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Modules:

  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Back to Module 6: Anxiety, Delirium, Depression
    Introduction to Anxiety, Delirium, Depression

    What is Anxiety?

    What is Delirium? What is Depression? Objectives of this Module

    What is Anxiety?

    Symptoms of Anxiety

    Anxiety usually presents with one or more symptoms or signs including:

      • Agitation
      • Restlessness
      • Sweating
      • Tachycardia
      • Hyperventilation
      • Insomnia
      • Excessive worry
      • Tension

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    Potential Factors Contributing to Anxiety

    • Patients facing a life-threatening illness commonly experience anxiety over their fears and uncertainties about their future
    • Their distress may be related to any of a number of issues, including:
      • Physical
      • Psychological
      • Social
      • Spiritual
      • Practical issues
    • Anxiety may also be a component of many other syndromes (eg, an underlying panic disorder that is unmasked by advanced illness)

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    What is Delirium?

    Symptoms of Delirium

    • Delirium is a global, potentially reversible change in cognition and consciousness that is relatively acute in onset
    • Delirium is likely present if a patient exhibits:
      • Disorientation
      • A fluctuating level of consciousness
      • Other signs of cognitive impairment

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    Common Causes of Delirium Include:

    • Infections, sepsis
    • Medications, street drugs (including withdrawal)
    • Hypoxemia, metabolic, vitamin deficiencies
    • Fecal impaction, urinary retention
    • Renal, hepatic failure
    • Tumor burden, secretions
    • Changes in environment

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    Terminal Delirium

    • Delirium is common in patients with advanced illness who are nearing death
    • Terminal delirium often presents as day-night reversal
    • Terminal delirium can be much more complex to assess and difficult to manage
    • When patients who are dying experience agitation, restlessness, moaning, and/or groaning due to terminal delirium, it is usually irreversible

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    What is Depression?

    Basic Facts about Depression

    • Depression affects 25-77% of persons with serious illness
      • Most patients with a serious illness experience periods of intense sadness and anxiety accompanied by depressive symptoms

      • These feelings are usually present for a relatively short period (days to weeks), and then resolve

      • However, in a variable number of patients, these feelings persist (between 25% and 77%, depending on the study)
    • Depression involves intense suffering
      • Depression is a source of intense suffering for patients who are affected by it

      • Because of this, physicians will want to be particularly diligent at assessing and detecting associated signs and symptoms
    • Depression is NOT "normal" or inevitable as the end of life approaches
      • Persistent symptoms of depression are not "normal" for patients at the end of life

      • It is a myth that feeling helpless, hopeless, depressed, and/or miserable are inevitable consequences of advanced life-threatening illness
    • Depression is treatable in most cases; early treatment is best
      • The earlier depression is diagnosed, the more responsive to treatment it is likely to be

      • Treatment for depression may help patients feel better and have the energy and interest to achieve their final goals before they die

      • This applies to teenage and young adult patients as well
    • Depression is NOT a cause for shame or a sign of weakness
      • Unfortunately, in our society, depression is often treated viewed as something to be ashamed of, or as a sign of weakness

      • Through patient and family education, the physician can help correct this misconception

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    Risk Factors for Depression

    Risk factors for Major Depression among patients with advanced illness include:

      • Pain, other symptoms
      • Progressive physical impairment
      • Advanced stage of disease
      • Medications—steroids, benzodiazepines
      • Particular diseases—pancreatic cancer, left hemispheric stroke
      • Spiritual pain
      • Fear
      • Preexisting risk factors:
        • prior history
        • family history
        • suicide attempts
        • substance use
      • Lack of social support
      • Stressful life events unrelated to illness

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    Objectives of this Module

    • Identify anxiety, delirium, depression in patients facing the end of their lives
    • Describe approaches to manage each symptom
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