Psychological Support of the Critically Ill Patient Alyce C. Gullattee, MD, FAPA Washington, DC
The topic, "Psychological Support of the Critically Ill Patient," is both provocative and timely. Provocative, because it implies the need to catalogue and define the series of ritual behaviors performed by those health care providers attending the seriously ill patient; and timely, since the cultural orientation towards critical illness, if critical connotes dying, is to supply supportive care, not palliative therapy only. The purist would define critical "as pertaining to, or in the nature of a crisis; of decisive importance with respect to the outcome." From the point of medicine, this purist definition is most applicable. To be ill bespeaks of crisis to the patient, the family, and the economic community in which the patient moves. The crises of self-worth, ego alteration, altered role expectation, and personal esteem are uppermost in the ill and more accentuated in the critically ill who are able to communicate
with you. The family crisis revolves around redefinitions of role responsibilities to absorb the void created by illness and to reassign tasks previously ascribed to the ill patient if death should occur. The economic community crisis is elusive of definition because it may refer to the extended family, to structured institutions such as the church, to the place of employment, or to any system that depends upon the work product of the ill person and is altered by the crisis of illness. What are the primary issues of emotional cathexis and decathexis most prominent in the ill? It has been my experience that anxiety, the presence of grief and mourning, and the process of dying and death are the major areas requiring interpretation, understanding, and intervention on behalf of both the patient and the family.
Alyce C. Gullattee, MD, is Assistant Editor, Journal of the National Medical Association. Requests for reprints should be addressed to Dr. Alyce C. Gullattee, Department of Psychiatry, Howard University Hospital, Washington, DC 20060.
Anxiety It is only natural that illness will create anxiety, anxiety about the alteration in physiological functioning,
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 6, 1979
anxiety over the impact that the illness will have on self and the lifestyle of the family; anxiety as it relates to the feelings of loneliness, fear, anger, and sometimes, hopelessness revolving around being sick. All people have similar reactions to illness, but among the poor and minorities, prolonged illness becomes a burden and the life adjustments for survival are well known to members of those cultures. The anxiety heightens when the diagnosis is of critical consequence and the patient may act out the fear through (1) regressive behavior, eg, demanding attention, being uncooperative, denying the severity of the illness; or (2) more aggressively avoiding overtures of help offered by family, friends, or staff, eg, being busy when hospital staff comes by; feigning sleep; frequent bathroom stops, if ambulatory; or general preoccupation with TV, reading, etc. All of these are designed as diversions from communication where discussion of the illness might take place. The need to maintain ego integrity is so strong that the patient is willing to cut off meaningful contact with the "outside" world rather than run the risk of an emotional explosion. Most patients do not know that it is all right to be afraid about illness and will say, "I'll trust in the 559
Lord"; "the Doctor knows best"; "I'm trying to be strong"; "I'll hold on"; "I needed this rest"; etc.
Grief and Mourning The presence of identifiable grief and mourning heralds the onset of depression. Depression ultimately comes with all illness. The hospital environment with its regimented rules and regulations is seen as a violation of one's constitutional and civil rights with cruel and unusual punishment. In discussion with patients, one finds out that many of them harbor the belief that if the clinician had been more astute, the illness would not have occurred in its present form. Intellectualization and/or rationalization, as well as alienation, become the major defense mechanisms utilized by the patient to cope with the loss of body integrity, the loss of ego strength, the reinstitution of dependency, and the humiliation, real or imaginary, that is endured. During this phase the patient is particularly sensitive to invasive and manipulative procedures, such as catheters, IVs, etc, and may not ask for explanations, preferring to grieve and become introspective. Mourning is an emotionally charged, affect-laden process that always accompanies the loss of organs or body parts, hidden or exposed, with variations in the individual responses based upon such variables as sex, age, ethnicity, income level, marital status, parenthood, education, and premorbid emotional state.
Dying and Death The phenomena of dying and death carry with them the greatest disruption of all. Death stands between the world of spirits and the world of human beings. Death concerns everybody, because sooner or later everyone personally faces it and it brings loss and sorrow to every family. Man philosophically has accepted death as a part of 560
the natural rhythm of life. The patient, however, goes through various stages regardless of his religious posture. One generally thinks of death and dying as a diad. Here we have transposed the words and will talk about dying and death. The dying patient upon realizing the critical nature of his/her illness will usually engage in psychological isolation separating out the idea of death from the emotion/affect as a means of protecting the ego. It is clear that death is viewed paradoxically; it is separation but not annihilation; it is an individual affair in which no one else can interfere or intervene. This is the height of death's agonies and pain for which there is neither cure nor escape. The dying patient becomes introspective, reviewing life's processes as if in rotogravure. If time permits, attempts may be made by the patient to reestablish contacts with family and friends. The critically ill person "reads" the nonverbal language of visitors and staff to determine the status of his illness and the degree to which hope is possible. There is anger by the patient with the living and well people about him/her which is not in response to any particular set of behaviors on their part. Rather, the patient feels abandoned by God and since blasphemy is feared, the anger is projected upon those persons with whom the patient comes in contact most frequently. The therapeutic modalities provided for the patient may produce a waxing and waning in the expression of the clinical symptomatology, thereby inducing magical thinking and fantasies of recovery. This may result in undue demands by the patient upon the therapists for more punctual and frequent visits and if the therapists do not comply, then there are accusations of diminished interest in the patient's hospital course. These early indications of greater contact need between patient and therapist bespeaks of the patient's impending separation anxiety which is associated with death. Death is very difficult to talk about and the patient engages in therapeutic alliances with staff based upon the level of services they can provide and the degree of guilt in staff perceived by the patient for not "curing" him. For this reason, patients are generally placed by staff in "death watch" areas of the wards- far enough away to assure contact in between periods of sedation. In the formal
therapeutic settings the patients progress through stages of oral or dependency needs (wanting you to feed them); aggressive or controlling phases (demanding that time allotted for them be rigid and consistent); and ego identity periods in which they will attempt to extract from you value judgements about their appearance such as, "How do I look?" As death approaches, the body language of the patient changes. There is an attempt to avoid eye contact, but the patient responds to touching the hand when entering and leaving the room. My experience indicates that death is imminent when the patient begins to make a concerted effort to maintain eye contact. The significance of this behavior is left to speculation. Some patients will say, "I want to remember you," or "I want to see what you look like." Physicians are in a unique position to provide continuity of psychological support to the patient. Once a commitment is made to provide "comfort," there is only the qualitative and quantitative management of that "comfort index" needed. If the therapy is t.i.d. and three therapists are to be involved, the "team" as a group should visit the patient at some point in time so that the notion of continuity and sharing of information about the status and mood of the patient is reinforced, in a tangible way, for the patient. You may wish from time to time to share your observations about the patient with the other staff members on the ward or with the individual therapist attending the patient. It goes without saying that all procedures to be performed on the patient must be explained to him, particularly in light of the fear of and hostility to invasive procedures. An acknowledgment of the fear, anger, or depressed mood of the patient frequently neutralizes, for the moment, the profound anxiety associated with
critical illness.
Psychological Support Ultimately, psychological support requires (1) commitment of time and investment of energies in the process of allowing improvement with dignity, even if death is the level of improve-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 6, 1979
ment sought, (2) a willingness to help the patient to help his/her family let him die, and (3) a quiet detachment on the part of the therapist to help to assuage his/her professional guilt about not being able to "save" the patient. The family sees the dead person as suddenly cut off from the human society, and yet, the corporate group clings to him. Death, thus, becomes a gradual process that is not completed for some years after the physical death. The period of Sasa, the present, is over and the person has entered in Zamani, the past. The mourning by the family may last for four years after the death and this is not pathological. My experience has been that grief is immediately experienced and is expressed by willful acts of the family to protect the image of the deceased. Approximately three months after the death of a loved one, there is a homicide-suicide paradigm. During this period, the family resents the fact that "certain others" still live while their loved one is dead. The family members also think ofjoining the dead loved one.
By six months, depression is evident and is directly related to the realization of the qualitative nature of the loss that has been sustained, and now mourning begins. At the end of year one following the death, there is a fusion of the idea of death with the affect/emotions associated with the loss. The family attempts then to regroup, but the second year is filled with emotional lethargy. There may be bursts of agitated depression, inappropriate behavior, and attempts at creativity, but the basic matrix is one of profound loss and longing for the dead member. During the third year there is an attempt to let go of the loved one. And finally during the fourth year there is a reevaluation of the loss, a diminution of the anger at having been abandoned, and a reemergence of the memory of the loved one. The aforementioned covers briefly the periods of psychological support that will be needed for the family of the critically ill patient. The depression may be masked as psychosomatic or psychophysiological illnesses.
NoMutionav-l
Conclusion We in the health professions are obliged to let every patient contact become a therapeutic moment. The psychological support thus becomes both therapeutic for the critically ill patient and preventive for the patient's family. Ultimately, it humbles the practitioner who is taught to heal and cure, but who must still acknowledge the power and inevitability of death.
Suggested Reading 1. Kubler-Ross E: On Death and Dying. New York, MacMillan, 1969 2. Schoenberg B, Carr AC, Pertz D, et al: Loss and Grief. New York, Columbia University Press, 1970 3. Sudnon D: Passing On. Englewood Cliffs, NJ, Prentice Hall, 1967 4. Beck AT: Depression. Philadelphia, University of Pennsylvania Press, 1967 5. Fann WF, Karacan I, Pokorny AD, et al (eds): Phenomenology and Treatment of Depression. New York, Spectrum, 1977
1979 NMA Convention The 84th annual convention and
scientific assembly of the National Medical Association will be held in Detroit, Michigan from July 29-August 2, 1979. The scientific program will include Aerospace and Military Medicine, Anesthesiology, Basic Science,
Community Medicine, Dermatology, Family Practice, Internal Medicine, Neurology and Psychiatry, Obstetrics and Gynecology,
Ophthalmology, Orthopedics, Otolaryngology, Pediatrics, Physical Medicine and Rehabilitation, Radiology, Surgery, and Urology.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 6, 1979
561
The topic, "Psychological Support of the Critically Ill Patient," is both provocative and timely. Provocative, because it implies the need to catalogue and define the series of ritual behaviors performed by those health care providers attending the seriously ill patient; and timely, since the cultural orientation towards critical illness, if critical connotes dying, is to supply supportive care, not palliative therapy only. The purist would define critical "as pertaining to, or in the nature of a crisis; of decisive importance with respect to the outcome." From the point of medicine, this purist definition is most applicable. To be ill bespeaks of crisis to the patient, the family, and the economic community in which the patient moves. The crises of self-worth, ego alteration, altered role expectation, and personal esteem are uppermost in the ill and more accentuated in the critically ill who are able to communicate
with you. The family crisis revolves around redefinitions of role responsibilities to absorb the void created by illness and to reassign tasks previously ascribed to the ill patient if death should occur. The economic community crisis is elusive of definition because it may refer to the extended family, to structured institutions such as the church, to the place of employment, or to any system that depends upon the work product of the ill person and is altered by the crisis of illness. What are the primary issues of emotional cathexis and decathexis most prominent in the ill? It has been my experience that anxiety, the presence of grief and mourning, and the process of dying and death are the major areas requiring interpretation, understanding, and intervention on behalf of both the patient and the family.
Alyce C. Gullattee, MD, is Assistant Editor, Journal of the National Medical Association. Requests for reprints should be addressed to Dr. Alyce C. Gullattee, Department of Psychiatry, Howard University Hospital, Washington, DC 20060.
Anxiety It is only natural that illness will create anxiety, anxiety about the alteration in physiological functioning,
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 6, 1979
anxiety over the impact that the illness will have on self and the lifestyle of the family; anxiety as it relates to the feelings of loneliness, fear, anger, and sometimes, hopelessness revolving around being sick. All people have similar reactions to illness, but among the poor and minorities, prolonged illness becomes a burden and the life adjustments for survival are well known to members of those cultures. The anxiety heightens when the diagnosis is of critical consequence and the patient may act out the fear through (1) regressive behavior, eg, demanding attention, being uncooperative, denying the severity of the illness; or (2) more aggressively avoiding overtures of help offered by family, friends, or staff, eg, being busy when hospital staff comes by; feigning sleep; frequent bathroom stops, if ambulatory; or general preoccupation with TV, reading, etc. All of these are designed as diversions from communication where discussion of the illness might take place. The need to maintain ego integrity is so strong that the patient is willing to cut off meaningful contact with the "outside" world rather than run the risk of an emotional explosion. Most patients do not know that it is all right to be afraid about illness and will say, "I'll trust in the 559
Lord"; "the Doctor knows best"; "I'm trying to be strong"; "I'll hold on"; "I needed this rest"; etc.
Grief and Mourning The presence of identifiable grief and mourning heralds the onset of depression. Depression ultimately comes with all illness. The hospital environment with its regimented rules and regulations is seen as a violation of one's constitutional and civil rights with cruel and unusual punishment. In discussion with patients, one finds out that many of them harbor the belief that if the clinician had been more astute, the illness would not have occurred in its present form. Intellectualization and/or rationalization, as well as alienation, become the major defense mechanisms utilized by the patient to cope with the loss of body integrity, the loss of ego strength, the reinstitution of dependency, and the humiliation, real or imaginary, that is endured. During this phase the patient is particularly sensitive to invasive and manipulative procedures, such as catheters, IVs, etc, and may not ask for explanations, preferring to grieve and become introspective. Mourning is an emotionally charged, affect-laden process that always accompanies the loss of organs or body parts, hidden or exposed, with variations in the individual responses based upon such variables as sex, age, ethnicity, income level, marital status, parenthood, education, and premorbid emotional state.
Dying and Death The phenomena of dying and death carry with them the greatest disruption of all. Death stands between the world of spirits and the world of human beings. Death concerns everybody, because sooner or later everyone personally faces it and it brings loss and sorrow to every family. Man philosophically has accepted death as a part of 560
the natural rhythm of life. The patient, however, goes through various stages regardless of his religious posture. One generally thinks of death and dying as a diad. Here we have transposed the words and will talk about dying and death. The dying patient upon realizing the critical nature of his/her illness will usually engage in psychological isolation separating out the idea of death from the emotion/affect as a means of protecting the ego. It is clear that death is viewed paradoxically; it is separation but not annihilation; it is an individual affair in which no one else can interfere or intervene. This is the height of death's agonies and pain for which there is neither cure nor escape. The dying patient becomes introspective, reviewing life's processes as if in rotogravure. If time permits, attempts may be made by the patient to reestablish contacts with family and friends. The critically ill person "reads" the nonverbal language of visitors and staff to determine the status of his illness and the degree to which hope is possible. There is anger by the patient with the living and well people about him/her which is not in response to any particular set of behaviors on their part. Rather, the patient feels abandoned by God and since blasphemy is feared, the anger is projected upon those persons with whom the patient comes in contact most frequently. The therapeutic modalities provided for the patient may produce a waxing and waning in the expression of the clinical symptomatology, thereby inducing magical thinking and fantasies of recovery. This may result in undue demands by the patient upon the therapists for more punctual and frequent visits and if the therapists do not comply, then there are accusations of diminished interest in the patient's hospital course. These early indications of greater contact need between patient and therapist bespeaks of the patient's impending separation anxiety which is associated with death. Death is very difficult to talk about and the patient engages in therapeutic alliances with staff based upon the level of services they can provide and the degree of guilt in staff perceived by the patient for not "curing" him. For this reason, patients are generally placed by staff in "death watch" areas of the wards- far enough away to assure contact in between periods of sedation. In the formal
therapeutic settings the patients progress through stages of oral or dependency needs (wanting you to feed them); aggressive or controlling phases (demanding that time allotted for them be rigid and consistent); and ego identity periods in which they will attempt to extract from you value judgements about their appearance such as, "How do I look?" As death approaches, the body language of the patient changes. There is an attempt to avoid eye contact, but the patient responds to touching the hand when entering and leaving the room. My experience indicates that death is imminent when the patient begins to make a concerted effort to maintain eye contact. The significance of this behavior is left to speculation. Some patients will say, "I want to remember you," or "I want to see what you look like." Physicians are in a unique position to provide continuity of psychological support to the patient. Once a commitment is made to provide "comfort," there is only the qualitative and quantitative management of that "comfort index" needed. If the therapy is t.i.d. and three therapists are to be involved, the "team" as a group should visit the patient at some point in time so that the notion of continuity and sharing of information about the status and mood of the patient is reinforced, in a tangible way, for the patient. You may wish from time to time to share your observations about the patient with the other staff members on the ward or with the individual therapist attending the patient. It goes without saying that all procedures to be performed on the patient must be explained to him, particularly in light of the fear of and hostility to invasive procedures. An acknowledgment of the fear, anger, or depressed mood of the patient frequently neutralizes, for the moment, the profound anxiety associated with
critical illness.
Psychological Support Ultimately, psychological support requires (1) commitment of time and investment of energies in the process of allowing improvement with dignity, even if death is the level of improve-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 6, 1979
ment sought, (2) a willingness to help the patient to help his/her family let him die, and (3) a quiet detachment on the part of the therapist to help to assuage his/her professional guilt about not being able to "save" the patient. The family sees the dead person as suddenly cut off from the human society, and yet, the corporate group clings to him. Death, thus, becomes a gradual process that is not completed for some years after the physical death. The period of Sasa, the present, is over and the person has entered in Zamani, the past. The mourning by the family may last for four years after the death and this is not pathological. My experience has been that grief is immediately experienced and is expressed by willful acts of the family to protect the image of the deceased. Approximately three months after the death of a loved one, there is a homicide-suicide paradigm. During this period, the family resents the fact that "certain others" still live while their loved one is dead. The family members also think ofjoining the dead loved one.
By six months, depression is evident and is directly related to the realization of the qualitative nature of the loss that has been sustained, and now mourning begins. At the end of year one following the death, there is a fusion of the idea of death with the affect/emotions associated with the loss. The family attempts then to regroup, but the second year is filled with emotional lethargy. There may be bursts of agitated depression, inappropriate behavior, and attempts at creativity, but the basic matrix is one of profound loss and longing for the dead member. During the third year there is an attempt to let go of the loved one. And finally during the fourth year there is a reevaluation of the loss, a diminution of the anger at having been abandoned, and a reemergence of the memory of the loved one. The aforementioned covers briefly the periods of psychological support that will be needed for the family of the critically ill patient. The depression may be masked as psychosomatic or psychophysiological illnesses.
NoMutionav-l
Conclusion We in the health professions are obliged to let every patient contact become a therapeutic moment. The psychological support thus becomes both therapeutic for the critically ill patient and preventive for the patient's family. Ultimately, it humbles the practitioner who is taught to heal and cure, but who must still acknowledge the power and inevitability of death.
Suggested Reading 1. Kubler-Ross E: On Death and Dying. New York, MacMillan, 1969 2. Schoenberg B, Carr AC, Pertz D, et al: Loss and Grief. New York, Columbia University Press, 1970 3. Sudnon D: Passing On. Englewood Cliffs, NJ, Prentice Hall, 1967 4. Beck AT: Depression. Philadelphia, University of Pennsylvania Press, 1967 5. Fann WF, Karacan I, Pokorny AD, et al (eds): Phenomenology and Treatment of Depression. New York, Spectrum, 1977
1979 NMA Convention The 84th annual convention and
scientific assembly of the National Medical Association will be held in Detroit, Michigan from July 29-August 2, 1979. The scientific program will include Aerospace and Military Medicine, Anesthesiology, Basic Science,
Community Medicine, Dermatology, Family Practice, Internal Medicine, Neurology and Psychiatry, Obstetrics and Gynecology,
Ophthalmology, Orthopedics, Otolaryngology, Pediatrics, Physical Medicine and Rehabilitation, Radiology, Surgery, and Urology.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 6, 1979
561
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