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This chapter looks closely at some of the more fine-grained processes of clinical care in order to suggest how cancer, as an emergent issue in African public health, forces longstanding questions of palliation to the foreground and highlights the intensely social nature of pain. It explores the conditions that facilitate the marginalization of pain and palliation in African clinical practice and in global health more widely, and examines the contemporary clinical dynamics that engender this marginalization in the specific context of oncology, where many patients suffer severe and intractable pain, as a result either of their illness or the effects of biomedical therapies. In other words, the chapter explores how and why biomedicine proceeds in Africa with so little palliation and so much compliance. The context for this ethnography is Botswana's lone cancer ward, where the author has been researching conditions of care since 2006.

Clinicians and researchers have been challenged to understand how fatigue may be related to depression and anxiety in patients with cancer. The need to understand this relationship stems from two basic facts: fatigue, in addition to being a symptom of cancer and its treatment, is a symptom of certain mood and anxiety disorders and depression and anxiety, like fatigue, are relatively common among cancer patients. This chapter asks several questions. First, what are the conceptual similarities and differences between fatigue, depression, and anxiety? Second, to what extent do depression and anxiety co-occur with fatigue, and how might they be distinguished? Third, what are the possible causal relationships between fatigue and depression and between fatigue and anxiety? Fourth, what are the treatment implications of the relationship of fatigue to depression and anxiety?

This chapter discusses how music therapy can help parents and infants affected by cancer. One of the most profoundly distressing aspects for parents with cancer is imagining that they will not be around to see their children grow up. Parents with infants with life threatening conditions may be so consumed by their own distress, fear, and anticipatory grief that they find it difficult to respond to the comfort needs of their children. Music therapy offers a range of methods that support parent-infant connectedness and attachment; promoting healthy relating and providing comfort for the work of adjustment which follows. Music therapy allows the experience of helpful musical moments, strategies, and legacies. This enables parents and infants to live more adaptively in the time available together and if ultimately separated, this prior experience can support infants' negotiation of future developmental transitions while easing the experience of bereavement.

There are always challenges to the initiation of new programmes in healthcare, especially given the propensity for politics to dominate decision-making in the healthcare system. Consequently, programmes that may intuitively be in the best interest of patients, even those supported by good science, often have to wait. Clearly then, we must learn to effectively communicate who we are, what we do, and how we can improve healthcare outcomes in a biopsychosocial world. In psychosocial oncology these communication issues are ubiquitous. This chapter discusses the impact of the psychosocial aspects of cancer and why psychosocial programme development should be considered as a key piece of the armamentarium in the fight against cancer. It also looks at communication strategies that might prove helpful for the development of psychosocial oncology programmes. A number of large studies exist that identify emotional distress as a significant challenge to cancer patients. This chapter examines the role of psychosocial oncology in comprehensive cancer care and the business aspects of psychosocial care.

A multidisciplinary team is a collection of individuals who are interdependent in their tasks, who share responsibility for outcomes, who see themselves and are seen by others as an intact social entity embedded in one or more larger social systems. Although there are emerging descriptions of the composition of multidisciplinary teams in cancer care, there is a paucity of research data to guide recommendations about the particular strategies that are likely to be of benefit in promoting optimal team functioning. In addition to the ‘obvious’ members of a team, such as pathologist, radiologist, surgeon, medical oncologist and radiation oncologist, the presence of allied health professionals enhances capacity for comprehensive treatment of cancer patients. This chapter also considers the impact of poor communication within multidisciplinary teams on outcomes and how communication skills training can address this problem.

Extensive research has shown that cancer, and the treatment thereof, can interfere with healthy sexual functioning. Indeed, sexual dysfunction is frequently cited as one of the top adverse effects of cancer treatment. However, while healthcare professionals routinely discuss quality-of-life issues with cancer patients, the literature suggest that too often this does not include an assessment of sexual concerns. The responsibility to initiate discussion on sexuality rests with the healthcare professional. Establishing the sexuality information needs of the cancer patient can sometimes be difficult and it becomes more so when healthcare professionals make erroneous assumptions concerning sexuality. Whether or not to assess sexuality is no longer an issue; it must be a routine part of cancer care. While there are several different models of intervention for patients suffering from sexual difficulties, the PLISSIT model is frequently used in cancer centres and can easily be adapted to various types of practice. The model describes four progressive levels that can be used to guide assessment and intervention: permission, limited information, specific suggestions, and intensive therapy.

This chapter examines organizational resilience within the National Health Service and cancer and palliative care in Great Britain. It explains that organizational resilience can be considered as the characteristic of managing the organization's activities to anticipate and circumvent threats to its existence and primary goals and this is shown in an ability to manage severe pressures and conflicts between safety and the primary production or performance goals of the organization. It provides an evaluation of the resilience of the NHS in the various aspects of its operation.

As the UK's leading holistic cancer charity, Penny Brohn Cancer Care (formerly the Bristol Cancer Help Centre) has pioneered the Bristol Approach to care for cancer patients and those close to them. This approach to cancer care works alongside mainstream cancer treatment, providing a combination of physical, emotional, and spiritual support, using complementary therapies and self-help techniques including practical advice on nutrition. Interventions on offer include group sessions, meditation and healing, relaxation and imagery techniques, counselling and psychotherapy, nutritional advice, touch therapies, creative therapies, gentle exercises, and integrative medical sessions. This chapter discusses the results of qualitative research on the Bristol Approach and describes education for healthcare professionals and complementary therapists.

Experience alone is not enough to ensure optimal doctor-patient communication at the end of life — formal communication skills training (CST) is necessary to produce improved outcomes. This chapter outlines the goals and strategies for end-of-life CST, emphasising common decision-making dilemmas, such as withdrawal of life-extending treatment and do-not-resuscitate directives. Common pitfalls seen in training are identified. The goal of end-of-life communication training is discussed, along with smoother implementation of palliative care, patient-centred communication in cancer care, and specific strategies for end-of-life communication such as gathering specific information about wishes and thoughts regarding death and dying.

Patient adherence (also termed compliance or concordance) involves the degree to which a patient carries out, correctly and completely, the medical regimen recommended by the patient's health professional. The regimen can involve medications, screenings, appointment-keeping, dietary management, and/or other treatments and life-style changes. Persistence refers to following a course of treatment for the entire period of time it is prescribed. In the context of cancer care, patients may be required to adhere to adjuvant hormonal therapy, faithfully attend all chemotherapy or radiation appointments, appear for regular follow-up screenings, and/or make recommended changes in diet and exercise patterns. This chapter discusses the importance of adherence, as well as the reasons why adherence may be difficult for cancer patients; the value of providers' awareness of their patients' non-adherence, and their open discussion and collaboration to help their patients achieve adherence; and the communication process that facilitates adherence. It also delineates specific strategies within healthcare provider-patient communication that can be used to promote adherence.

In Australia, management of cancer patients occurs along a continuum starting with screening and diagnosis, through treatment and supportive care, to follow-up, and, in some cases, palliative and end-of-life care, with services provided in both tertiary and primary settings. Communication skills training for health professionals involved in cancer care is available in Australia through a number of avenues. Courses and workshops are provided through professional colleges representing different disciplines involved in cancer care, cancer organisations, and local service providers, in both the public and private sectors. The majority of formal communication skills training occurs at the postgraduate level, primarily in the form of interactive workshops implemented by one or more trained facilitators. This chapter describes current approaches to communication skills training for oncology health professionals in Australia, including the benefits and limitations of the current model, as well as future directions and priorities. It also describes the National Breast and Ovarian Cancer Centre's National Communication Skills Training Initiative.

As with other professions, pharmacists have experienced a change from traditional drug-oriented services, including distribution and preparation, toward patient-oriented services. Many professional organisations and societies believe that pharmacists have a pivotal role in the provision of information in oncology, hospice and palliative care; pharmacists should be integral members of interdisciplinary teams. High-quality cancer care requires both traditional and expanded pharmacist activities, including a variety of clinical, educational, administrative and support responsibilities. This chapter describes the pharmacists' roles and responsibilities in the provision of care to cancer patients, with a particular emphasis on communication and the promotion of patients' treatment adherence.

The task of navigating the maze of potential complementary and alternative medicine (CAM) treatments and integrating CAM into a personal cancer care plan is often complex, time-consuming, and stressful. It can also be empowering, health enhancing, and life transforming. A trusted and wise guide can provide valuable support for people along this journey. There are many facets to the role of a guide, depending on the individuals concerned and their circumstances. These might include helping them decide what they want from CAM, finding the right therapy and therapist, evaluating CAM interventions, preventing adverse effects, and co-ordinating their care while keeping sight of the bigger picture. Family doctors have a range of skills and attributes that make them eminently suited to being such a guide and this can be a tremendously satisfying and rewarding role.

Reflexology is practised in many countries and has an ancient history. It involves working on the feet and besides increasing comfort, relaxation, and well-being for patients and carers, it can help to relieve cancer-related symptoms such as anxiety, pain, nausea, and lethargy. It is not unusual to find this therapy available within hospices but there have been concerns about its use when patients are receiving medical treatments such as radiotherapy and chemotherapy. This chapter reviews the theories and practice of reflexology, explores research evidence, and reports on innovative approaches to adapt treatments for cancer patients and their carers in cancer care settings. It also discusses the ‘reflexology package’ in the cancer care setting and myths surrounding reflexology.

Clinicians must be prepared to allow the expression of a variety of emotions, including anger, in cancer care. There are times during the illness when emotional responses may be anticipated, such as when a patient is first diagnosed with cancer, when a recurrence occurs, or when the disease is progressing despite anti-cancer treatments. There will be other times when the physician is unaware of the particular stimulus for emotional distress. A seemingly benign discussion can result in an unexpected response. Additional sources of vulnerability do occur in the lives of cancer patients, not directly related to the cancer care. To be supportive, physicians must be skilled in the delivery of empathic responses when dealing with a difficult patient. These are teachable skills. The assessments of physicians and their responses will vary according to the acuity or chronicity of the emotions expressed. This chapter takes the angry patient as one example of an emotionally difficult encounter and offers a model as to how the clinician can respond. This approach can be applied to a range of other challenging interactions.

Acupuncture is a therapeutic technique that evolved from ancient Oriental theories and practices of medicine. Since the 1970s, it has become increasingly popular in the West as a means of preventing and treating a variety of disorders. In cancer care, it is used to complement conventional management, helping to control cancer symptoms and the side effects of treatment, as well as being used in the supportive care of cancer patients. It is suitable at any stage of the cancer experience, from diagnosis through active treatment, in palliative and end of life care, and to support survivors in re-establishing their lives. This chapter focuses primarily on the use of needling and moxibustion, as used in traditional forms of acupuncture. First, it defines acupuncture and discusses its history as well as modes of action. It also examines the evidence base on the effectiveness of acupuncture in managing cancer pain, chemotherapy-induced nausea and vomiting, breathlessness (dyspnoea), dry mouth (xerostomia), hot flushes and night sweats, anxiety and depression, immune function, and in treating overall well-being. The contraindications of acupuncture are also considered.

Family meetings in oncology occur most commonly in four settings. The first is soon after diagnosis, when the cancer patients and their families are being oriented to the disease, potential treatment options, and the system of care with available supports. The second is in the setting of an inpatient admission, when goals of care need to be re-defined and treatment options reviewed. The third is during palliative care, where the support of the family in planning ongoing care is essential to optimise such care. And the fourth is when there is conflict about the direction of cancer care, sometimes in the setting of a patient without capacity, when the medical staff and the patient's healthcare agent disagree with goals of care and treatment. Family meetings are commonly held in paediatric oncology or genetic counselling settings. This chapter describes a model of conducting the basic, planned family meeting in the setting of a patient with advanced disease. It discusses communication skills used in facilitating family meetings and the key process tasks in conducting such meetings.

Shared decision-making (SDM) between physician and patient is now widely considered to be a desirable goal in many healthcare contexts. However, little is known about current SDM practice in cancer care. Moreover, there are few data about physician perceptions of SDM or about outcomes for cancer patients. Now, most cancer patients are told the diagnosis, and expect to be informed about their disease and its treatment. There are many reasons for the recent increased emphasis on patients' rights. As communities have become better educated and information about healthcare issues has become more accessible, a fundamental shift in society's expectations of the appropriate role for physicians has occurred. Surveys of patients with advanced cancer have revealed not only that patients' desire for information and involvement in decision-making is high, but also that patients whose condition has recently worsened are more likely to want progressively less involvement in decision-making. This chapter reviews the literature pertaining to the potential relevance of the particular patient circumstance and the consequences for embracing SDM.

Technological advances have made the observation and analysis of large numbers of medical visits feasible, and indeed, the number of empirical studies of communication between doctors and patients has grown markedly over the last three decades. The Roter Interaction Analysis System (RIAS) has emerged over this period as the single most widely used system of medical interaction assessment worldwide. It has been used in more than 150 communication studies conducted in North America, Europe, Asia, Africa, and Latin America. These studies have described communication across a spectrum of medical specialties and healthcare settings, including adult and paediatric primary care, emergency medicine, obstetrics and gynaecology, surgery, nursing, podiatry, genetic counselling, family planning services, dentistry, and veterinarian practice, as well as cancer care and palliative care. This chapter provides a broad overview of the characteristics of RIAS and illustrates its contribution to the field of cancer communication by reviewing a body of cancer and palliative care studies in which the RIAS has been used.