Background
Methods
The Quantitative study
Patients
The Questionnaire
Item number | Item text | % of Yes | % of missing data |
---|---|---|---|
1 | I need more information about my diagnosis | 40 | 1 |
2 | I need more information about my future conditions | 61 | 2 |
3 | I need more information about the exams I am undergoing | 35 | 0 |
4 | I need more explanations on treatments | 32 | 1 |
5 | I need to be more involved in the therapeutic choices | 30 | 1 |
6 | I need clinicians and nurses to give me more comprehensible information | 32 | 0 |
7 | I need clinicians to be more sincere with me | 20 | 0 |
8 | I need to have a better dialogue with clinicians | 45 | 1 |
9 | I need my symptoms (pain, nausea, insomnia, etc.) To be better controlled | 24 | 1 |
10 | I need more help for eating, dressing, and going to the bathroom | 11 | 0 |
11 | I need more respect for my intimacy | 18 | 1 |
12 | I need more attention from nurses | 13 | 1 |
13 | I need to be more reassured by the clinicians | 34 | 1 |
14 | I need better services from the hospital (bathrooms, meals, cleaning) | 59 | 1 |
15 | I need to have more economic-insurance information (tickets, invalidity, etc..) In relation to my illness | 40 | 3 |
16 | I need economic help | 19 | 1 |
17 | I need to speak with a psychologist | 17 | 1 |
18 | I need to speak with spiritual assistant | 13 | 1 |
19 | I need to speak with people who have had my same experience | 39 | 1 |
20 | I need to be more reassured by my relatives | 12 | 1 |
21 | I need to feel more useful in my family | 28 | 0 |
22 | I need to feel less abandoned to myself | 18 | 1 |
23 | I need to be less commiserated by other people | 19 | 2 |
Statistical Analysis
The Qualitative study
Results
Results of the quantitative study
Characteristics | N | % |
---|---|---|
Sex
| ||
Male | 90 | 49 |
Female | 92 | 51 |
Age
| ||
Median (range) | 60 | 21–89 |
Educational level
| ||
Primary school | 60 | 33 |
Secondary school | 47 | 26 |
High school | 54 | 29 |
University | 13 | 7 |
Missing | 8 | 5 |
Primary tumor site
| ||
Head & Neck | 35 | 19 |
Colon-rectum | 30 | 16 |
Breast | 20 | 11 |
Others | 94 | 52 |
Missing | 3 | 2 |
Number of previous admissions
| ||
None | 74 | 41 |
One | 45 | 25 |
Two or more | 63 | 34 |
Days of hospitalization (with regard to the present admission) | ||
Median (range) | 7 | 3–13 |
Autonomous movement
| ||
Yes | 166 | 91 |
No | 14 | 8 |
Missing | 2 | 1 |
Item number | Informative 1st (*) factor | Informative 2nd (**) factor | Communicative factor | Relational factor |
---|---|---|---|---|
1 | 0.99 | - | - | - |
2 | 0.78 | - | - | - |
3 | - | 0.96 | - | - |
4 | - | 0.99 | - | - |
5 | - | - | 0.92 | - |
6 | - | - | 0.97 | - |
7 | - | - | 0.93 | - |
8 | - | - | 0.90 | - |
20 | - | - | - | 0.94 |
21 | - | - | - | 0.84 |
22 | - | - | - | 1.00 |
Cronbach's alpha indexes | 0.63 | 0.76 | 0.76 | 0.64 |
Results of the qualitative study
The Pros and Cons |
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In my opinion having information on my disease means knowing all there is to know about the illness. Knowing what are the pros and cons: what you can do after the operation, how my life and my eating habits will change; and what the effects will be of therapy. Knowing everything – no. Knowing everything would hurt you. But knowing the most
important
things is indispensable.
|
The Doctor's Round
|
Take the Doctor's Rounds in the morning when they tell us how the tests went or they sum up to that moment. In that time, I need information; but often this 'round' is characterized by a Hermetic language. I, at least, understand a little, thanks to my scientific background. Then they are extremely laconic when it comes to the outcome of a test that could determine a change of therapy because the result is less positive than expected. So I would say that not only do more things need to be said, but things need to be explained in more detail so that they can perhaps reassure the patient as to why such and such a test did not go so well.
But in a few words they tell you that the previous therapy did not have a great effect, that the results of the last exam showed a lack in efficacy, and so therapy must be changed.
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Percentages
|
Not long ago, after six months of being cured, they told me that this kind of therapy improved my cancer by 40%. They told me this was an extremely positive result because 1.) I had been getting worse and so the tendency was reversed. And 2.) for them, 40% was a lot; I was very distraught because I had thought that after six months of very heavy therapy, 40% for me was very little. Therefore not only did they not obtain the response they" desired" from me in communicating the result, but I was thinking that another 6 months of therapy was going to be necessary.
They communicated this to me with satisfaction; but considering how much I had suffered up until that moment and considering how long the therapy took, I thought the result was poor. From their medical point of view probably my observation was seen as unreasonable. What for them was a good result lost all meaning and became demoralizing for me when it reached me as simply a number.
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Percentages 1
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The idea of calling a doctor for a response in terms of percentages is not the kind of answer I would like. Yes, I would like to know I had lost about half the hair on my head; or that in a certain percentage of cases the stomach resumes its normal functions with great difficulties which need to be progressively overcome. This way of answering I consider to be fully satisfactory.
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Percentages 2
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"He/she told me straight away: 'In 80% of cases, these are things that cure.... You are in the other 20%. This means that you are unlucky...."'.
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Quality of Life |
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By 'future' I mean also the quality of life because someone can say "you will live for 10 years", but "how will I live?". More detailed information is needed; like, for example: "you must cope with this or that"; but doctors just give summarized information. This is true above all about oncologists.
Also I mean the possibility of being cured, but here everything is reported in statistical terms; it is very schematic: "50% responded like that; 30% like this". But no one knows what their own percentage will be. They don't consider your own case. This
case
must be considered; for with the same disease one patient may be in a bad state, while another feels OK. They cannot be equal; this should be considered. But they only consider the state of the disease and everything is related to that.
They tend not to speak. They don't open up. If you continue to ask questions maybe you will hear things said that you wouldn't want to hear. The answer, beyond a certain point, is not stimulating but soul destroying. It is worth asking questions, but only up to a certain point.
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Length and Quality of Life
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For me it is more important to think "the years that I have left to live will have a certain quality of life," rather than "I have so and so many years to live".... of course. While before I, who had never been ill, used to think that nothing could happen to me or, rather, I took it for granted instead of thinking about it, now, I don't take anything for granted and this illness changes my life a lot. You have to re-see everything. However, you lose 2 years of your life. You can see it is impossible to keep your old job, your place of responsibility, and then you choose to have a life different from the one before. You try to analyze what didn't go well before. I, now, would remedy a certain degree of superficiality of my old life. I am very attentive now; much more of my attention is focused on many things; many signs. Before, I used to pass over things that were important; things that would always be done 'afterwards'. Now I make different choices; of course I would not neglect so many signs any more. This cancer was discovered by chance; I had completely neglected to heed certain messages my body communicated to me...
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Things Precise and Nearby
|
I feel great discomfort as I go along this winding path that changes from time to time; and from time to time my future conditions also change. From time to time cloudy and uncertain information is given to me, probably because my response to treatments is cloudy and uncertain; however, my future conditions are completely dependent on contingencies.
It's not about a far off future, but about things precise and nearby.
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Adaptive to My Demands |
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For me, choosing the therapy together with a doctor means knowing what I will be up against with the therapy that the doctor decides to give me. And speaking about it together with him/her could help to find a more adaptive solution to my demands, perhaps changing a little of what he/she might administer to me. It would be good to be able to come up with a 50:50 understanding arrangement where I understand the doctors' demands who wishes to use therapy on me, and where he/she understands my demands too. Up to now I haven't taken part in such an arrangement.
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The Choice
|
It is clear that therapeutic choice should be made by the doctor because I am not a doctor. However, the doctor must explain the purpose of the therapy he/she adopts so that I can make a distinction too. The doctor should make the choice, but he/she should also "listen" if the patient is willing to go through with such a choice. He/she should say: 'I propose this for this reason.' And I, who am the person directly involved will say: 'Yes. That's ok for me because I understand what it's supposed to do!
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Hermetic Communication |
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Communication with the patient is hurried and fairly hermetic also for a person of average cultural background. Therefore given that this is an illness which has important psychological implications, communication in 'snatches' will not do.
Communications are given in a very formal context (the 'round'), but it is obvious that for the patient it is more difficult to ask for explanations from 10 doctors instead of just one.
They give the impression of speaking in abbreviations. They speak to one another about the results of tests in such a condensed way that it almost gives the impression they don't want to communicate to the patient at all; that the information is more or less for their own internal use. Sometimes they give contradictory information among themselves (depending on the doctor) and this worsens the situation. One time I said to one of them that because patients have so little time available (with the doctors) their 5 minutes of explanation in the morning is meditated on later on in the day, sometimes during the whole day, so they can try to interpret what was said. The doctor's reply was that they are so involved in a whole series of practical problems, urgencies, that they don't rate this aspect and that if they weren't made to observe it a second time they wouldn't even be aware of the damages that some of their words could cause to the patient. For me a more interactive, more simple and human situation needs to be created. First of all maybe it is necessary that there be one same version in the sense that sometimes three different doctors come and each one gives a different version of the same exam; this naturally doesn't help. And, apart from this problem, the way in which these communications are expressed is not like a dialogue, but like an authoritative lecture. And more often than not, it is expressed not for communication with the patient, but for communication among the specialists themselves in which the patient is lucky if he/she understands anything at all; otherwise... see you in another moment; maybe after three days.
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Politeness First and Foremost
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I have had the experience of being admitted to hospital wards in other institutions. There are enormous differences: in one of the two cases, no doctor came. Things were allowed a little to be like that. But a doctor coming and stopping for a time to speak to the patient is extremely important for me; otherwise people feel rather abandoned...I was there for what should have been three days; and then in one week I saw one doctor only pass by once. He was the consultant surgeon. The consultant surgeon didn't say hello; he didn't ask patients what they had. No – he asked the swarm of practitioners – young doctors who were learning – instead! I heard someone answer about my case: "He had a problem, but now it's been resolved!" But what problem? Why doesn't he ask me what I had? I was there for that mistaken experience .... Because they had made a mistake in a certain kind of operation... Then they moved on, without saying hello, without making eye contact.
This is lack of politeness first and foremost. I saw that they acted like this with all the beds in the room. This surely must be improved upon.
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Sincerity
|
Sincerity is something one realizes subsequently; for, during the moment when it is verified that the things the doctor said really are what he said they would be, one understands a posteriori the sincerity of the doctor. A priori, a stronger act of trust is needed; for this it is important to have an empathetic rapport with patients.
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Dialogue Among Patients |
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Often what takes place among patients is a dialogue among 'deaf' (sic) people; for most of the time they don't listen to the others. They only have this need to communicate the horror that they are experiencing; a whole series of somber heavy feelings which, in that moment, they absolutely need to communicate and they don't even listen to what the other person is saying; so there is no real conversation. There is a passing of information; there is an irresistible urge to broadcast, to communicate. I often go to have breakfast in a common area and I hear myself asking 'Where do you have your cancer?' before asking me: 'What's your name?' or 'Where do you live?'. It is really absurd, but justified because I feel the fear that lies behind it and the necessity for recounting one's own story. It is an irresistible necessity; within about half an hour you can discover just about everything about such and such a person; and not only his/her illness, but also everything else that person had experienced previously.... But everything is centered on the disease, with extreme heaviness, with an extreme sense of claustrophobia.
By now I've got to the point where I listen to my walkman so as to avoid communication, so as not to listen to what the others are saying, and so as not to be involved in conversations with those who pretend to be interested in your disease, but who really wish to speak about their own.
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The Rest of the World
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The fact of being a cancer patient makes people enter into a role and makes them always speak about the same things. It makes others assume the belief that the rest of life, also of their life, is useless when faced with the gravity of the experience the patient is undergoing. There exists a disproportion. At times others, also friends, refuse to recount their things because of this disproportion of pain in mind; and this prevents the rapport from being on an equal level. Patients are seen as poor little animals who are 'people truly with a problem'; while the rest of the world has silly and inessential problems. This, therefore, causes others to always speak of the same things. So they speak not only of such and such a disease, but of everybody else's disease as well. What a nice catalogue of disasters and misfortune!! To sum up: our problems are vain; they're silly; they're frivolous; only you have true problems; let's speak only about your problems.
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A Very Physical Presence |
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I found the nursing staff reasonably attentive. I remember there being a very physical presence. Maybe if we understand it in a wider context, the fact of sharing living space with another person... well...this could be a violation of intimacy. Undergoing certain particularly heavy therapies while sharing your room with another person can, at times, create situations lacking in intimacy which only makes everything heavier to bear.
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Involuntary Hearing
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For example, when doctors come along on their rounds – I am in a room with four beds – it annoys me to hear everything about other people's diseases; just as it annoys me when the others hear things about my situation.
I don't think this is right. I feel uncomfortable when I can't get up because usually when the doctor finishes speaking to me I leave; but I have found myself in situations where I couldn't get up; where I had to stay there and listen to the doctor who maybe said some things which were a little unpleasant to another patient and I felt the patient's state of being ill at ease; he/she maybe felt embarrassed; maybe he/she couldn't express what he/she wanted to. I have noticed this both in myself and in other persons.
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Being Seen Naked
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...I mean, above all, the fact of being seen naked... Situations do exist where nurses wash a woman in the same room in front of you; or where a male nurse comes to wash you because it's his shift and involuntarily it wasn't thought of to send a female nurse.
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Sensitivity
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...for example, when a person has a stoma and a person needs to be clean; because if you are operated on you shouldn't have to go and beg to the nursing staff for them to change you; it should be a logical thing; immediate. I have found myself having to beg for this. If I had been capable I would have done it myself.
This touches a person deeply, for it is his/her way of feeling, of being sensitive. Intimacy is not represented only by certain things, but it also consists in moving to touch a person in the area where he/she feels; touching his/her sensitivity.
Sensitivity is a very intimate property (part) of a person.
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Dividing Men and Women
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From the point of view of one's own intimacy, it is an infamy state of affairs. Last night I went in to the bathroom and there was a gentleman there: I felt inhibited. The doors don't close properly. And, anyway, I didn't particularly feel like going into the bathroom and seeing that man cleaning his set of false teeth. Again, one can't get undressed in order to wash properly. These are things that make you feel bad.
They could, at least, divide men and women: at least then (for me) it would be only women encountering one another in the bathroom.
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