Module #7 http://www. growthhouse .org/ stanford END-OF-LIFE CARE: Module 7 Psychiatric Issues & Spirituality
Dec 15, 2015
Module #7http://www.growthhouse.org/stanford
END-OF-LIFE CARE:Module 7
Psychiatric Issues & Spirituality
Module #7http://www.growthhouse.org/stanford
Orientation
‘Non-ideal’ Fantasy Death Exercise
• No pain or other physical symptoms
• Where are you?
• What are you doing?
• Who is with you?
Module #7http://www.growthhouse.org/stanford
Distress in Dying Comes in Many Different Forms
Any ‘bad’ death is a medical emergency
Module #7http://www.growthhouse.org/stanford
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
Module #7http://www.growthhouse.org/stanford
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
Module #7http://www.growthhouse.org/stanford
Case Example
• You find your dying patient curled up in the bed, facing the wall, and unresponsive
• What might this patient be experiencing?
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Depression at the End of Life
• Not inevitable
• Under-recognized
• Under-treated
• Challenging to treat
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Evaluation of EOL DepressionLook for:
• Worthlessness, excessive guilt, self-loathing• Hopelessness, helplessness• Pervasive despondency, despair• Suicidal ideation• Social withdrawal• Tearfulness
Module #7http://www.growthhouse.org/stanford
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?”
Module #7http://www.growthhouse.org/stanford
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
Module #7http://www.growthhouse.org/stanford
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
Module #7http://www.growthhouse.org/stanford
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
Module #7http://www.growthhouse.org/stanford
Depression Normal Grief
Normal Dying
Depression Overlaps with Grief and Normal Dying
Module #7http://www.growthhouse.org/stanford
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
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Assessment
“What is worrying you?”
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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
Module #7http://www.growthhouse.org/stanford
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
Module #7http://www.growthhouse.org/stanford
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
Module #7http://www.growthhouse.org/stanford
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
Module #7http://www.growthhouse.org/stanford
Assessment
Reversible Medical Causes of Delirium at the End of Life:
• Urinary retention
• Constipation
• Pain
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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
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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
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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
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‘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
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GRIEF
• Keen mental suffering or distress over affliction or loss
• Sharp sorrow
• Painful regret
Webster’s College Dictionary, 1997
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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
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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
Module #7http://www.growthhouse.org/stanford
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
Module #7http://www.growthhouse.org/stanford
Grief and Loss: Temporal Element
• Preparatory or anticipatory grief
• Bereavement (after the patient dies)
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Preparatory or Anticipatory Grief
Losses for:
• The Patient
• The Family
• The Physician
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Patient Losses
• Self image• Functional status• Loved ones• Work• Simple pleasures• Future life
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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
Module #7http://www.growthhouse.org/stanford
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
Module #7http://www.growthhouse.org/stanford
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
Module #7http://www.growthhouse.org/stanford
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?
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Spirituality
“Whomever or whatever gives one a transcendentmeaning in life.” (Puchalski, 1998)
Module #7http://www.growthhouse.org/stanford
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”
Module #7http://www.growthhouse.org/stanford
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
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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
Module #7http://www.growthhouse.org/stanford
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)
Module #7http://www.growthhouse.org/stanford
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
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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
Module #7http://www.growthhouse.org/stanford
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
Module #7http://www.growthhouse.org/stanford
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
Module #7http://www.growthhouse.org/stanford
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
Module #7http://www.growthhouse.org/stanford
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