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Helen has been diagnosed with stomach cancer. She and her husband are both aware of the prognosis. Helen has a very caring sister, Margaret, but does not want her to know too many details about her illness as Helen feels she may become a nervous wreck. You meet Margaret during a home visit to Helen. Margaret stops you in the corridor, she is upset and angry. She knows her sister is ill but feels she is hiding something from her. She asks you to tell her what's going on.

Should angry relatives be told the whole story?

Patients may wish to protect family and friends by keeping them ignorant of the facts. They may ask your advice about whether to reveal details or not. Explain carefully that the relative will know something is amiss and hiding things could damage the relationship, especially if the relative is their main carer. So encourage patients to prepare relatives for bad news.

The patient may also wish to have you present when telling their relatives. Your expertise can offer support at this difficult time.

If patients are adamant that relatives are not to be informed about the prognosis then you must respect this.

If a relative asks you for information you should ask them to speak to the patient. This can get increasingly awkward so attempt to negotiate with the patient again. Reaffirm the positive aspects of sharing the news – strengthening relationships, mutual trust, planning ahead.

What about relatives who know the prognosis but do not want to tell the patient?

Occasionally relatives may have been told the prognosis while the patient is still ignorant of all the facts. This is relatively rare these days but can still happen if the patient is very elderly. The relatives may ask you not to share the news with the patient. They may argue that since their relative is going to die shortly anyway why ruin their last few weeks/ months? Relatives can become very adamant and angry.

You are sometimes faced with the whole family trying to bear down on you. You must assure them that although you respect their feelings you cannot lie to your patient.

The patient may ask for a diagnosis and if they really want to know you have to tell them in a sensitive way. Explain to the relatives that the patient can often sense that something is not right and may detect a conspiracy of silence building up around them. This will only damage relationships. Instead, encourage relatives to prepare their loved ones for the news as they may be the most appropriate person to talk to them. If it is decided that a relative breaks bad news, make sure they are fully supported.

Why do terminally ill patients or their relatives sometimes get angry?

Patients' and relatives' reactions vary immensely. Most remain calm and ask careful questions. A few are

accepting and philosophical. Some will become angry and overtly emotional. Anger is a natural response to the awareness of our own mortality. It may be specific or general and be expressed towards the patient themselves, the carer, other relatives, towards a member(s) of the professional team or against God.

Situations that often bring on anger in terminal care include perceived treatment or management, uncertainty and painful news. Often just listening to a patient or carer's concerns and allowing them to vent their anger helps enormously. Let the patient or carer tell you why they are angry.

Do not interrupt or dispute their recollections. You will find that once the anger has been expressed further interactions will be more fruitful. It is important to find out why and at whom the patient or carer is angry. The person may initially be angry at something trivial. The real reason may come out much later.

What do I do if the anger is directed towards me?

If a patient or carer becomes angry with you, look carefully at the care you have given. If you feel it is the best possible care, state firmly that you deeply regret they feel angry and that you and the team are doing your best. Do not be drawn into an argument. Arguments always make things worse and damage any future support. Acknowledge the patient or carer's anger and allow them to express themselves. Be attentive and sympathetic. Sometimes a cooling-off period may be better where it may be advisable for one of your colleagues to visit for a short while. But if care could be improved, ask the patient or carer what they would suggest and what they expect to happen – remember ideas, concerns and expectations.

At a later date the patient or carer may feel embarrassed about their outburst. If they apologise, accept humbly and reassure them that anger is understandable. Do not be patronising. If appropriate, emphasise the positive aspects of anger – it can sometimes trigger a change for the better.

How can I help my patients cope with family issues such as anger?

These are some of the ideas that many specialists and carers suggest to patients.

lLet others know what to expect and what not to expect. Do not feel you must keep the house perfectly neat and tidy because you always did in the past.

lLet people know what you can and cannot do.

lGive yourself time. You and your family may be able to adjust to the changes cancer brings. Just being open with each other can help ensure each person's needs are met.

lHelp your children (or grandchildren) understand that you were treated for cancer. Children of cancer survivors have said the following things are important:

– being honest with them

– speaking as directly and openly as possible

– allowing them to become informed about your cancer and involved in your recovery

– spending extra time with them.

lWith your permission, other family members should also be open with your children about your cancer and its treatment.

Tanvir Jamil, a GP in Burnham, Buckinghamshire, is on a year's sabbatical in Canada

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