Breaking bad news to a patient is not always an easy task for a doctor. It requires training, tact, diplomacy, empathy and sometime sympathy – something that I strongly believe should be fortified in many of us in the health sector.
Receiving the bad news of a medical diagnosis such as diabetes, hypertension, cancer and any other debilitating or life-threatening diseases can be such a hard pill to swallow, that many patients express various types of emotions when informed of their diagnosis.
I recently had a patient who went to the drug store to buy some antibiotic that a friend told her to buy for “bladder infection,” but was told to see a doctor for prescription before she could buy it. After consulting with her and hearing her complaints, I decided to do urinalysis and blood sugar testing which turned out to be a random blood sugar of 453mg/dl – way beyond normal.
When I told her she is diabetic, and needs to be treated promptly, the reactions that followed were heart breaking, and it took another half hour consoling, educating, reassuring and counselling her to deal with the issues.
The demands of self-care in individuals with diabetes and the complexity of daily treatment regimen may exacerbate the normal pressures of day to day living. The diagnosis of diabetes is first followed in most individuals and their relatives with passage through the various stages of grief. These stages of grief are emotional behaviours that follow a life-changing medical diagnosis or a loss, and include denial, anger, bargaining, depression and acceptance.
Those in the denial phase discount the reality of the situation. This should be a temporary situation and the individual should accept the reality of the diagnosis of diabetes and try to keep the blood sugar under control in order to prevent further damage to the body.
As in other chronic diseases, the factors involved in psychological adaptation to a diagnosis of diabetes include stress, coping ability and the social and family environment. The course and outcome of diabetes can be affected by stressful experiences. Multiplicity of these stressful life events tends to portend an untoward outcome.
The association between stress and onset of both Type 1 and Type 2 diabetes has long been suspected. Some studies have suggested that early life stresses in children, including disturbed feeding patterns, may trigger the onset of Type 1 diabetes in physiologically susceptible children. Psychological stress can raise the levels of the stress hormones which include cortisol, glucagon and growth hormone that are all known to raise blood sugar levels. These studies also highlighted the fact that individuals with Type 1 diabetes are more likely to report a major life stressor or family loss prior to the onset of symptoms of diabetes. But the interplay between stress and the onset of Type 2 diabetes is not presently as clear-cut.
Both psychological and physical stress can produce direct and indirect effects on blood sugar control. Indirect effects are seen in the self-care behaviour of the person with diabetes, which subsequently affects the blood sugar control; routines are changed, self-care patterns are disrupted, and resources are depleted. The disease itself and its treatment modalities represent chronic stressors that the individual with diabetes must confront. The direct effect is the increase in stress hormone levels.
The coping skills of individuals refer to the strategies that people use to manage and master stressful circumstances and to minimise the negative impact of life stressors on psychological well-being. A person with diabetes must have coping skills to face lifelong treatment procedures, have lifelong contact with healthcare workers, and have a good emotional balance and self-image.
It is advised that individuals with diabetes and other chronic illnesses learn problem-focused coping, which involves focusing energy and resources on solving the stress instead of emotion-focused coping such as avoidance of the issue at hand, denial or distraction. The demands of self-care in diabetes are un-remitting and substantial. The earlier the person with diabetes realises and accepts this, the better it is.
The social and family environment is important in helping them manage the disease well. Social support is believed to have a mediating effect on the stress associated with diabetes. The family provides support for the day to day management of the diabetic state in relation to medications and blood glucose monitoring, while friends provide support during times of exercise and periods when meals have to be eaten outside the home. Individuals with diabetes should not hide their diabetic state from family and friends because their support has a positive role to play in achieving and maintaining good blood sugar control. There is a bi-directional relationship between family harmony and diabetes control. Family stress is known to raise blood sugar levels while poor blood sugar control is also known to be a source of family stress.
The degree of compliance with medication can also be adversely affected, to the extent that a patient accepts and comes to terms with their medical condition as well as the level of stress to which they experience.
A person with diabetes should look for a strategy that eases the diabetes stress, provides comfort, calms the mood and has a constructive effect on the mind and body. Exercise, humour, writing, keeping a diabetes diary or log, joining a diabetes support group can help.
Mental health evaluation and psychological counselling is therefore important for patients who are diagnosed with and living with chronic diseases.
Contact Dr Maxwell on 363-1807 or 757-5411.