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
Clergy and Faith Communities
Step 3. Psychological
Step 4. Decision-Making
Step 3. Psychological
See Module 6: Anxiety, Delirium, Depression and Module 16: Social and Psychological Considerations
Ask screening questions to assess delirium, dementia
- Are there times of confusion? hallucination?
Ask about mood—anxiety, sadness
Depression and anxiety are among the most prevalent and most underdiagnosed symptoms in patients facing the end of life
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
- Acceptance, spiritual peace
Ask about how the patient is responding to the fact of being ill
Consider naming some common responses, such as:
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
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
Almost all patients have fears for the future as they face the end of life
- 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
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?