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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 3: Whole-Patient Assessment
    Nine Dimensions

    Step 3. Psychological Step 4. Decision-Making

    Step 3. Psychological

    See Module 6: Anxiety, Delirium, Depression and Module 16: Social and Psychological Considerations

    Cognition

    • Ask screening questions to assess delirium, dementia
      • Are there times of confusion? hallucination?

    Affect

    • Ask about mood—anxiety, sadness
    • Depression and anxiety are among the most prevalent and most underdiagnosed symptoms in patients facing the end of life

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    Emotional Responses to Illness

    • There is always an emotional response to serious illness; it challenges a person’s sense of themselves and their role in life
    • Common emotional responses prompted by illness include:
      • Avoidance, denial
      • Fear, anger
      • Lability, irritability
      • Intellectualization
      • Grief
      • Acceptance, spiritual peace
    • Ask about how the patient is responding to the fact of being ill
    • Consider naming some common responses, such as:
      • Anger
      • Grief
      • Instability
      • Tranquility
    • Be aware of common patterns of emotional response to illness:
      • Some people move through stages of shock, struggle, and eventually reach resolution

      • Most people move between a range of emotions and not always in a predictable order

      • Emotions come in surprising waves and/or can be persistent
    • It helps to give the patient (or parent if the patient is a child) a sense that their emotional response is normal
      • One way to do this is to inquire about his or her emotions, and then actively listen to the patient’s responses

      • It frequently helps the patient if the physician, or other health care giver, identifies the emotion, acknowledges it in an accepting way and thereby normalizes it
    • In the case of a dying child, the emotional responses of the parents and the siblings are particularly relevant, since they directly affect the child as caregivers
      • There needs to be attention from members of the psychosocial team to these adults and children, at an age-appropriate level

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    Coping Responses

    • Assess the individual and determine:
      • Whether the patient is coping adequately
      • Whether referral should be recommended
    • Do not hesitate to ask screening questions about suicidal ideation
      • As a routine question among others, or indeed as an explicit and exploratory discussion, there is no evidence that it fosters thoughts of self-harm

      • Rather it sets the groundwork for later discussions if they are needed, and it allows for self-expression, which can be therapeutic

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    Fears

    • Almost all patients have fears for the future as they face the end of life
    • Common fears include:
      • Loss of control
      • Loss of dignity
      • Loss of relationships
      • Fears of physical suffering
    • In tailoring a therapeutic relationship and a plan of care it is critical to know what it is that the patient tends to fear

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    Unresolved Issues

    • Unresolved issues in personal matters and especially in relationships are a prominent part of the experience of patients at the end of life
    • You may discover that what stands between the patient and a comfortable frame of mind is an unresolved issue
    • These issues have to do with:
      • Settling old feuds
      • Making or receiving last visits
      • Completing a life-time project or piece of work
    • In any case, creating a plan of care that allows for that work is important
    • These issues are rarely apparent to a physician unless questions directed to this area are asked. Examples might be:

    Questions to Assess Unresolved Issues at the End of Life

    • Is there something that you would like to do before you get too sick?
    • Many people have old differences they would like to settle before they die. Do you?
    • Many people have places or people they would like to visit. Do you?
    • Some have a piece of work they would like to finish. Do you?
    • In what ways has this illness affected you emotionally?
    • Are you doing things that you enjoy?
    • How has your mood been lately?
    • How have you been coping with all of this?
    • How have you handled stress in your life?
    • Are you concerned about being a burden to others?
    • Do you feel in control of your life right now?
    • Have you thought about taking your child on one more trip before she dies?
    • I think your child could manage a few half-days in school each week. Do you think that would help him?
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