Transcript PALLIATIVE CARE ST PETERSBURG SUMMIT 2003

MENTAL HEALTH ISSUES IN
PALLIATIVE CARE PATIENTS
may be
reversed
controlled
understood
MENTAL HEALTH ISSUES
IN PALLIATIVE CARE
UNDERSTANDING AND RESPONDING
WITH SENSITIVITY
Terry Magee,
THE MYTHS OF MENTAL ILLNESS
Labels
Mad Bad or Sad?
Incapable Incompetent
Vulnerable
Weak
Hysterical (esp. women)
Attention seeking
Potty, Bonkers, Nutty,Daft
Eccentric.
Incurable
Nervy
Artistic temperament
Pandora's box
A Magical shaman or guru
MENTAL ILLNESS
NATURE OR NURTURE?
DEPRESSION AND ANXIETY
IN PALLIATIVE CARE
Depression and Anxiety are
common in all patients with serious
illness.
They impact upon the psychosocial
profile of the patient.
They are often responsive to
treatment .
But a lack of attention to them may
lead to ongoing
dysphoria ( a disorder of affect
characterised by depression and
anguish)
family conflict
non compliance with treatment
increased length of hospitalisation
persistent worry
suicidal ideation
needless suffering
DEPRESSION
• What is it that becomes
depressed ? might it be anger ?
• Is it because of our Genes?
• Is it a reaction to stress?
• Is it a chemical imbalance?
(hormones or serotonin)
• Is it a result of our environment
and socialisation?
• Is it our unconscious reacting to
early childhood trauma or faulty
parenting?
SYMPTOMS INDICATING
DEPRESSIVE DISORDER IN THE
MEDICALLY ILL
• Enduring depressed or sad mood, tearful
• Marked disinterest or lack of pleasure in social activities, family, and
friends
• Feelings of worthlessness and hopelessness
• Excessive enduring guilt that illness is a punishment
• Significant weight loss or gain not explained by dieting, illness, or
treatments.
• Hopeless about the future
• Enduring fatigue
• Increase or decrease in sleep not explained by illness or treatment
• Recurring thoughts of death or suicidal thoughts or acts
• Diminished ability to think and make decisions
INTERVENTIONS TO ASSIST THE
DEPRESSED PATIENT
COMPLEMENTARY THERAPIES
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Guided imagery and visualisation
Aromatherapy and massage
Art and music therapy
Aerobic exercise
Life revue, life story and reminiscence therapy
Humour
Dance and movement therapy
Progressive somatic relaxation and biofeedback
INTERVENTIONS TO ASSIST THE
DEPRESSED PATIENT
COGNITIVE INTERVENTIONS
Help the patient to identify and reality test
Self defeating assumptions
Negative automatic thoughts
Rumination on failure
Ability to set and achieve goals
Ability to determine realistic expectations
Teach “stop think strategy”
Assist to accomplish personal enhancement activity
Avoid denying the patient’s sadness
Avoid chastising the patient for feeling low
Minarik (1996)
INTERVENTIONS TO ASSIST THE
DEPRESSED PATIENT
INTERPERSONAL
• Enhance social skills through modelling, role play,
feedback and positive reinforcement
• Build rapport with frequent short conversations, exchanges
and connectedness
• Give attention even when the patient is withdrawn
• Mobilise family creative and social support networks
• Encourage open communication about feelings
• Teach the family how they can help
• Allow the patient time and space for reflection and reverie
Minarik (1996)
INTERVENTIONS TO ASSIST THE
DEPRESSED PATIENT
BEHAVIOURAL
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Provide directed activities
Use graded task assignment hierarchy
Develop daily activity schedule
Encourage the patient to keep a journal of
successful actions and revue
• Use systematic application of reinforcement
• Encourage self monitoring of predetermined
behaviours such as sleep pattern, diet and physical
exercise
• Focus on goal attainment and adaptive coping
SYMPTOMS INDICATING ANXIETY
DISORDER IN THE MEDICALLY ILL
• Chronic apprehension, worry, inability to relax which is not related to
illness or treatment
• Difficulty in concentrating
• Irritability or outbursts of anger
• Difficulty falling asleep or staying asleep
• Trembling or shaking
• Exaggerated startle response
• Perspiring for no obvious reason
• Chest pain and shortness of breath unrelated to medical condition
• Extreme fear of places, events, certain activities.
• Recurring and persistent ideas, thoughts or impulses
• Repetitive behaviours to prevent discomfort
• Fear or “going crazy”
• Exaggerated fear of dying
Barraclough (1997)
INTERVENTIONS TO ASSIST THE
ANXIOUS PATIENT
LEVEL 1 PREVENTION
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Provide concrete objective information
Ensure stressful event warning
Increase opportunity for control
Increase patient and family participation in care activity
Openly acknowledge fears
Explore near miss events
Control symptoms
Structure uncertainty
Limit sensory deprivation and isolation
Encourage hope
INTERVENTIONS TO ASSIST THE
ANXIOUS PATIENT
LEVEL 2 RESPONSE
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Hold the patient
Use presence as an emotional anchor
Support the open expression of feelings, doubts and fears
Explore near-miss events
Provide information and alternatives for restructuring
fearful ideas
Teach anxiety reduction strategies e.g. focussed breathing,
relaxation imagery
Use contact, therapeutic touch and massage
Review the day’s events and reduce stressors
Consult mental health experts
INTERVENTIONS TO ASSIST THE
ANXIOUS PATIENT
LEVEL 3 MANAGEMENT
• Stay with the patient
• Calm the environment
• Remove any unnecessary auditory, olfactory, visual, tactile
and environmental stimulants
• Administer anti anxiety medication
• Use distraction and refocusing techniques
• Repeat realistic reassurances
• Communicate with repetition, clarity and simplicity
• Consult mental health experts
Leavitt 1996
BIPOLAR DISORDER
BIPOLAR DISORDER
• Emotional pendulum
• Roller coaster
• Manic high
Omnipotent thoughts
• Paralysing low
suicidal thoughts
• Nurturing calm
SCHIZOPHRENIA
SCHIZOPHRENIA
Schizophrenia is characterised by ideas of reference, auditory
and/or visual hallucination, thought blocking, delusional
association and often the patient believes that they are being
persecuted, possessed or accompanied by imaginary figures.
There is often mania present with ideas of grandeur and
often the individual will feel they possess vital information
or talent. There is also often persistent worry, suspicion and
anxiety which has no factual basis. In addition there are
often severe abnormalities in thought, feeling and behaviour
including compulsion.
Schizophrenia is a serious illness which demands our
compassion, our patience, our persistence and our utmost
respect for the suffering that accompanies this illness.
SCHIZOPHRENIA