Psychological Distress in End-Stage Oral Cancer: A Case Study of Palliative Care Challenges

Patient demographics and background

A 67-year-old illiterate male farmer from rural Chennai presented with Stage IV oral cancer. The patient lived in a joint family structure with his wife, three sons, three daughters, and their children. He had been the primary breadwinner through agricultural work since adolescence, having never attended formal schooling. The overall view is illustrated in Figure 1.

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Figure 1:

Conceptual framework illustrating the multifaceted nature of psychological distress in end-stage oral cancer, showing the interconnected factors contributing to severe distress and the intervention approach.

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Tobacco use history

The patient-initiated snuff use at age 25 years, consuming two packets daily for thirty-nine years. This habit was acquired through observational learning from his father, who also used snuff. The patient discontinued tobacco use three years prior to cancer diagnosis, at age 64 years. The detailed history is shown in Table 1.

Clinical presentation

The patient presented with advanced oral cancer characterized by visible lymph node swelling below the mandible, extending to the submandibular region. Disease progression rendered him unable to maintain oral nutrition, necessitating Ryle's tube feeding. Communication was severely impaired due to anatomical distortion and associated pain.

Systemic spread included lymph node involvement and distant metastases to multiple organs, including the brain. One cycle of palliative chemotherapy was administered, with further treatment deemed futile given the extent.

Psychological assessment

Mental status examination

Appearance: Visible facial swelling and anatomical distortion secondary to tumor progression

Behavioral observations: Maintained appropriate eye contact throughout assessment. Facial expressions were limited by pain and structural changes. Attitude toward examiner remained cooperative and appropriate.

Cognitive function: Orientation remained intact across all spheres. Abstract thinking ability was preserved. Attention and concentration were moderately impaired, likely secondary to pain and psychological distress.

Motor function: Both gross and fine motor skills demonstrated restlessness, consistent with anxiety and discomfort.

Mood and affect: Depressed mood with congruent affect. Patient demonstrated appropriate emotional responses to the situation's severity.

Speech: Significantly impaired audibility due to anatomical changes and pain.

Insight: Demonstrated good understanding of diagnosis and prognosis. Table 2 presents the Mental Status Examination findings observed during clinical evaluation.

Psychosocial factors

Intervention and management

Rural healthcare challenges

Several factors complicated the delivery of care, including limited healthcare literacy that affected the patient’s understanding of treatment options, geographic barriers restricting access to specialized cancer services, financial constraints that narrowed available management choices, and cultural factors that may have influenced acceptance and engagement with psychological interventions.

Psychological distress in terminal illness

The high distress score (8/10) aligns with literature demonstrating elevated psychological morbidity in advanced cancer patients.¹⁰ The multifaceted nature of distress encompassing physical symptoms, family concerns, and existential issues requires comprehensive intervention approaches. Research indicates that untreated psychological distress in cancer patients can significantly impact quality of life, treatment adherence, and family functioning.¹¹

Palliative care considerations

The decision to limit chemotherapy to one cycle reflects appropriate palliative care principles, prioritizing quality of life over potentially futile interventions.¹² However, the case highlights the need for enhanced psychological support services in palliative care settings, particularly in resource-limited environments.

Limitations

This case study has several limitations, including limited follow-up data to evaluate the effectiveness of the interventions, the absence of validated screening tools for depression and anxiety, a lack of formal psychological assessment of family members, and limited exploration of cultural and spiritual coping mechanisms that may have influenced the patient’s and family’s responses to end-of-life care.

Recommendations

Based on the findings from this case, several recommendations emerge, including the implementation of routine psychological distress screening for all patients with advanced cancer, development of comprehensive family support services that address both practical and emotional needs, enhancement of healthcare provider training in culturally sensitive end-of-life care, creation of accessible psychological support resources tailored for rural cancer populations, and promotion of integrated care models that foster close interdisciplinary collaboration between oncology and mental health services.