17.1 Vignettes
1. A 50-year-old man was referred for a psychiatric consultation because he refused a surgical procedure. He also had visual hallucinations of old friends and angels that were comforting for him. The patient was a homeless man who was brought in by the police after he was found on the street lying in a puddle of blood. He was bleeding from the rectum, was found to have a large rectal mass with extensive involvement of other pelvic structures. A hemicorpectomy was proposed, which the patient refused. The psychiatric consultant determined that the patient understood the nature, benefits, and risks of the proposed operation. As the hallucinations were comforting rather than frightening, no antipsychotic drugs were administered. Sufficient pain relief was recommended.
The patient died in his sleep several days later.
2. An 84-year-old man who was recently placed in a nursing home was found with a plastic bag over his head in a suicide attempt. He was brought to a psy- chiatric facility, and then transferred to the general hospital as he was bed- bound. His medical history revealed metastatic prostate cancer. The general hospital medically cleared him, as no immediate treatment for the carcinoma was planned. The nursing home refused to take the patient back because of his suicidal ideation. He was depressed, felt hopeless, and wished to die. The psy- chiatric consultant interviewed his wife, who told her that the patient was a self- made man, who was always independent, and she wanted nature to take its course. She was willing to have her husband at home, but had problems with constantly changing caregivers; also the bathroom door was too narrow to accommodate the patient’s wheelchair. The consultant arranged a meeting with family, the responsible physician, and the social worker, in which arrangements
17
The Chronic Patient, Palliative Care Settings, and the Dying Patient
Hoyle Leigh
CONTENTS
17.1 Vignettes . . . 187
17.2 The Chronically Ill and Disabled Patient . . . 188
17.3 The Dying Patient and Palliative Care . . . 189
17.4 Care of the Caregivers . . . 190
187
were made for the patient to be cared for at home with a more reliable caregiver, and to provide a commode at the bedside. He was prescribed methylphenidate 5 mg in the a.m. and escitalopram 10 mg in the a.m. The patient felt relieved when hearing these plans, and at follow-up a month later he was quite energetic with no symptoms of depression.
3. A 35-year-old woman was admitted for an overdose of sedatives in a suicide attempt. The patient was diagnosed with metastatic breast cancer about a year previously, and as she was experiencing increasing bone pain, she decided to take her “exit pills.” As she survived the suicide attempt, she was interested in dis- cussing the meaning of her cancer with the psychiatric consultant. Eventually, the patient became an outpatient of the consultant, who, at the patient’s request, did a weekly exploratory psychotherapy. She gained insight concerning the meaning of the cancer in view of her own personal history, and died in about a year’s time, feeling more in control with herself.
17.2 The Chronically Ill and Disabled Patient
Chronic patients, patients with permanent disability, and the terminal patients all have in common the fact that their medical condition cannot usually be reversed.
Such patients often engender a feeling of helplessness in the physician. Physicians are trained to seek out the cause of the illness and cure it, and patients who do not fit this model are frustrating indeed. The physician must recognize that there is a need for a role adjustment, from that of an active fighter against disease to that of a comforter, in dealing with chronic and palliative care patients. This involves accepting that the patient’s condition is not reversible, and, in terminal patients, letting go while providing maximum pain relief and comfort. Many physicians feel uncomfortable with this role adjustment, and may unconsciously tend to avoid or neglect such patients, or use heroic measures to “save” the patient (as in the first vignette above). The role of the consultant, then, is to help reduce the discomfort on the physician’s part so that optimal medical care can occur.
Psychiatric consultation may be requested on chronically ill and disabled patients for evaluation of comorbid psychiatric illness per se, psychological reactions to the chronicity or disability such as demoralization and depression, for issues concerning possible addiction to pain or antianxiety medications, noncompliance with a chronic regimen (such as insulin self-administration), and suspicion that the patient is unwilling to get better. Any comorbid psychiatric conditions, if diagnosed, should be treated appropriately with psychopharmacologic agents when indicated, keeping in mind possible drug interactions with the medical condition.
Psychotherapeutic approaches for adjustment to chronic illness and disability include support groups, supportive psychotherapy and problem solving, and cognitive-behavioral therapy. Physical therapy is often an excellent psychother- apeutic tool as it instills a sense of hope and expectation for improvement or recovery. Web sites are available for most chronic illnesses and disabilities and can provide excellent educational material as well as information about support groups.
The issue of possible addiction to pain medication is discussed in Chapter 11.
As for addiction to antianxiety agents, particularly benzodiazepines, the consultation- liaison (CL) psychiatrist often encounters patients who have withdrawal symptoms
in the hospital setting when they were receiving much higher doses chronically prior to admission (Fontaine et al., 1984). Such withdrawal symptoms may be seen by the medical staff as excessive anxiety. Caution is needed in elderly patients because benzodiazepines may cause sedation, disinhibition, delirium, and falls. Interactions with narcotic analgesics and alcohol should be kept in mind.
For the demoralization syndrome seen in chronic illness and disability, stimu- lants such as methylphenidate or dextroamphetamine may be effective (as in vignette 2 above) (see Chapter 9).
17.3 The Dying Patient and Palliative Care
For the terminally ill patient, the most important approach for the consultant to keep in mind is that, from the patient’s perspective, here-and-now comfort, relief of pain, and small pleasures including not having to think about his or her terminality are the important concerns. Elisabeth Kubler-Ross (1969) proposed that there are five stages of psychological adaptation to dying: denial and iso- lation, anger, bargaining, depression, and acceptance. Though these stages are useful in understanding dying patients when they show one or more of the char- acteristics of these stages, the health care professional should be aware that these stages do not necessarily occur in sequence, and, in fact, many patients may never undergo some of the stages, such as bargaining or acceptance. Some patients may adaptively fight to the end, even by engaging in an exploratory psychotherapy (as in vignette 3) (Leigh, 1974).
For some patients, having the option or means of suicide, such as consulting the book Final Exit (Humphry, 2002), gives a sense of mastery and control so that they gain the courage to live for today in spite of pain and discomfort. Thus, the pos- session or acquisition of a lethal medicine or weapon is not ipso facto evidence of immediate suicide risk requiring psychiatric certification. Executing an advance directive, appointing a durable power of attorney, and drawing up a will all provide a sense of mastery and autonomy for the terminal patient. Pleasurable activities and any distraction from illness should be encouraged for the terminally ill patient.
Patients’ individual coping strategies should be respected and supported.
Thus, one patient may choose to avoid discussing the disease and prognosis entirely, while another may read voluminously about the disease and become an expert in it, and another may find solace in philosophy or literature. Patients should be asked about whether they would like visits by clergy.
There is controversial evidence that psychotherapy may prolong survival of metastatic cancer patients (Chow et al., 2004; Goodwin et al., 2001; Spiegel et al., 1989), but there is a consensus that psychotherapy and psychoeducation can reduce the pain and depression associated with terminal cancer.
Many terminal patients feel comforted by simply being with another human being. For dying patients with no relatives or friends, volunteers can provide needed support and nonprofessional human contact. Where applicable, pets can also provide comfort and companionship, as well as a sense of usefulness for the patient.
For further discussion of psychotherapeutic (particularly “narrative”) approaches for seriously ill patients, see Psychosocial Treatments Relevant to Consultation-Liaison Psychiatry in Chapter 20.
Hospice care, either as an inpatient or as an outpatient, may be particularly helpful for the terminally ill patient as it can provide expert care and support for both the patient and the family.
Pharmacologically, immediate comfort and pain relief is the utmost goal of treatment, even if there is attendant risk of delirium, respiratory depression, and other consequences. Narcotic analgesics, which are also good antianxiety agents, should be administered liberally, as well as antianxiety and antidepres- sant drugs as needed. Historically, the Brompton cocktail, consisting of mor- phine, cocaine, and alcohol, has been used in Great Britain for treatment of pain in terminal cancer patients (also used in modified form in many hospices). As one oncologist remarked, “There is no drug test at the pearly gate to Heaven.”
17.4 Care of the Caregivers
The caregivers of seriously chronically ill and dying patients suffer from as much, if not greater, stress as the patients themselves. Epel et al. (2004) showed that healthy mothers who cared for chronically ill children showed premature cellular aging (telomere shortening) in proportion to the number of years of such caring, and cellular aging also correlated with the amount of perceived stress. Psychological support should be provided for the caregivers, which may include support groups, classes, and scheduled holidays (with someone else tak- ing over the caring). Respite care, which entails hospitalization of the patient for a short period during which the caregiver can rest and recoup, may be essential, especially for caregivers of patients with advanced dementia.
For the caregivers of patients with dementia, the issue of placement of the patient in a nursing home can bring much psychological conflict, guilt feelings, and indecision that may call for professional counseling. The psychiatric con- sultant, as well as the responsible physician, neurologist, or a member of the nursing home staff, can provide such counseling by discussing various options, what can be expected in the nursing home, and reassuring the caregivers that psy- chological conflicts and guilt feelings are universal in such situations, and that patients with advanced dementia are usually better cared for by professionals who are accustomed to meeting their specific needs.
References
Chow E, Tsao MN, Harth T. Does psychosocial intervention improve survival in cancer?
A meta-analysis. Palliat Med 2004;18(1):25–31.
Epel ES, Blackburn EH, Lin J, et al. Accelerated telomere shortening in response to life stress. Proc Natl Acad Sci USA 2004;101:17312–17315.
Fontaine R, Chouinard G, Annable L. Rebound anxiety in anxious patients after abrupt withdrawal of benzodiazepine treatment. Am J Psychiatry 1984;141:848–852.
Goodwin PJ, Leszcz M, Ennis M, et al. The effect of group psychosocial support on survival in metastatic breast cancer. N Engl J Med 2001;345(24):1719–1726.
Humphry D. Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying. New York: Dell, 2002.
Kubler-Ross E. On Death and Dying. New York: Simon & Schuster/Touchstone, 1969.
Leigh H. Psychotherapy of a suicidal, terminal cancer patient. Int J Psychiatr Med 1974;5(2):173–182.
Spiegel D, Bloom JR, Kraemer HC, Gottheil E. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet 1989;14;2(8668):888–891.
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