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VIEW FROM THE OTHER SIDE OF THE STETHOSCOPE: Managing Uncertainty (Part 2): Serenity

Harpham, Wendy S. MD

doi: 10.1097/01.COT.0000407953.74987.e8
Opinion
WENDY S

WENDY S

How can you help your patient deal with uncertainty? In Part 1 of this series in the October 10th issue, I proposed a focus on “managing patients' reactions to uncertainty” (instead of “managing uncertainty”) and borrowed a respected dichotomy to distinguish probabilistic uncertainty from uncertainty due to incomplete information.

Uncertainty Matrix

Uncertainty Matrix

With an eye toward developing interventions, I suggested looking at how a patient's reactions to uncertainty impact two categories of survivorship: decision-making and quality of life.

Here in Part 2, I introduce an approach that has helped me through the ups and downs of repeated cancer recurrences. It's one you may find useful when helping your patient respond to uncertainty in healthy ways.

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A Patient's Decisions

Every day, some of your patients cross a threshold when the first inkling of a problem breaks through to consciousness. It may happen while showering if your patient's fingers unexpectedly roll over a hard irregularity beneath a faded surgical scar. Or after a routine checkup if your patient sees your telephone number light up on caller-ID.

Suddenly your patient's world is flooded with uncertainty. “What's this? What's going to happen to me…to my life? What should I do?”

One night during my initial chemotherapy I developed a fever. Unsure of its meaning, I hesitated to finish dialing my doctor's telephone number while rationality wrestled with self-doubt and fear.

That's not unusual. Throughout survivorship, a patient's reactions to uncertainty may hamper efforts to make wise decisions or take effective action.

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The possibility of bad news may keep a patient from reporting warning signs in a timely manner. The prospect of serious side effects may lead a patient to decline effective therapies. If a patient in remission feels hyper-aware of the fragility of life, he or she may become risk-averse and disengage from relationships and activities. Or, paradoxically, a patient may abandon caution and, with a rallying cry of Carpe diem, take irresponsible risks.

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A Patient's Quality of Life

A patient's reactions to uncertainty may compromise quality of life, too. Distressing thoughts and feelings about the future can be subliminally distracting, overtly tormenting or anything in between.

I remember how uncertainty spawned competing games before my doctor visits: predicting what my doctors would find, polling friends' prophecies, and alternately preparing for the worst and the best. None of my mental gymnastics decreased the uncertainty—or my anxiety.

During my first remission, my toggling between confidence and insecurity about my health tainted any sense of normalcy. Whether accepting a dinner date with friends or a new patient to my practice, bubbling under the surface was the question: “When the appointed time arrives, will I still be okay?”

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Clichéd Self-help

Yearning for relief, I turned to others for insights and advice. Soon enough I found my answer in, of all places, a self-help book.

“This is it,” I thought, while underlining Reinhold Niebuhr's popular Serenity Prayer: “…grant me serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.”

Against a backdrop of uncertainty, asking “What can I change?” gave me new eyes for seeing opportunities to decrease uncertainty. It's not that I didn't already know how to optimize my care and increase the odds for a good outcome. As a physician, I knew better than most. But uncertainty scrambled my thoughts and short-circuited self-confidence.

As a patient, I learned it takes courage to do the right thing—to change the things I can—when doing so isn't easy (which is why, I suppose, some people call Niebuhr's verse the Courage Prayer). And it wasn't obvious to me where to find that courage.

Equally important—and often more difficult—was accepting the things I could not change. Serenity certainly sounded poetic. But for years I felt distressed, knowing my cancer treatments might not work. Knowing an abnormality labeled “probably scar” might harbor cancer. Knowing my children might lose me. Remembering my patients who'd handled uncertainty gracefully, I regretted never having asked them how they got there.

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The Clinician's Role

In your care of patients, you manage your own reactions by distinguishing between different types of uncertainty, as illustrated in the Uncertainty Matrix. If faced with uncertainty due to inadequate information, you are mobilized to action: You take a thorough history and order proper tests in your efforts to become as knowledgeable as possible.

In contrast, if dealing with probabilistic uncertainty, you step back and let go. Trained to accept your inability to know for sure or to predict, you don't fret. Instead, you wisely move on to other more productive activities.

Your patient can benefit from making the same distinctions.

Niebuhr's Serenity Prayer offers a patient-friendly way to talk about the two different types of uncertainty. Sharing the idea, if not the actual verse, about things one can and cannot change may lead your patients to a healing outlook—to wisdom.

Whenever you are addressing uncertainty due to lack of knowledge, guide your patients to action: “Let's change what we can change.” Offer a team approach to minimizing uncertainty. Emphasize the vital role of your patient—such as the value of calling with problems, providing complete information and taking steps to stack the odds for a favorable outcome.

Whenever you are dealing with probabilistic uncertainty, reassure your patient, “Together we've made the best decisions. Now it's time to let go of the decisions and focus on changing what we can change as you go through the next phase.”

By encouraging your patient to channel anxiety, anger, and other negative emotions into efforts to “change the things I can,” you may initiate a healing positive-feedback loop: Your patient takes effective action, which reduces distress, which, in turn, further helps your patient take proper actions.

But what if after providing information, instructions and encouragement, your patient continues to feel immobilized by fear or despair? What if your patient's quality of life continues to be diminished due to unpleasant reactions to uncertainty? How can you help your patient find courage? Serenity?

The answer lies in an essential ingredient to responding well in any setting of uncertainty: hope. In Part 3 I'll explore the role of hope in managing patients' reactions to uncertainty.

© 2011 Lippincott Williams & Wilkins, Inc.
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