1. 
   

   What steps are most likely to relieve caregiver distress?

   
   
2. 
   

   What steps are most likely to address a patient’s anger?

   
   
3. 
   

   What questions have been found to be moderately effective in screening for health care literacy?

   
   
4. 
   

   What is the FICA Spiritual History Tool?

Psychosocial aspects of care influence patient outcomes, compliance, and decision making. Patients experience illness within the context of their cultural and spiritual experience and do so surrounded by a network of family and caregivers. This chapter will identify and discuss the assessment and management of cultural, spiritual, and family caregiver aspects of care.

Emotional Distress

Response to emotional distress is an important aspect of forging the therapeutic relationship. Patient encounters may reveal intense emotions such as fear, anger, sadness, and hopelessness, especially when patients face unexpected serious or life-threatening illness. The patient may already be experiencing significant life stressors prior to hospitalization, such as divorce, death or illness of a close relative, financial worry, difficulty with family relationships, or substance use or abuse. The patient may have undiagnosed or undertreated psychological or behavioral issues including anxiety or depression. When presented with empathetic opportunities, physicians often shift their focus to biomedical explanations. Responding to emotional distress with a supportive approach can help promote an atmosphere of trust, improved patient satisfaction, and better patient outcomes (Table 218-1).

When clinicians encounter anger, they should determine whether the source of the anger is internalized (eg, related to fear, loss of control, being a burden, or a result of anticipatory grief of life goals not accomplished) or externalized (eg, directed at others including health care providers). Personal feelings of guilt or fear may lead to anxiety, depression, or self-neglect. Effectively addressing anger may build trust and a strong therapeutic relationship, which are essential to optimal care (Table 218-2).

Caregiver Burden

Similar to a chronic stress experience, care giving creates physical and psychological strain over an extended period of time. The often unpredictable and uncontrollable nature of chronic disease, such as the need to be hospitalized, can cause additional distress in multiple life domains including family and work relationships. It has been suggested that physicians should support family caregivers in five key areas (1) excellence in communication with the family, (2) advance care planning and clear decision making, (3) support for home care, (4) empathy for family emotions and relationships, and (5) attention to grief and bereavement (Table 218-3).

Financial Burden of Disease

The economic impact of illness is substantial to patients, families, and our health care system. It is estimated that 16% of families spend more than one-twentieth of their income on health care. Thirty-nine percent of terminally ill patients reported that health care costs have caused moderate or severe financial problems for them or their families. Health care costs have the potential to leave patients and families in financial ruin. In a 2007 study, it was estimated that 62% of all bankruptcies were due to medical care. The bankrupt patients and families, typically middle class, educated, homeowners, may then join the ranks of the uninsured or underinsured as a result. It is estimated that medical end-of-life care consumes 10% to 12% of the total health care budget in the United States and 27% of the Medicare budget.

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