Transcript End-ofLife Care Curriculum

END-OF-LIFE CARE:
Module 7
Psychiatric Issues & Spirituality
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Module #7
Orientation
‘Non-ideal’ Fantasy Death Exercise
• No pain or other physical symptoms
• Where are you?
• What are you doing?
• Who is with you?
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Distress in Dying Comes in
Many Different Forms
Any ‘bad’ death is a medical emergency
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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
http://www.growthhouse.org/stanford
Module #7
Outline of Module
• Psychiatric and social aspects of EOL care
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Depression
Anxiety
Delirium
Grief/bereavement
• Assessment and care of spiritual distress
• Personal goals
• Conclusion of the ELC course
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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 Depression
Look for:
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Worthlessness, excessive guilt, self-loathing
Hopelessness, helplessness
Pervasive despondency, despair
Suicidal ideation
Social withdrawal
Tearfulness
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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?”
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Module #7
Risk Factors for Clinical
Depression at the End of Life
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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
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Depression Medications:
Advantages & Disadvantages
Tricyclics and
Atypical
Antidepressants
Documented coanalgesic effect,
especially in
neuropathic pain
Time to onset 14-28
days
Side effects
SSRIs
Speed of onset
Well tolerated
Less clear coanalgesic effect with
neuropathic pain
Psychostimulants
Quite safe
Cardiotoxicity is
uncommon with low
doses
Rapid onset
Contraindicated in
depression associated
with anxiety or
delirium
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Module #7
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
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Depression Overlaps with Grief
and Normal Dying
Depression
Normal Grief
Normal
Dying
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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
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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
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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
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What is ‘Terminal’ Delirium?
Terminal Delirium
• Occurs in advanced
stage of dying
• Relatively refractory to
clearing through
medical interventions
http://www.growthhouse.org/stanford
Non-Terminal Delirium
• Can occur in any
fragile patient,
especially geriatric
patients when very ill
• Usually has a
correctable underlying
cause
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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
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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
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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
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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
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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
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Module #7
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
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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 transcendent
meaning in life.” (Puchalski, 1998)
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Patients’ Spiritual Concerns
that 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”
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Module #7
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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Module #7
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
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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)
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Module #7
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
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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
http://www.growthhouse.org/stanford
Module #7
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
http://www.growthhouse.org/stanford
Module #7
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
http://www.growthhouse.org/stanford
Module #7
Self-Rating Exercise II
(
(Self-Rating Scale: 1 = Low to 5 = High)
Knowledge, Skills, Attitudes Confidence to Teach
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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
http://www.growthhouse.org/stanford
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5
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://www.growthhouse.org/stanford
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