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

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Presentation on theme: "Module #7 END-OF-LIFE CARE: Module 7 Psychiatric Issues & Spirituality."— Presentation transcript:

1 http://www.growthhouse.org/stanford Module #7 END-OF-LIFE CARE: Module 7 Psychiatric Issues & Spirituality

2 http://www.growthhouse.org/stanford 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?

3 http://www.growthhouse.org/stanford Module #7 Distress in Dying Comes in Many Different Forms Any ‘bad’ death is a medical emergency

4 http://www.growthhouse.org/stanford Module #7 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

5 http://www.growthhouse.org/stanford Module #7 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

6 http://www.growthhouse.org/stanford Module #7 Case Example You find your dying patient curled up in the bed, facing the wall, and unresponsive What might this patient be experiencing?

7 http://www.growthhouse.org/stanford Module #7 Depression at the End of Life Not inevitable Under-recognized Under-treated Challenging to treat

8 http://www.growthhouse.org/stanford Module #7 Evaluation of EOL Depression Look for: Worthlessness, excessive guilt, self-loathing Hopelessness, helplessness Pervasive despondency, despair Suicidal ideation Social withdrawal Tearfulness

9 http://www.growthhouse.org/stanford Module #7 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?”

10 http://www.growthhouse.org/stanford Module #7 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

11 http://www.growthhouse.org/stanford Module #7 Depression Medications: Advantages & Disadvantages Tricyclics and Atypical Antidepressants Documented co- analgesic effect, especially in neuropathic pain Time to onset 14-28 days Side effects SSRIsSpeed of onset Well tolerated Less clear co- analgesic effect with neuropathic pain PsychostimulantsQuite safe Cardiotoxicity is uncommon with low doses Rapid onset Contraindicated in depression associated with anxiety or delirium

12 http://www.growthhouse.org/stanford 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

13 http://www.growthhouse.org/stanford Module #7 Depression Normal Grief Normal Dying Depression Overlaps with Grief and Normal Dying

14 http://www.growthhouse.org/stanford Module #7 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

15 http://www.growthhouse.org/stanford Module #7 Assessment “What is worrying you?”

16 http://www.growthhouse.org/stanford Module #7 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

17 http://www.growthhouse.org/stanford Module #7 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

18 http://www.growthhouse.org/stanford Module #7 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

19 http://www.growthhouse.org/stanford Module #7 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

20 http://www.growthhouse.org/stanford Module #7 Assessment Reversible Medical Causes of Delirium at the End of Life: Urinary retention Constipation Pain

21 http://www.growthhouse.org/stanford Module #7 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

22 http://www.growthhouse.org/stanford Module #7 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

23 http://www.growthhouse.org/stanford Module #7 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

24 http://www.growthhouse.org/stanford Module #7 ‘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

25 http://www.growthhouse.org/stanford Module #7 GRIEF Keen mental suffering or distress over affliction or loss Sharp sorrow Painful regret Webster’s College Dictionary, 1997

26 http://www.growthhouse.org/stanford Module #7 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

27 http://www.growthhouse.org/stanford Module #7 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

28 http://www.growthhouse.org/stanford Module #7 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

29 http://www.growthhouse.org/stanford Module #7 Grief and Loss: Temporal Element Preparatory or anticipatory grief Bereavement (after the patient dies)

30 http://www.growthhouse.org/stanford Module #7 Preparatory or Anticipatory Grief Losses for: The Patient The Family The Physician

31 http://www.growthhouse.org/stanford Module #7 Patient Losses Self image Functional status Loved ones Work Simple pleasures Future life

32 http://www.growthhouse.org/stanford Module #7 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

33 http://www.growthhouse.org/stanford Module #7 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

34 http://www.growthhouse.org/stanford 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

35 http://www.growthhouse.org/stanford Module #7 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?

36 http://www.growthhouse.org/stanford Module #7 Spirituality “Whomever or whatever gives one a transcendent meaning in life.” (Puchalski, 1998)

37 http://www.growthhouse.org/stanford Module #7 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”

38 http://www.growthhouse.org/stanford 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

39 http://www.growthhouse.org/stanford 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

40 http://www.growthhouse.org/stanford Module #7 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)

41 http://www.growthhouse.org/stanford 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

42 http://www.growthhouse.org/stanford Module #7 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

43 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

44 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

45 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 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

46 http://www.growthhouse.org/stanford Module #7 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


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