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Fast Fact and Concept #59: Dealing with anger

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Title: Fast Fact and Concept #59: Dealing with anger

Author(s): Becky Wang-Cheng, MD

Anger is a common emotion expressed by seriously ill patients and their families. The most typical reaction by the health professional, confronted by the angry patient or family, is to either get angry back or to physically and psychologically withdraw; neither are helpful coping strategies. A guide to managing these situations is presented below:

Understand the source of anger

Fear is probably the most common source of anger, especially in the dying and their families--fear of the unknown, being in pain or suffering, the future well-being of family members, abandonment, leaving unfinished business, losing control of bodily functions or cognition, being a burden to the family, and dying alone. Other sources of anger include: 1) a genuine insult -- so called "rational anger" (e.g. waiting six hours to see the doctor); 2) organic pathology: frontal lobe mass, dementia or delirium; 3) personality style/disorder-the person whose approach to much of life is via anger or mistrust.

Recognize the direction of anger

Anger may be directed internally (e.g. I didn't take care of myself, I'm abandoning my family), leading to withdrawal, anxiety or depression. Others direct their anger outward at physicians, hospitals, family members or a deity. Recognizing the underlying fear behind both internal and external anger is critical to effective management.

Use the "BATHE" approach when dealing with anger (1)

Background. Use Active Listening to understand the story, the context, the patient's situation.

Affect. Name the emotion; "you seem very angry?" It is crucial to validate feelings so the angry person feels that you are listening. Attempting to defuse it, counter it with your own anger or ignore it, will be counter-productive. Acknowledging their right to be angry will help start the healing process and solidify the therapeutic relationship.

Troubles. Explore what scares or troubles them the most about their present and future. Just asking the question, "tell me what frightens you", will help them to focus on circumstances they may not have considered.

Handling. Knowledge and positive action can help mitigate fears and reduce anger. How are they handling the dying---are they making concrete plans about their finances, their things, their family? Have they thought about formal counseling to help deal with the depression, the anger?

Empathy. By displaying empathy and concern you can help the person feel understood, less abandoned and alone. Avoid trite statements, "I know what you're going through." Paraphrasing the patients comments is an effective way to convey that you heard and are seeking to understand. "So you feel like it's so unfair that the cancer appeared out of nowhere after all these years."

The journey from life to a good death almost always is accompanied by some degree of anger. A caring physician can assist the patient in recognizing, mobilizing, and modifying the anger into positive emotional energy.

References

M R Stewart, J Lieberman III.The Fifteen Minute Hour: Applied Psychotherapy for the Primary Care Physician, 2nd Edition Praeger Publishing, Westport, Connecticut, 1993

Rueth, TW and Hall, SE Dealing with the anger and hostility of those who grieve A J Hos Pall Care 1999; 16:743-746.

Faulkner A. Dealing with anger in a patient or relative: a flow diagram Pall Med 1994; 8:51-57.

Copyright and Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing. Fast Facts and Concepts #59 Wang-Cheng B. Dealing with anger. January, 2002. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Fast Facts and Concepts was originally developed as an end-of-life teaching tool by Eric Warm, MD, U. Cincinnati, Department of Medicine. See: Warm, E. Improving EOL care--internal medicine curriculum project. J Pall Med 1999; 2: 339-340.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 1/2002

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)
Training: Fellows, 1st/2nd Year Medical Students, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Clergy/Chaplains, General Public, Graduate Students, Lawyers, Patients/Families, Nurses, Social Workers

ACGME Competencies: Interpersonal and Communication Skills, Patient Care

Keyword(s): Caring for families, Family conference, Giving bad news, Grief/bereavement, Negotiating treatment goals, Personal reflection


The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).