issues

9]. In addition, there are also the practical implications of illness, and a patient and their family may have difficulties in terms of their financial and employment status, as well as disruption caused by changes in their role and the family dynamics.

For the patient coming to terms with a cancer diagnosis, it has become helpful to think of their emotional adjustment as a series of different emotional stages. Barraclough [10] describes patients initially experiencing shock, numbness or disbelief, often with the bad news seeming ‘too much to take in’. This usually short-term denial is then followed by distress as the reality of the situation becomes clear and is often associated with anger, anxiety, protest and bargaining. This phase often lasts a number of weeks and can be followed by sadness and depression again taking several weeks before gradual movement to adjustment and acceptance, taking weeks and even months.

Although this is a useful guide to apply to many situations associated with ‘loss’ of any kind, it is important to caution against using it as a simple sequential model of what every patient (and their carers) will experience. Although many will react with some of the above emotions, we should not expect all to be initially shocked by a diagnosis and then work through all the stages to a final acceptance. Often there are more individual emotions and they may not occur in any clear order, or may overlap or may be gone through more than once, particularly in an illness that has remissions and relapses or a series of progressive deteriorations. Heightened anxiety and intensity of these emotions will occur most strongly at diagnosis, during treatment episodes and at times of recurrence and in terminal phase.

A summary of some of the common responses and influencing factors is illustrated in Figure 34.1, which aims to illustrate the dynamic that emotional adjustment changes through time, and is affected by many different factors which will be highly individualized for each patient. These reactions do not occur in any particular order and are particular to the individual who may move in and out of the different responses as the stimuli change.