Psychiatry and End of Life Care

Question 1

Where do most people die? Where would people like to die?

Answer 1

500,000 people die a year – 60% in hospital or care homes, <6% in specialist hospice
And yet most people would prefer to spend their final days at home with loved ones

Question 2

What are some psychiatric conditions that might reduce life expectancy?

Answer 2

Dementia, severe eating disorders, depression and bipolar disorder, schizophrenia

Question 3

What are potential aetiologies of depression in patients with TI?

Answer 3

Multiple losses – physical and social functioning
Uncertain and feared future
Pain, constipation, metabolic upsets
Treatment side effects
Neuroinflammation and endocrine effects of disease +/- treatment
A direct effect of cancer at neurotransmitter level

Question 4

What is important with diagnosing depression in patients with TI?

Answer 4

Needs to focus on the psychological (low mood, guilt, hopelessness, anhedonia etc) rather than somatic aspects of depression as sleep, appetite and energy will all be changed by the illness and its treatment

Question 5

What should you use to assess depression in patients with TI?

Answer 5

The Endicott criteria
Simply asking ‘Are you depressed?’ has high sensitivities in in-patient palliative settings
The Hospital Anxiety and Depression (HAD) scale has been validated
Traditional rating scales should not be used as they put too much weight on somatic symptoms

Question 6

What is the Endicott criteria?

Answer 6

Presence of >5/9 symptoms over the past 2wks is highly suggestive of depression in the terminally ill:

1) Fearful or withdrawn appearance
2) Social withdrawal or decreased talkativeness
3) Psychomotor retardation or agitation
4) Depressed mood, subjective or observed
5) Marked diminished interest or pleasures in most activities, most of the day
6) Brooding, self-pity or pessimism
7) Feelings of worthlessness or excessive or inappropriate guilt
8) Recurrent thoughts of death or suicide
9) Mood non-reactive to environmental events

Question 7

What is the prevalence of delirium in general hospitals? What about in EoL settings?

Answer 7

11-42% in general hospitals, the same in inpatient palliative units but increasing up to 88% in the days and hours before death
30-50% of cases – especially those caused by medication – are reversible, the remainder are progressive and irreversible
Causes, presentation (hyper/hypoactive/mixed) and management are largely the same but making sure to minimise the amount of unnecessary investigation looking for biological causes

Question 8

What is necessary for the diagnosis of delirium?

Answer 8

Disturbance of attention/awareness
Recognition of the acute change from baseline and fluctuations
An additional disturbance in cognition
A medical aetiology

Question 9

What screening tools are available for delirium?

Answer 9

Confusion Assessment Method (CAM)
Nursing Delirium Rating Scale (Nu-DESC)
Single Question in Delirium (SQiD) 
For severity assessment: 
Memorial Delirium Assessment Scale (MDAS)
Delirium Rating Scale, revised (DRS-R)

Question 10

What is adjustment disorder?

Answer 10

Conceptually – an intermediate health condition between a normal response to stress and more severe emotional disorders
c.15.4% in patients with advanced cancer (increasing to 24.7% when combined with depression)
Can be managed with antidepressants if severe + prolonged
Benzodiazepines should be avoided in all but very short-term as inhibit psychological processing
Often the de-pathologising of distress + reassurance + good communication is enough

Question 11

How do anxiety and panic present in people living with a TI?

Answer 11

Studies of cancer patients reveal:
7.6% meet criteria for anxiety disorder – more likely to be younger, female and have poorer physical health
Patients are less likely to trust their doctors, less likely to ask questions, less likely to understand information imparted
Symptoms are similar, often comorbid with depression; anticipatory anxiety associated with chemotherapy; uncontrolled pain, hormone-secreting tumours, withdrawals from alcohol/opioids/benzos, use of steroids/bronchodilators/stimulants can all lead to anxiety states

Question 12

How should you manage dementia from a palliative perspective?

Answer 12

Palliative care should be available from the time of diagnosis
Advance care plan is important – communication aids, delirium planning, pain management, no tube feeding etc
Anticipatory grief management of family members including maximising positive experiences with the patient

Question 13

What is essential for the physical management of the TI patient?

Answer 13

Maintaining hydration 
Reviewing medication + discontinuing any that aren’t providing symptomatic benefit or may cause harm 
Management of pain symptoms 
Management of breathlessness 
Management of nausea and vomiting

Question 14

What are some methods for the psychological management of the TI patient?

Answer 14

Dignity Therapy
Meaning-Centred Therapy
Managing Cancer & Living Meaningfully (CALM)

Question 15

What other management should be implemented?

Answer 15

Social workers, OT, PT, chaplaincy, lawyers, financial review

Question 16

What are the stages of loss?

Answer 16

Elisabeth Kubler-Ross 5 stages:
1) Denial + shock 
2) Anger 
3) Bargaining 
4) Depression 
5) Acceptance 
Though these don’t have to be linear or in isolation 
Individuals earlier attachments and the nature/strength of these are likely to change how the person relates to loss broadly and to specific things

Question 17

What are the 8 dimensions of distress experienced by seriously ill patients and their families? (Ferris, 2002)

Answer 17

1) Disease management – diagnoses, prognoses, evidence, complications/comorbidities, adverse treatment effects
2) Physical – pain + symptoms, level of consciousness and cognition, functioning (motor, sensory, organ systems, sexual), fluids + nutrition, habits e.g. alcohol, smoking
3) Psychological – personality, strengths, motivations, fears, loneliness, anger, control, dignity, self-image/esteem
4) Social – cultural values/practices, relationships, community, privacy vs intimacy, routine, finances, legal (PoA, ADs, Wills)
5) Spiritual – meaning, value, beliefs, practices, community
6) Practical – ADLs for personal and household activities, caregiving, dependents, transport, connectivity
7) EoL care/death management – goodbyes + tying up ends (business etc), gift giving (incl. organs), legacy, preparation, anticipation of physiological changes in last hours of life, ritual, peri-death care of family, funerals/memorials/celebrations
8) Loss, grief – acute, chronic, anticipatory, bereavement planning, mourning

Question 18

What things are important in the care of the family of those with TI?

Answer 18

Emotional burden of learning about the illness and its terminal nature means relinquishing the hope of a cure
Everyone needs support to plan for the various decisions that need to be made
If family is palliating patient at home, there is a direct caregiving burden as well as an emotional one
After the death – bereavement needs need to be managed + monitored for risks of psychiatric illness/suicide
Key points of help: timely, frequent and consistent communication that is geared to need; encouragement of family planning and awareness of family conflicts; accommodation of family’s grief; refocussing of hope and on the patients wishes; attending to the comfort of the patient and following up with the family after death
Psychiatrists must be aware of the stresses put on themselves – external supervision and support of a cohesive palliative team is essential