For Residents

How we can improve end-of-life care

Current Psychiatry. 2013 May;12(5):33-36

References

1. Leydon GM, Boulton M, Moynihan C, et al. Cancer patients’ information needs and information seeking behaviour: in depth interview study. BMJ. 2000;320(7239):909-913.

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4. U.S. Department of Health and Human Services. Centers for Medicare and Medicaid Services. Medicare hospice benefits. http://www.medicare.gov/Pubs/pdf/02154.pdf. Revised January 2013. Accessed March 1, 2013.

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7. Center to Advance Palliative Care. America’s care of serious illness: a state-by-state report card on access to palliative care in our nation’s hospitals. 2011. http://reportcard-live.capc.stackop.com/pdf/state-by-state-report-card.pdf. Accessed March 1, 2013.

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9. Billings JA, Block S. Integrating psychiatry and palliative medicine: the challenges and opportunities. In: Chochinov HM Breitbart W, eds. Handbook of psychiatry in palliative medicine. New York, NY: Oxford University Press; 2009:13–19.

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14. Chochinov HM, Hack T, Hassard T, et al. Dignity therapy: a novel psychotherapeutic intervention for patients near the end of life. J Clin Oncol. 2005;23(24):5520-5525.

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In terminally ill patients, psychological pain often manifests as symptoms of depression and anxiety. Diagnostic criteria for depression may need to be reconsidered because in patients with terminal illness depressive symptoms commonly are associated with functional decline. For example, restrictions on a patient’s ability to participate in activities and disengagement from some areas of interest are common among individuals facing the end of life, but if a patient is unable to find pleasure in any event or activity, he or she may meet criteria for depression. Endicott¹⁰ proposed a list of substitute symptoms of depression in terminally ill patients:

weight loss or gain is substituted with depressed appearance
loss of energy is substituted with brooding and self-pity
insomnia or hypersomnia is substituted with social withdrawal
loss of concentration is substituted with lack of reactivity or inability to be cheered up.

These substitutions are not in DSM-IV-TR but should be considered when assessing a terminally ill patient.

Most recommendations for pharmacologic treatment of depression in terminally ill patients are based on depression treatments for the general population. Selective serotonin reuptake inhibitors are commonly prescribed for terminally ill patients. Mirtazapine, a noradrenergic and serotonergic antidepressant, has been shown to effectively treat adjustment, mood, and anxiety disorders in patients with breast or gynecological cancer.¹¹ Its major side effects—sedation and weight gain—might be beneficial in patients with terminal illness. Psychostimulants also have been shown to elevate mood in patients with advanced malignancies.¹²

Potential triggers for anxiety in terminally ill patients include chemotherapy, radiation therapy, or acute pain. Also consider anxiety related to death and dying. Certain drugs commonly used in palliative care—such as corticosteroids and psychostimulants—may contribute to anxiety and restlessness. Cancer patients may develop posttraumatic stress disorder symptoms, including re-experiencing frightening aspects of their diagnosis and treatment, nightmares, hypervigilance, and autonomic hyperactivity.¹³ Pharmacologic treatment of anxiety in dying patients is similar to that in the general population; benzodiazepines and antidepressants are first-line agents.

Several forms of psychotherapy can help terminally ill patients address existential issues (Box).^14-16

Box

Psychotherapy for terminally ill patients: 3 modalities

Dignity therapy is a form of brief individual therapy developed by Chochinov et al¹⁴ that focuses on existential distress to help patients feel that their lives have been worthwhile. The goal is to have patients describe what they are most proud of, what they want to be remembered for, and what is most meaningful to them.

Viederman et al¹⁵ characterized a type of therapy known as the psychodynamic life narrative. Palliative care psychiatrists use this technique to examine patients’ lives and take stock of successes and failures. The narrative attempts to create a new perspective within terminally ill patients that increases self-esteem by emphasizing past strengths and coping mechanisms that have been successful.

Meaning-centered group therapy, developed by Breitbart,¹⁶ emphasizes group didactics, discussion, and experiential exercises, with a focus on themes related to advanced cancer.

A need for training

In a survey of psychiatry residents, 97% of respondents believed psychiatrists should be trained in end-of-life care and 94% felt there should be formal education on palliative care during residency.¹⁷ A study evaluating psychiatry residents’ attitudes, perceived preparedness, experiences, and needs in end-of-life care education found that residents felt least prepared when dealing with cultural and spiritual aspects of dying and helping patients with reconciliation and saying goodbye.¹⁸ These residents also expressed a desire for more longitudinal exposure to palliative care.

Clinical Point

Residents may feel underprepared to deal with cultural and spiritual aspects of dying and helping patients with reconciliation

A dedicated palliative care rotation during psychiatry residency training would help build a foundation of knowledge in this field. Residency programs should make a greater effort to incorporate end-of-life issues into consultation-liaison and geriatric rotations. Education on psychosocial, existential, and spiritual distress should be highlighted, with an emphasis on integrating specific psychotherapy techniques into training. These opportunities would provide residents with necessary skills to help patients cope with end-of-life issues.

Clinical Point

Residency programs should make a greater effort to incorporate training and education on end-of-life issues

As a psychiatry resident, I believe training in this field is one way to decrease barriers for patients to access end-of-life care. End-of-life psychiatric training could help build a culture where end-of-life care is integrated into the medical care system, with the goal of helping terminally ill patients die well.

Related Resources

Chochinov H, Breitbart W. Handbook of psychiatry in palliative medicine. New York, NY: Oxford University Press; 2009.
Harvard Medical School Center for Palliative Care. www.hms.harvard.edu/pallcare.

Drug Brand Name

Mirtazapine • Remeron