Spiritual and Existential Issues in the Care of the Dying

Spirituality is important in the lives of patients with serious illnesses. Terminally patients may experience a number of spiritual issues, including lack of meaning, guilt, shame, hopelessness, loss of dignity, loneliness, anger toward God, abandonment by God, feeling out of control, grief, and spiritual suffering. Assessment of a patient’s spiritual beliefs, assessing the importance of spirituality in his or her life, exploring whether he or she belongs to a spiritual community, and offering chaplaincy referral or connection with the patient’s religious or spiritual leaders comprise essential components of a spiritual assessment. Psycho-oncologists should seek both specialized training, as well as referrals to appropriate sources, in order to help patients deal more effectively with the often complicated and painful spiritual issues that arise as a consequence of serious illness. Existential concerns are intrinsic to the human experience of facing mortality in palliative care settings. Patients diagnosed with terminal cancer often confront universal existential issues such as death anxiety, isolation, and meaninglessness. Psycho-oncologists must therefore be familiar with these existential concerns, their manifestations, and approaches to deal with existential issues. Psycho-oncologists have the unique ability to use a variety of psychotherapeutic interventions to alleviate existential distress in palliative care settings including cognitive therapies to help patients and families modify their appraisal of their lives with terminal illness, known as cognitive restructuring, life review techniques to facilitate a constructive reappraisal of life events, dignity-conserving therapies, and meaning-centered therapies have been shown to effectively reduce existential distress in this patient population.

Anxiety Disorders in Palliative Care

Anxiety is common in palliative care patients and may significantly impact patients’ quality of life. Anxiety can have many etiologies resulting in different anxiety syndromes, ranging from adjustment disorder, anxiety resulting from general medical condition, to medication-induced anxiety disorders. Pre-existing anxiety disorders should also be taken into consideration in palliative care settings. Different screening and assessment tools have been used to improve recognition and assessment of anxiety in the terminally ill. Treatment of anxiety in this patient population includes use of a variety of pharmacological agents to relieve severe anxiety symptoms and use of psychotherapy interventions that have been shown to be safe and effective in the terminally ill. This chapter includes an overview of the prevalence, assessment, and management of anxiety disorders in palliative care settings.

Management of Fatigue in Palliative Care Settings

Fatigue is highly prevalent in palliative care settings. Studies suggest that as many as 60% to 90% of advanced cancer patients experience fatigue. Fatigue is frequently under-recognized and undertreated in the terminally ill. This chapter provides a comprehensive overview of the prevalence of fatigue in palliative care settings, instruments used in screening and assessment of fatigue, common contributing factors of fatigue in advanced cancer patients, and the most recent evidence on the strategies for management of fatigue in palliative care settings.

Psychiatric and Psychological Interventions for the Control of Pain and Selected Physical Symptoms

In addition to the diagnosis and treatment of psychiatric disorders in palliative care settings, pain and other troublesome physical symptoms must also be aggressively treated in efforts aimed at the enhancement of the patient’s quality of life. These symptoms must be assessed by the psycho-oncologist concerned with the assessment and treatment of affective and other syndromes in the terminally ill population. This chapter provides a brief overview of the prevalence, assessment, and management of the commonly encountered, distressing physical symptoms such as pain, insomnia, and nausea among patients with advanced cancer.

Suicide, Assisted Suicide, and Desire for Hastened Death

Suicide, suicidal ideation, and desire for hastened death are all important and serious consequences of unrecognized and inadequately treated clinical depression. Desire for hastened death is one the most controversial topics in palliative care. Despite legal prohibitions against assisted suicide, a substantial number of patients think about and discuss those alternatives with their physicians, family, and friends. This chapter provides a comprehensive overview of the prevalence, assessment, and management of suicide, suicidal ideation, and desire for hastened death in palliative care settings.

A Global Perspective on Death

Psycho-oncologists must be familiar with the information on why, when, where, and how patients die to best understand and manage psychiatric issues of terminally ill patients. This chapter provides an overview of the common causes of death, age and location of death, including a discussion on patient preferences for the location of death. World Health Organization guidelines for a “good death“ and Weisman’s criteria for an “appropriate death“ are reviewed to serve as general guidelines for psycho-oncologists in caring for terminally ill patients.

Doctor-Patient Communication in Palliative Care

Doctor-patient communication is an essential component in caring for a dying patient. Communication problems have been identified in 84% to 94% of clinical encounters. Good doctor-patient communication reduces the risk of iatrogenic suffering, mood, anxiety, and adjustment disorders among cancer patients and their families. This chapter provides an overview of the guidelines for communication and empathy in caring for terminally ill patients, including essential strategies for effective doctor-patient communication, core communication skills, and teaching methods utilized in communication training programs.

Psychotherapy and Behavioral Interventions in Palliative Care

A range of psychotherapeutic and behavioural interventions have been demonstrated to be effective and useful for patients struggling with advanced life-threatening illness. Despite lack of evidence for prolonged survival, psychosocial interventions have been shown to be effective in decreasing depressive symptoms and suffering in advanced cancer patients. This chapter provides an overview of the commonly used, effective individual, group, and family psychotherapy modalities among advanced cancer patients and their families.

Delirium in Palliative Care

Delirium is the most common and serious neuropsychiatric complication in palliative care settings. Delirium is often under-recognized or misdiagnosed in terminally ill patients. Delirium is highly prevalent and is a source of morbidity in patients, family members, and staff. Delirium is often a harbinger of impending death and can significantly interfere with pain and symptom control among terminally ill. This chapter provides an overview of the prevalence, assessment, and management of delirium among advanced cancer patients reviewing the most recent evidence-based data on the use of psychopharmacological agents in treatment and prevention of delirium in this patient population.

Depression in Palliative Care

Depression is prevalent, but under-recognized, underdiagnosed, and undertreated in palliative care settings. Risk factors associated with depression in patients with advanced cancer are well defined and include a variety of medical and psychosocial factors. It is challenging to diagnose depression in palliative care settings because of the presence of overlapping physical symptoms specific to the cancer, such as fatigue and decreased appetite. Inclusive, exclusive, etiological, substitutive, and high-threshold approaches have been proposed to improve diagnosis of depression among medically ill patients. Management of depression in the palliative care settings comprises use of psychopharmacological agents and individual and group psychotherapies. The psycho-oncology clinician should take into consideration that antidepressants alone may not be adequate in patients with shortened life expectancies. Psychostimulants might be preferred in patients with less than a month to live. Cognitive behavioral interventions, supportive expressive group therapy, meaning-centered psychotherapy, dignity therapy, and mindfulness-based meditation therapy have emerged as effective psychotherapy modalities in decreasing depressive symptoms and suffering in advanced cancer patients.