PSYCHOLOGICAL MANAGEMENT OF THE TERMINALLY ILL
Terminal illness is used to describe patients with advanced disease and a drastically reduced lifespan, with perhaps months or weeks to live. The range and severity of physical symptoms increase and will be having a profound effect on how the patient lives his life. General symptoms such as fatigue, pain and sleeplessness are common which further leads to emotional and psychological concerns.
How well a patient copes is dependent on a number of variables, age of patient, level of education, religion, previous experience of illness, social support, personality and medical factors.
Breaking Bad News
When the prognosis is actually given to the patient it is best to avoid giving a specific time limit as the patient views this as a death sentence, and will be counting off the days. It is far better to talk in terms of months whilst giving them some hope in the future in terms of new treatments that may come out, or other patients who have beaten the odds and survived far longer. In other words they should prepare for the worst, but hope for the best.
Adjustment to Life Threatening Illness
The patient may react in a number of ways when faced with a life-threatening situation.
In the late 1960s Elizabeth Kubler Ross described five stages in coping with loss, a period of denial followed by anger, bargaining, depression and finally acceptance. Greer and Watson described five adjustment styles that a patient may exhibit when confronted with a life threatening illness.
- Fighting spirit,
- Avoidance or denial,
- Helplessness and hopelessness,
- Anxious preoccupation
A patient who exhibits fighting spirit sees the illness and the difficulties as a challenge. They often do all they can to beat the disease and have an optimistic outlook on life.
Avoidance or Denial
Some degree of avoidance or denial can be beneficial in that it can allow the patient to carry on with their lives without undue worry, but greater degrees may interfere with treatment compliance.
These patients are unduly passive and feel they have little influence over the course of the disease.
Hopelessness and Helplessness
The patient is unduly hopeless and feels powerless in the face of such an overwhelming threat. He feels that he has no influence over the course of the disease so he might as well give up. The patient becomes death centered rather than life centered.
Anxiety is a normal reaction to threat, however in these patients it is severe. Living with the uncertainty of the future causes them distress and they seek constant reassurance from the Doctor or relatives
The commonest psychiatric disorders seen in the terminally ill :-
- Adjustment disorders
When evaluating a terminally ill patient, a holistic approach has to be taken. The patient may well have fatigue, anorexia, and poor sleep, all of which could be attributed to the physical illness; therefore when assessing terminally ill patients greater weight must be given to psychological symptoms such as hopelessness, guilt and worthlessness than to somatic complaints. Persistent dysphoric mood, which shows no reactivity in pleasant situations i.e. as when relatives visit, and voicing a wish to die are other important symptoms
The management of depressive illness depends on the severity.Mild cases respond well to cognitive-behavioural psychotherapy (CBT).
A problem solving approach is used for current difficulties. The principles of behaviour therapy are utilized to increase pleasurable activities. Activities are important to boost morale and distract from unpleasant ideas.
Where depression is severe, anti- depressants are required.
The patient may appear apathetic and at times may be very agitated. Clouding of consciousness may get reflected in difficulty taking a history, the patient being vague and circumstantial in speech. Due to the very high incidence of delirium in terminally ill patients a short cognitive screen must always be done, this will usually show deficits in memory.
Normally the treatment for delirium is to find the causative factors and treat them.
Anxiety is a common reaction to threat, and patients diagnosed with terminal illness are under the greatest threat of all, a threat to their very existence. When dealing with a diagnosis of terminal illness, the initial reaction is one of disbelief, which is swiftly followed by anxiety depressive symptoms. Patients may feel agitated and restless, have difficulty sleeping, eating, and have intrusive thoughts about their illness.
Treatment consists of short acting Benzodiazepines, given in sufficient quantity to alleviate symptom.
Cognitive behavioural techniques are also employed, such as muscle relaxation exercises. Low dose antidepressants are also used, especially if depression is present.
Caring for the Carers
There are some carers who are so diligent, and spend all their time at the hospital that carer fatigue sets in, and they become ill and exhausted themselves. These latter carers need counseling and help in how to pace themselves over a long illness.
Each family has their own way of communicating and it is important to know whether issues are openly discussed, or if information is being withheld from certain members of the family. In all cases open communication should be encouraged, as this allows for more supportive relationships to develop.
We at Mumbai Psychiatry Clinics have a dedicated team of counsellors and clinical psychologists who will help you with your problems, cite interventions and assess the progress on regular intervals. There are experienced psychiatrists who will be guiding you throughout your journey and our Multidisciplinary team will try to assure you with the best help possible.
- Handbook of Psycho-oncology: Psychological Care of the Patient with Cancer; Edited by
immie C Holland, Julia H Rowland. Oxford University Press, 1998.
- Psychological Therapy for patients with Cancer. Stirling Moorey. Heinemann, 1989.