Background    Anger is a common emotion expressed by seriously ill patients and their families.  A 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 particularly helpful coping strategies.  A guide to managing these situations is presented below.

Look for the underlying 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; and 3) personality style/disorder – the person whose approach to much of life is via anger or mistrust.

Recognize the direction of anger.     Recognizing the difference between internal and external anger is critical to effective management, because internal anger may lead to potentially harmful patient consequences.  When the patient directs anger internally because of fear and guilt (e.g. I didn’t take care of myself; I’m abandoning my family.), this can lead to withdrawal, self-neglect, anxiety, depression, or a combination of these.   Others direct their anger outward at physicians, hospitals, family members or a deity. Particularly in the case of an angry parent of a dying child, he or she may feel helpless and guilty about many things – not bringing the child for medical care soon enough, not being a loving enough or “great” parent (1).  This internal guilt and blame can then be displaced towards health care professionals.

Engage rather than withdraw from the patient.  The natural tendency for clinicians is to cut short the office or hospital visit, find ways to avoid contact with the angry patient or family member, or to try to mask his/her own anger in order to continue to interact with the patient.  Robert Houston MD has written a very helpful article listing 10 rules for engaging the dying patient which will have a beneficial impact on the physician/patient relationship and the quality of the patient’s end-of-life experience (2).  One of his most important tips is to refrain from personalizing the anger when the patient accuses you of “missing the diagnosis” or under treating the pain.  Some of his rules which are pertinent to this discussion are:

• Engage the patient, but do not enmesh with and do the emotional work for the patient.
• Maintain adult-adult communication rather than fostering the patient’s dependency.
• Do not personalize the patient’s anger.
• Adopt a patient-centered worldview by ascertaining his/her values, priorities, hopes.
• Normalize anger so that the patient can move through this stage.

Use the “BATHE” approach to create an empathic milieu (3).    As with any difficult patient situation, communication techniques are especially important so that both the patient and physician do not become further embittered and frustrated.

• Background:  Use active listening to understand the story, the context, the patient’s situation.
• Affect:  Name the emotion; for instance, 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 such as I know what you’re going through.  Paraphrasing the patient’s comments is an effective way to convey that you heard and are seeking to understand: You feel like it’s so unfair that the cancer appeared out of nowhere after all these years.

Summary    The journey from life to death almost always is accompanied by some degree of anger. A caring, patient clinician can assist the patient and the family in recognizing, mobilizing, and modifying the anger into positive emotional energy. Established communication approaches are available such as BATHE which have shown improvements in self-efficacy for communicating with angry patients.

References

1. Grossman L.  Understanding anger in parents of dying children.  Am Fam Physician. 1998; 58(5):1211-2.
2. Houston RE.  The angry dying patient. Prim Care Companion J Clin Psychiatry. 1999; 1:5-8.
3. Stewart MR, Lieberman J, III.  The Fifteen Minute Hour:  Applied Psychotherapy for the Primary Care Physician. 2nd Edition.  Westport, CT: Praeger Publishing; 1993.
4. Rueth TW, Hall SE.  Dealing with the anger and hostility of those who grieve.  A J Hos Pall Care. 1999; 16:743-746.
5. Bialer PA, Kissane D, et al.  Responding to patient anger: Development and evaluation of an oncology communication skills training module.  2011; 9: 359-65.

Version History:  This Fast Fact was originally edited by David E Weissman MD.   2nd Edition published July 2006; 3rd Edition May 2015. Current version re-copy-edited April 2009; then again May 2015.