Palliative Care and Pain Management at the End of Life ___________________________________________
Prevalence Severe anxiety varies widely among adults with life-limiting disease, ranging from 8% to 79%, with the highest rate among patients with cancer [211]. Etiology One of the primary causes of anxiety is inadequate pain relief. Anxiety may also be the result of a patient’s overwhelming concern about his or her illness, the burden of the illness on the family, and the prospect of death. In addition, anxiety is a potential side effect of many medications, including corti- costeroids, metoclopramide, theophylline, albuterol, antihy- pertensives, neuroleptics, psychostimulants, antiparkinsonian medications, and anticholinergics. Lastly, withdrawal from opiates, alcohol, caffeine, cannabis, and sedatives can result in anxiety, particularly in the first few days of admission [404]. Prevention Effective pain management is the best way to prevent anxiety. Also, educating the patient and the family about what to expect over the course of the illness and providing adequate psycho- logical and spiritual support can help comfort the patient, thereby preventing anxiety. Assessment Family members and friends may be able to provide informa- tion about the level of anxiety experienced by the patient cur- rently and in past situations. All members of the healthcare team should evaluate the patient and the clinical record for reversible causes of anxiety, such as those caused by medica- tions or withdrawal syndromes, and should try to distinguish anxiety from delirium, depression, or bipolar disorder [405; 406]. Anxiety manifests itself through physical as well as psycho- logical and cognitive signs and symptoms. These signs and symptoms include dyspnea, paresthesia, tachycardia, chest pain, urinary frequency, pallor, restlessness, agitation, hyperventi- lation, insomnia, tremors, excessive worrying, and difficulty concentrating. Management Nonpharmacologic approaches are essential for managing anxiety, and the addition of pharmacologic treatment depends on the severity of the anxiety [67; 407]. Effective management of pain and other distressing symptoms, such as constipation, dyspnea, and nausea, will also help to relieve anxiety. If the anxiety is thought to be caused by medications, they should be replaced by alternate drugs. Other strategies include psy- chological support that allows the patient to explore fears and concerns and to discuss practical issues with appropriate healthcare team members. Relaxation and guided imagery may also be of benefit [408]. A consult for psychological therapy may be needed for patients with severe anxiety.
their families or have been subjected to social stigma, leading to fears of abandonment and isolation. In some instances, spiritual crises may be the result of guilt and shame from past behaviors. Many patients with HIV/AIDS have suffered through the loss of loved ones to the same disease, some of whom may have been part of the individual’s defined family and network of social support. As with physical symptoms, assessment of distress and the psy- chosocial and spiritual well-being of the patient must be ongo- ing, as changes occur over time [6; 67]. In addition, worsening symptoms and disease progression can affect patients’ coping mechanisms [227]. One study found significant correlations between the will to live and existential, psychological, and social sources of distress. In that study, hopelessness, burden to others, and dignity were the variables with the most influence [397]. Other studies have consistently shown that psychosocial suffering has a stronger association than pain with a desire to hasten death [398; 399; 400; 401; 402; 403]. How a patient responds to his or her disease and care is strongly influenced by attitudes and values learned through family interactions, and social workers should evaluate the patient and family to assess psychosocial as well as practical problems and recommend and/or carry out interventions [6; 396]. For many patients, the primary concern about their illness is its impact on the family. The need for palliative care raises issues regarding power, structure, and roles among the patient and his or her family [67]. The impact of a life-limiting disease and the ensuing care threatens the structure and integrity of the family, as family roles are reassigned, the rules of daily liv- ing are altered, and methods of problem-solving are revised. Families vary in their ability to adapt to such restructuring, and dysfunction can result from either limited or excessive adaptation. At one end of this spectrum, family members have difficulty breaking away from coping mechanisms, even though they are ineffective. At the other end of the spectrum, family members continually try new coping strategies to meet each crisis, resulting in chaos [67]. Both types of dysfunction can lead to increased demands on the healthcare team and can interfere with the delivery of appropriate care. ANXIETY Anxiety is a feeling of fear, apprehension, and dread. The patient feels uneasy, insecure, and uncertain about the future. Often, the patient is not able to identify the source of anxiety, but it can be related to any number of physical, psychological, social, spiritual, or practical issues common during the end of life.
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MDCA1525
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