he assumed he was healthy. After the colonoscopy, Arthur definitely didn't know how to deal with his current illness. He took on an attitude of introspection and stopped communicating with his family. Rescue attempts made by Heloise were frustrated. Arthur was not explicitly aggressive, but his current behavior generated feelings of fear and emotional instability in all family members. Martha has always been very close to the father, but Arthur has discouraged her in the quest for rapprochement over the past two weeks. Luis remained attentive, listening to the dialogue in silence, but showing a very apprehensive facial expression.
Due to Arthur's sudden change in behavior, my intuition pointed to some kind of association of ideas that might be taking place in his shocked mind. I asked if he had recently lost a family member or close friend. Heloise thought for a while and said that he probably had. Artur was an electronic engineer and had recently attended his 45th graduation party. He was surprised to be informed of the deaths of two colleagues with whom he had had a lot of contact in the past. The losses would have occurred about six months ago and Arthur regretted having been informed, ironically, at that moment of celebration. Heloise was unable to describe the causes of death, as Arthur had not commented on them.
I asked the family to describe Arthur's previous lifestyle.
Heloisa mentioned that he was a dedicated and competent professional. He had been CEO of a multinational high-tech company and was currently a senior consultant with flexible hours. He had an excellent relationship with the family, without conflicts or dislikes. He had a loving relationship with his grandchildren, contributing to the modulation of their character in a playful way. He was very organized and even a little obsessed with cleanliness and schedules. Arthur was not religious, but he used to participate in social support campaigns for poor children and abandoned elderly people. Martha interrupted by saying that she had accompanied her father to charity meetings and noticed that he felt gratified in donating his time and skills. She stated that her father was always a kind, affectionate and magnanimous man. He had the profile of a leader, he thought collectively, both in his family environment and in his professional and social life. He always put the common good above his personal needs. Luis, interrupted remembering that a few weeks ago his father expressed a strange thought. Luis traveled frequently for professional reasons and Arthur, who had never commented on his activities, asked him to rethink his work routine. He stated that Luis should spend more time with his family. Luis didn't answer. Arthur never brought up the subject again and Luis didn't try to resume that dialogue either. Luis said he did not understand his father's comment at the time, but in the current emotional context it could be relevant.
One hour passed and interestingly this family had never asked questions about Arthur's current malignant disease. Despite being unusual, it seemed to me to be an appropriate behavior, as the focus was on the person and not on the disease. They needed to rescue Arthur's emotional condition first and then think about the cancer. Although it was a well-structured family, that was not enough. Coping with the disease would have to come from Arthur. They had already taken the initiative and would be available and ready to help him. The problem was how to reach Arthur, how to motivate him, how to break through the wall of isolation he had built around himself.
I looked at the family and suggested that Luis would be the best rescue option. The reason was the interrupted conversation a few weeks ago. I directed Luis to look for his father saying that he had reflected on his previous advice. I assured Luis that the interruption of conversation with his father was not the cause of Arthur's recent communication block. However, trying to start it over seemed like an adequate stimulus to bring him back. Luis no longer had that defensive and formal behavior shown at the beginning of the consultation. He seemed to have understood his role in resolving the family crisis. I suggested that Luis strengthen the relationship with his father by expressing his affection and recognition. Luis should thank his father for the example shown throughout his life, emphasizing values and shaping the character of his children and grandchildren. He was supposed to reinforce Arthur's central role in the family and make him aware of everyone's effort to get him back. He must not hide his suffering, caused by the feeling of futility in reversing his father's suffering. Luis should mention that the family looked for a doctor who was willing to assist him and help him out of that uncomfortable situation.
However, Arthur would have to agree...
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James Fleck, MD, PhD is a full professor of clinical oncology at Federal University of Rio Grande do Sul, Brazil
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