END-OF-LIFE CARE: Module 7

1. END-OF-LIFE CARE:Module 7 • Psychiatric Issues & Spirituality Module #7

2. Orientation • ‘Non-ideal’ Fantasy Death Exercise • No pain or other physical symptoms • Where are you? • What are you doing? • Who is with you? Module #7

3. Distress in Dying Comes in Many Different Forms • Any ‘bad’ death is a medical emergency Module #7

4. 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 #7

5. 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 #7

6. Case Example • You find your dying patient curled up in the bed, facing the wall, and unresponsive • What might this patient be experiencing? Module #7

7. Depression at the End of Life • Not inevitable • Under-recognized • Under-treated • Challenging to treat Module #7

8. Evaluation of EOL DepressionLook for: • Worthlessness, excessive guilt, self-loathing • Hopelessness, helplessness • Pervasive despondency, despair • Suicidal ideation • Social withdrawal • Tearfulness Module #7

9. 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 #7

10. 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 #7

11. Depression Medications:Advantages & Disadvantages Module #7

12. 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 #7

13. Depression Overlaps with Grief and Normal Dying Depression Normal Grief Normal Dying Module #7

14. 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 Module #7

15. Assessment • “What is worrying you?” Module #7

16. 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 #7

17. 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 #7

18. 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 #7

19. 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 What is ‘Terminal’ Delirium? Module #7

20. Assessment • Reversible Medical Causes of Delirium at the End of Life: • Urinary retention • Constipation • Pain Module #7

21. 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 Module #7

22. 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 Module #7

23. 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 Module #7

24. ‘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 Module #7

25. GRIEF • Keen mental suffering or distress over affliction or loss • Sharp sorrow • Painful regret Webster’s College Dictionary, 1997 Module #7

26. 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 Module #7

27. 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 #7

28. 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 #7

29. Grief and Loss: Temporal Element • Preparatory or anticipatory grief • Bereavement (after the patient dies) Module #7

30. Preparatory or Anticipatory Grief • Losses for: • The Patient • The Family • The Physician Module #7

31. Patient Losses • Self image • Functional status • Loved ones • Work • Simple pleasures • Future life Module #7

32. 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 #7

33. 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 Bereavement Module #7

34. 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 #7

35. Discussion: Physician Loss • Physicians experience loss around death in caring for patients • Bring a specific patient to mind • What was this loss about foryou? Module #7

36. Spirituality • “Whomever or whatever gives one a transcendent • meaning in life.” (Puchalski, 1998) Module #7

37. 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 #7

38. 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 Module #7

39. 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 #7

40. 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 #7

41. 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 Module #7

42. 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 #7

43. 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 #7

44. 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 #7

45. 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 5 • Module Titles • Overview: Death and Dying • in the U.S.A. • Pain Management • Communicating with Patients • and Families • Making Difficult Decisions • Non-Pain Symptom • Management • Venues and Systems of Care • Psychiatric Issues and • Spirituality Module #7

46. 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 Module #7