Home > Dr. Ward's Newspaper Column Home > 2010
The complexities of grief in cancer
June 01, 2009 My new friend grieved for her dead husband, and that was difficult enough, but in cancer the grief is before, during and after death. Even when the expected outcome of cancer therapy is a cure, the specter of dying looms large in our psyche even as we seek to avoid it.
Cancer-induced grief is further complicated by the fact that the grieving is done by both the caregivers and the dying patient, at differing speeds, and often during a time when the demands are so intense that minding the grief is something for which it seems that no time can be put aside. Though attending to the healing of sorrow may often be the preeminent need, it can be neglected not only by physicians and nurses, but by the entire health care system.
The five stages of grief, proposed and popularized by Elisabeth Kubler-Ross in her 1969 classic book On Death and Dying, are denial, anger, bargaining, depression and acceptance. Though there are criticisms that her observations are oversimplified, they have stood the test of time and are a common starting point to a discussion of the emotions that surround cancer.
Denial can be a tremendously positive or incredibly self-defeating tool, depending on the context in which it is being used. It is the ability to be hopeful that gets many patients to and through their treatments, and it allows patients and families to function when they might otherwise fall apart. However, it is a sword that cuts both ways, for complete denial can also lead to refusal of treatments that can improve survival and quality of life in favor of therapies that hold empty promises of cure. In the best of circumstances, denial is a temporary state.
I don’t believe that there is a positive side to anger or blame that is borne of grief. It shuts out those who love and care for you. Patient anger can be directed at self, particularly when smoking results in cancer, and can become very destructive self-loathing, but generalized anger that often lashes out against spouses and family is most common. As a physician, I have had to learn to accept that anger directed at the health care team may be a natural reaction, and though I welcome constructive criticism, I cannot be offended by it. Perhaps the most difficult anger is when families become angry at the patients who desperately need understanding and acceptance in order to continue to progress towards emotional comfort.
Bargaining and negotiating in cancer grief is most often with a higher power or insurance companies, though when patients and families turn to unproven therapies, be they within or without traditional medicine, that too can be a bargaining that may delay acceptance.
Depression is, in the Kubler-Ross model of grief, the final stage before acceptance. In reality, depression can occur at any stage. I think of depression as being this fog that comes in and clouds ones ability to cope. Patients understand that they need to get from emotional point B to point A but cannot see how to get there. Most patients work through the fog, but sometimes they get lost and the fog stays. In those circumstances, antidepressant medications may be very helpful, not to mask the problems, but to lift the fog so that one can find their way to point A and acceptance.
I am not entirely comfortable with the term acceptance. It sounds too much like resignation. Acceptance in my mind, however, can mean that a patient has come to terms with illness and prognosis in a way that allows them to maximize their will to beat their cancer when they can, and live as well as possible for as long as possible when they cannot. It is when families are able to provide the best in support and love. It is when healing can occur even when a body is dying.
Dr. Ward is a medical oncologist at Puget Sound Cancer Centers. He can be reached at (425) 775-1677.