**4. Physical factors affecting caregiver distress**

Patients with advanced cancer usually have multiple physical symptoms, with varying degrees of severity. In addition to this, the symptoms burden is dynamic, i.e., ever changing in severity and pattern, as the disease profile changes. The **Table 2** shows the prevalence of common physical symptoms in an advanced cancer patient.

The caregiver of an advanced cancer has to be able to care for above symptoms. Seeing your loved one in pain or with anorexia can be a source of distress, caring for someone with dyspnea can be quite scary and cause a lot of distress in the caregiver. Due to fatigue, patients with terminal cancer are unable to carry out recreational or occupation activities and even sometimes activities of daily living. Their caregiver, usually a family member, is equally affected emotionally by the changes in life style the patient may have to make to adapt to constant fatigue. In an Indian study, the researcher asked about the most bothersome symptoms reported by parents of dying children. Pain (85%) and respiratory distress (73%) were the commonest [5]. Much of the fear is due to past experiences of uncontrolled symptoms. This eventually leads to anticipatory psychological distress in both patients and their caregivers. In India, many complex factors like cost, scarcity of medical facilities in remote areas, taboo, etc., contribute to reduced expert medical care opportunities and hospice care. Advanced cancer patients with smelly fungating wounds, oro-cutaneous malignant fistulas, large bed sores, bowel and bladder dysfunction are being managed primarily at home by caregivers. The caregivers have the added responsibility of taking over the nursing role, usually full time. This may leave little or no time for personal needs, being a source of distress. Consider a patient who has a colostomy due to malignant bowel obstruction, this patient will have body image issues. He may become socially recluse, irritable, depressed and feel overall limited by the colostomy bag. Seeing him in psychological pain, the patient's caregiver and loved ones may find it distressing. So, change in body image of a patient whether due to a stoma, or amputation, or mastectomy not only affects the psyche of the patient but their family members and caregivers.


**Table 2.**

*Prevalence of common symptoms in patients with advanced cancer. [4].*
