http:// module #7 end-of-life care: module 7 psychiatric issues & spirituality

Module #7http://www.growthhouse.org/stanford

END-OF-LIFE CARE:Module 7

Psychiatric Issues & Spirituality

http://sfdc.stanford.edu/


Orientation

‘Non-ideal’ Fantasy Death Exercise

• No pain or other physical symptoms

• Where are you?

• What are you doing?

• Who is with you?



Distress in Dying Comes in Many Different Forms

Any ‘bad’ death is a medical emergency



Learning Objectives

• Identify and treat EOL depression, anxiety, delirium, and grief

• Demonstrate the ability to take a spiritual history

• Define possible physician roles in the spiritual life of the patient/family

• Incorporate this content into your clinical teaching



Outline of Module

• Psychiatric and social aspects of EOL care– Depression– Anxiety– Delirium– Grief/bereavement

• Assessment and care of spiritual distress• Personal goals• Conclusion of the ELC course



Case Example

• You find your dying patient curled up in the bed, facing the wall, and unresponsive

• What might this patient be experiencing?



Depression at the End of Life

• Not inevitable

• Under-recognized

• Under-treated

• Challenging to treat



Evaluation of EOL DepressionLook for:

• Worthlessness, excessive guilt, self-loathing• Hopelessness, helplessness• Pervasive despondency, despair• Suicidal ideation• Social withdrawal• Tearfulness



Quick Depression Screen

• “Do you find yourself depressed most of the time?”

• “As compared to other people in your situation, do you feel that you are depressed?”

• “Inside yourself, how do you feel about yourself?”



Risk Factors for Clinical Depression at the End of Life

• Poorly controlled pain• Advanced illness• Alcoholism or other substance abuse• Pancreatic cancer, stroke, untreated

hypothyroidism • Medications• Personal or family history of affective disorder• Other pre-existing psychiatric diagnosis• Multiple losses



Depression Medications:Advantages & DisadvantagesTricyclics and

Atypical

Antidepressants

Documented co-analgesic effect, especially in neuropathic pain

Time to onset 14-28 days

Side effects

SSRIs Speed of onset

Well tolerated

Less clear co-analgesic effect with neuropathic pain

Psychostimulants Quite safe

Cardiotoxicity is uncommon with low doses

Rapid onset

Contraindicated in depression associated with anxiety or delirium



Non-pharmacological Interventions

• Supportive counseling within context of medical visit– Understand what’s bothering them– Explore content– Mobilize support

• Improve quality of life issues

• If appropriate, refer



Depression Normal Grief

Normal Dying

Depression Overlaps with Grief and Normal Dying



What is Unique About Anxiety at the End of Life?

• Anxiety is inevitable, part of being human

• What factors associated with dying might raise anxiety?

• Assessment

• Treatment



Assessment

“What is worrying you?”



Types of Treatment for Anxiety

• Explore content; avoid premature reassurance• Normalize perceptions, feelings, and

experiences• Provide updated information• Include, reassure, and support family• Identify past strengths and successful coping

strategies• Facilitate use of behavioral interventions• Benzodiazepines



Delirium Very Close to Death

• Very common at the end of life (estimated 50%)• Can be very troublesome to patients, families,

and clinicians• May differ significantly from non-terminal

delirium• May challenge our traditional assumptions • May have implications for effective treatment



Differentiating Delirium from Dementia

• Shared clinical features:– Impaired memory, thinking, judgment, orientation

• Dementia: – Relatively alert– Little or no clouding of consciousness– Gradual onset

• Delirium:– Disturbance in level of consciousness– Fluctuation of symptoms– Acute onset



What is ‘Terminal’ Delirium?

Terminal Delirium• Occurs in advanced

stage of dying• Relatively refractory to

clearing through medical interventions

Non-Terminal Delirium• Can occur in any

fragile patient, especially geriatric patients when very ill

• Usually has a correctable underlying cause



Assessment

Reversible Medical Causes of Delirium at the End of Life:

• Urinary retention

• Constipation

• Pain



Treating Delirium Close to Death

• Differences common in terminal delirium:• Expect normal lab values in the actively dying

patient• You probably won’t be able to normalize

metabolic status• Often not reversed by withdrawing analgesics• Decreasing opioids can exacerbate distress• Sedating medications are often used to treat

terminal delirium



Special Interventions for Terminal Delirium

• Reassure patient and family

• Create or maintain peaceful environment

• Medicate: what is your goal?

• Refer to specialist if response is poor



Medications for Terminal Delirium

• Neuroleptics (arranged from least sedating)– Haloperidol – Thioridazine – Chlorpromazine

• Benzodiazepines– Sedating but may worsen confusion

• Barbiturates and Anesthetics – For severe delirium

• Avoid opioids for sedation



‘Confusion’ without Distress

• Pleasant visions or hallucinations– Dead relatives, guardian beings, young children, or

babies

• Requires no intervention– Benzodiazepines can increase confusion: avoid

• Reframe positively if family is distressed– May also need to reframe for staff members



GRIEF

• Keen mental suffering or distress over affliction or loss

• Sharp sorrow

• Painful regret

Webster’s College Dictionary, 1997



Eight Myths about Grief

Myth 1: We only grieve deaths

Reality: We grieve all losses

Myth 2: Only family members grieve

Reality: All who are attached grieve

Myth 3: Grief is an emotional reaction

Reality: Grief is manifested in many ways



Myths 4-6

Myth 4: Individuals should leave grieving at home

Reality: We cannot control where we grieve Myth 5: We slowly and predictably recover from

grief Reality: Grief is an uneven process, a roller

coaster with no timeline Myth 6: Grieving means letting go of the person

who has died Reality: We never fully detach



Myths 7-8

Myth 7: Grief finally ends

Reality: Over time most people learn to live with loss

Myth 8: Grievers are best left alone

Reality: Grievers need opportunities to share their memories and grief, and to receive support

Doka, 1999



Grief and Loss: Temporal Element

• Preparatory or anticipatory grief

• Bereavement (after the patient dies)



Preparatory or Anticipatory Grief

Losses for:

• The Patient

• The Family

• The Physician



Patient Losses

• Self image• Functional status• Loved ones• Work• Simple pleasures• Future life



Family Losses

• The dying person

– As he/she was

– As she/he might have become

• Customary family roles

• Financial stability

• A shared past

• A shared future



Bereavement

Normal• Broad cultural range• See/hear the dead person soon

after the death• No absolute time markers• Gradual adjustment

Complicated

Symptoms:• Clinical Depression• Psychosis• Lack of progress over time

Risk factors:• Traumatic, violent,

unexpected deaths• Death involving children• Multiple losses• Overt mental illness



What You Need to Do:

• Consider bereavement consultation prior to death where complicated bereavement is likely

• Refer complicated bereavement

• Insure institutional mechanism for follow-up bereavement call to all families

• Be prepared for questions only a physician can answer



Discussion: Physician Loss

• Physicians experience loss around death in caring for patients

• Bring a specific patient to mind

• What was this loss about for you?



Spirituality

“Whomever or whatever gives one a transcendentmeaning in life.” (Puchalski, 1998)



Patients’ Spiritual Concernsthat will Require Your Response...

“Why did God do this to me?”

“What do you think will happen to me when I die?”

“Doctor, do you believe in God (or Jesus, heaven, etc)?”

“I know this is God’s will. Only God knows when someone will die, so…” (either)– “…keep my loved one on life support forever” – “…I don’t need therapy because I’m waiting

for a miracle”



Concerns Physicians Have About Addressing Spirituality

• Science versus religion

• Not my job (division of labor)

• Don’t wish to impose my beliefs on others

• Don’t want others to impose their beliefs on me



1997 Gallup Poll

• 65-70% of people polled in the U.S. say if they are in distress, they want their physicians to address their spiritual issues

• Only about 10 % of physicians actually do



Spiritual Assessment

• F: Faith or beliefs– “Tell me something about your faith or beliefs.”

• I: Importance & influence– “How does this influence your health/well-being?”

• C: Community

– “Are you part of a supportive community?”

• A: Address or application

– “How would you like me to address these issues in your health care?”

(Puchalski, 1999)



Application Exercise

• A’s: Interview the person on your left (= B)

Experiment with finding your own comfortable way to ask the questions

• B’s: It is your choice who to “be”: a patient, yourself, make something up, etc.

• After 3 minutes, switch roles



Debrief

• How was that for you?• What did it feel like to ask these questions?• How did it feel to be asked?• What, if anything, did you find difficult?• What was surprising?• What did you learn



Interventions

• Affirm

“This is very important for you.”

“This is a real source of strength for you, isn’t it?”

“It takes courage to grapple with these things.”• Share your beliefs as appropriate (do not

impose)• Facilitate environmental support for ritual• Refer as appropriate



Learning Objectives

• Identify and treat depression, anxiety, delirium, and grief at the end of life

• Take a spiritual history

• Define possible physician roles in patient’s spiritual life

• Incorporate this content into your clinical teaching



Self-Rating Exercise II((Self-Rating Scale: 1 = Low to 5 = High)

Knowledge, Skills, Attitudes Confidence to Teach

1 2 3 4 5 1 2 3 4 5Module Titles Overview: Death and Dying

in the U.S.A.Pain ManagementCommunicating with Patients

and Families Making Difficult Decisions Non-Pain Symptom

ManagementVenues and Systems of CarePsychiatric Issues and

Spirituality



ELC Curriculum Goals

• To enhance physician skills in ELC

• To foster a commitment to improving care for the dying

• To improve the dying experience for patients, families, and health care providers

• To improve teaching related to ELC


http:// module #7 end-of-life care: module 7 psychiatric issues & spirituality

Documents

delirium slide

normal dying slide

outline of module psychiatric

depression medications

clinical depression

medical emergency slide

clinical teaching slide

elc course slide