Palliative Care and Pain Management at the End of Life ___________________________________________
Management The effective management of depression requires a multimodal approach, incorporating supportive psychotherapy, cognitive strategies, behavioral techniques, and antidepressant medica- tions [47]. Patients with depression should be referred to men- tal health services for evaluation, and resultant approaches may include formal therapy sessions with psychiatrists or psycholo- gists or counseling from social workers or pastoral advisors. In addition, physicians can help by having discussions with the patient to enhance his or her understanding of the disease, treatments, and outcomes, and to explore expectations, fears, and goals. Behavioral interventions, such as relaxation tech- niques, distraction therapy, and pleasant imagery have been effective for patients with mild-to-moderate depression [47]. Strong evidence supports the use of tricyclic antidepressants or SSRIs, along with psychosocial interventions, for the management of depression in patients with cancer [47; 212]. Evidence to support the use of specific pharmacologic agents to treat depression in patients with noncancer diagnoses is not as strong, but psychostimulants may also be helpful [47; 67; 227; 416]. The choice of medication depends on the time available for treatment. The most immediate effect (within days) is achieved with a rapid-acting psychostimulant (e.g., dextroamphetamine, methylphenidate); longer times to thera- peutic effect are associated with SSRIs (two to four weeks) and tricyclic antidepressants (three to six weeks). SPIRITUAL NEEDS Medical ethicists define spirituality as the ways people live in relation to transcendent questions of meaning, value, and relationship, whereas religion involves a community of beliefs and practices sharing a common orientation toward these spiritual questions [530]. Spirituality is unique to each person. It is founded in cultural, religious, and family traditions and is modified by life experiences. Spirituality is considered not to be dependent upon formal religious faith, and many surveys have shown that spirituality or religion is an integral component of people’s lives [67; 417]. Spirituality also plays a significant role in health and illness. Studies have shown spirituality to be the greatest factor in protecting against end-of-life distress and to have a positive effect on a patient’s sense of meaning [411; 418]. Thus, a spiritual assessment and spiritual care to address individual needs are essential components of the mul- tidimensional evaluation of the patient and family [206; 419]. A life-limiting disease will lead patients to ask questions that may give way to spiritual conflicts, such as “Why would God let me suffer this way?” Patients may also carry out life review in search of meaning for their illness; some may view their ill- ness as punishment for past “sins.” Left unanswered, spiritual questions and concerns lead to spiritual distress and suffering, which can cause or exacerbate pain and other physical and psy- chosocial symptoms. It then becomes critical for the healthcare team to facilitate pastoral services to address patients’ spiritual concerns [6]. In general, the spiritual and existential concerns of patients at the end of life relate to four areas: the past, the present, the future, and religion ( Table 23 ) [206].
comorbidities and polypharmacy, both of which can increase the risk of depression [412; 413]. Psychosocial causes include despair about progressive physical impairment and loss of independence, financial stress, family concerns, lack of social support, and spiritual distress. Prevention Adequate management of pain, attention to psychosocial and spiritual well-being, and early referral for mental health or pas- toral counseling are the best strategies to prevent depression. Assessment The diagnosis of depression is complicated, as the usual somatic signs of depression—anorexia, sleep disturbances, weight loss, and fatigue—are often symptoms related to the underlying disease or part of the constellation of symptoms experienced by patients with life-limiting disease [227]. Because of this, assessment should focus on psychological and cognitive symptoms, such as: • Persistent dysphoria • Loss of pleasure in activities • Frequent crying • Loss of self-esteem • Sense of worthlessness • Excessive guilt • Pervasive despair • Thoughts of suicide A diagnosis of depression requires the presence of at least five depression-related symptoms within the same two-week period, and the symptoms must represent a change from a previous level of functioning [378]. A simple screening tool that has been found to be effective is to ask the patient, “Are you depressed?” or, “Do you feel depressed most of the time?” [227; 414; 415]. The physician should also discuss the patient’s mood and behavior with other members of the healthcare team and family to help determine a diagnosis. Patients who have thoughts of suicide must be assessed carefully. The physician should differentiate between depression and a desire to hasten death because of uncontrolled symptoms [67]. Psychological counseling should be sought, as well as measures to enhance the management of symptoms.
It is important to differentiate grief from depression. Grieving can be an appropriate response to loss, but if the symptoms persist, the Institute for Clinical Systems Improvement recommends that depression be considered.
(https://www.icsi.org/wp-content/uploads/2021/11/ PalliativeCare_6th-Ed_2020_v2.pdf. Last accessed October 14, 2024.) Level of Evidence : Expert Opinion/Consensus Statement
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