The Psychiatry of Palliative Medicine

The Dying Mind

Sandy MacLeod

• Publisher: CRC Press
• Year: 2018
• Print ISBN:
  9781846195358
• eBook ISBN:
  9781315357331
• Topic: Medizin
• Subtopic: Medizinische Theorie, Praxis & Referenz

This Second Edition of The Psychiatry of Palliative Medicine remains a practical and pragmatic distillation of the psychiatry relevant to the terminally ill. Revised throughout and greatly expanded by the addition of two entirely new chapters, it reviews the major psychiatric syndromes encountered in palliative care - depression, anxiety, delirium - and examines psychopharmacological and psychological interventions in detail. It succinctly considers the psychiatric aspects of pain, sleep, cognitive impairment, terminal neurodegenerative diseases, sedation, artificial feeding and euthanasia. The dying, chronically ill psychiatric patient is also discussed. The author has drawn on his great experience in both consultation-liaison psychiatry and palliative medicine to produce an essential, evidence-based guide for all healthcare professionals involved in palliative care. These include consultants and senior nurses, as well as psychiatrists, especially consultation-liaison psychiatrists, and trainees. 'I find this an immensely sympathetic book, beautifully written. It is a testimony to the summation of specialist psychiatric knowledge, broad scholarship and a rich personal practice in bedside palliation.' From the Foreword by Ian Maddocks Reviews of the first edition: '...a relevant, highly readable and reasonably priced book which will be of interest to all, whether from a psychiatric or palliative care background, who seek to improve the care of dying patients INTERNATIONAL PSYCHOGERIATRICS 'Practical, scientifically based and scholarly, addressing a comprehensive set of common and important clinical problems in palliative care. The book will doubtlessly be highly valued by palliative care clinicians for its practical and thorough overview of some of the most challenging clinical problems they face. Excellent and timely.' AUSTRALIAN AND NEW ZEALAND JOURNAL OF PSYCHIATRY

   CHAPTER 1 

Psychiatry and palliative medicine

It is the special vocation of the doctor to grow familiar with suffering.

John Greenleaf Whittier (1807–92)¹

The cardinal goal of medical care is to alleviate suffering. Suffering is an unpleasant and distressing emotional experience that undermines quality of life.² When illness confronts the integrity of how we define ourselves, of how we function, of what roles we perform, and how we perceive ourselves, suffering eventuates. The individual’s personhood is threatened by an event such as disease.³ Illness erodes ‘the self’, and suffering is the symptom of this damage. Suffering encompasses physical, psychological, spiritual and philosophical aspects of the person. Medicine does not have armamentarium to address all the components of suffering induced by disease. Suffering in advanced cancer patients cannot be eliminated, but if adequate relief is achieved then coping and personal growth can occur.⁴ Multidisciplinary healthcare teams are necessary to tackle this challenge. Modern medicine, preoccupied by curing rather than caring, focuses on biology rather than psychology and sociology. The fragmentation of medicine, made inevitable by the huge clinical and scientific knowledge base, distracts from the commonalities between the various specialties and subspecialties. Psychiatry and palliative medicine attend patients who are mentally distressed and dying. Neither condition is easily amenable to biomedical interventions. These ‘old-fashioned’ medical specialties practise biopsychosocial medicine with as much artistry as science. The clinical outcome in psychiatry is ‘good’ palliation of mental distress. In palliative medicine it is a ‘good death’. The diseases of neither patient group are curable. The best that can be achieved is symptom control and maintenance of that control. Quality of (remaining) life is thereby improved and some suffering relieved.

Dame Cicely Saunders – the founder of the modern hospice movement – envisioned a field that would encompass the physical, psychological and spiritual dimensions of care. In its earlier years the movement was exquisitely focused on the physical aspects of symptom management, though there are indications that this is beginning to change towards a more holistic approach.⁵ Many of the distressing symptoms experienced in the ‘deathbed’ are not exclusively physical. Some are primarily psychological or psychiatric, and some are psychosomatic or ‘somato-psychic’. Formalising ‘distress’ as the ‘sixth vital sign’ in the assessment of cancer patients may encourage an improved clinical appreciation of the importance of the mind of the sick.⁶ As John Donne (1572–1631) commented, ‘That which destroies body and soul, is in neither, but in both together’.⁷

Terminally ill patients can develop psychiatric illness. The provision of specialist psychiatric care to the dying is sporadic and inadequate. Psychiatrists rarely venture off their patch and into palliative care facilities. Despite the interest and want of a few psychiatrists, this situation is unlikely to change. There are few psychiatrists interested, trained, and practising both subspecialities. However, according to Susan Block, professor of psychiatry at Harvard Medical School, ‘there are a lot of frustrated humanists (in psychiatry) who are getting pushed into just doing psycho-pharmacology, but who really care about the patient’s existential issues’.⁸ But funding psychiatrists to work in palliative care can be a difficult prospect, despite the obvious need and the opportunities for collaboration. Some fortunate patients are seen through consultation–liaison psychiatric services to general hospitals. Finlay correctly points out the variability of the provision of consultation–liaison services throughout the UK.⁹ The decline of consultation–liaison psychiatric services worldwide over the last two decades, because neither mental health nor medical services are willing to fund these services despite being appreciated and effective, makes the reality of better access to psychiatry unlikely. A ‘solution’ is that of enhancing the psychiatric skills of palliative care practitioners and fostering the partnership. In the foundation period of modern palliative medicine the deficits identified were those of ‘communication skills’. More recently, depression, the psychosocial aspects of pain, and delirium have been areas of educational endeavour. The claiming of palliative medicine by physicians’ colleges, and the narrow base of specialist medicine training, has resulted in very limited exposure to psychiatry by prospective palliative medicine specialists. Palliative care nurses usually possess considerable experience and intuitive skill in dealing with disturbed patients, but lack a sound psychiatric knowledge base. As palliative care is slowly expanding outside its traditional oncology base into neurological, cardiovascular, renal and many other areas, there is a need to extend expert knowledge. These challenges rely upon a working familiarity with mental illness and with its management.

The fundamental clinical skill of medicine is acquiring the history of the illness from the patient. The patient is the one suffering, they know their symptoms and the doctor’s task is to extract this knowledge and expertly interpret it. The history provides the information on which diagnostic hypotheses are formulated. The definitive diagnosis is determined from the differential diagnoses with the assistance of objective information provided by the clinical examination and the investigations. Acquiring a psychiatric history is little different to any other medical history. Providing the patient with the opportunity to describe their symptoms, to reveal their narrative, is the key to good history taking. The interrogative pronoun that ensures a description of ill health is ‘how’. ‘How is your health affecting you?’, ‘How are you feeling?’, ‘How do you toilet?’, followed by repeated requests to further describe and elaborate, provides copious information, and more efficiently than with closed questions. Allowing the patient the first half to two-thirds of the interview time for this is appropriate and efficient. The doctor assumes control for the final portion in order to further clarify any details and ask specifically about medications, allergies and personal habits. This interview format applies equally to a full 50-minute psychiatric assessment and a 10-minute general practice consultation. Terminally ill patients are certainly not an exception. Their symptom load and appreciation of the preciousness of time encourages productive history taking in a brief period. Often 10–15 minutes is sufficient. Specific questions need to be asked of the terminally ill concerning fatigue, hallucinations and suicide risk, for these symptoms tend not to be volunteered.

What constitutes an adequate mental status examination in the dying should be influenced by what the examiner hopes to confirm. Delirium, depression, anxiety and cognitive dysfunctions are the common mental health problems of the dying. Time is limited, for energy and ability to cooperate are compromised. The bare essentials of a mental status examination in a terminally ill patient should include estimates of consciousness, orientation, recent memory, simple calculation and mood. Physical examination of the terminally ill is predominantly a psychological exercise. While academically it is gratifying to confirm the historical impression of an enlarged liver or bronchopneumonia, rarely does this influence a management plan. Most persons have a belief that medical examination, rather than history, is the key to medical practice. Until physically examined, even if the examination is only cursory, most don’t consider they have been properly assessed. The stethoscope and the percussion hammer are powerful tools of comfort. This is not to suggest that a medical examination doesn’t provide useful confirmatory information, including for mental illness. The traditional medical history and examination is a better assessment tool than the multitude of scales and psychometric measures available.

The practice of clinical psychiatry and medicine in general, requires knowledge of psychology. Personality traits, coping skills, general intellectual function and current stressors impact upon adjustment to, and living with, terminal illness. Modern psychology is cognitive and behavioural in philosophy. Psychodynamic conceptualisation is less emphasised. There is a considerable literature concerning psychology and severe illness. The psychiatric literature is less robust. The discipline of psychiatry encompasses both organic and psychological dysfunction. The vast majority endure a sad and unfortunate terminal illness with courage and stoicism. They manage ‘normally’. For them, psychiatry has nothing to offer. For those with dual pathology, good psychiatry and good palliative medicine can enhance the quality of remaining life.

REFERENCES

1  Whittier JG. Quoted in: Strauss MB, editor. Familiar Medical Quotations. Boston: Little, Brown & Company; 1968. p. 578.

2  Cherny NI, Coyle N, Foley KM. Suffering in the advanced cancer patient: a definition and taxonomy. J Palliat Care. 1994; 10: 57–70.

3  Cassel EJ. The nature of suffering and the goals of medicine. N Engl J Med. 1982; 306: 639–45.

4  Cherny NI. The treatment of suffering in patients with advanced cancer. In: Cochinov HM, Breitbart W, editors. Handbook of Psychiatry in Palliative Medicine. Oxford: Oxford University Press; 2000. pp. 375–96.

5  Chochinov HM. Psychiatry and palliative care: 2 sides of the same coin. Canad J Psychiatry. 2008; 53: 711–12.

6  Chaturvedi S, Venkateswaran C. New research in psychooncology. Curr Opin Psychiatry. 2008; 21: 206–10.

7  Donne J. Devotions upon Emergent Occasions. Raspa A, editor. Montreal, QC: McGill Queen’s University Press; 1975.

8  Meier DE, Beresford L. Growing interface between palliative medicine and psychiatry. J Palliat Med. 2010; 7: 803–6.

9  Finlay I. In: Lloyd-Williams M, editor. Psychosocial Issues in Palliative Care. Oxford: Oxford University Press; 2003. p. viii.

CHAPTER 2

Adjustment and anxiety

The human race is the only one that knows it must die, and it knows this only through its experience. A child brought up alone and transported to a desert island would have no more idea of death than a cat or a plant.

Voltaire (1694–1778)¹

Dying is a personally unique experience and one that we cannot share with another, nor rehearse with any certainty as to how it will be. Yet we know it will happen. ‘Never-before-encountered’ psychological challenges are presented to the terminally ill.² ‘Can this be death?’ thought the mortally wounded Prince Andrew in Tolstoy’s War and Peace, moments before his death. For many, until they are incurably ill, consideration of the psychology and spirituality of death is not contemplated with seriousness. Adjustments and anxieties are inevitably created.

ADJUSTMENT DISORDER (OR DISTRESS)

Care more particularly for the individual patient than the special features of the disease.

William Osler (1849–1919)³

The Diagnostic and Statistical Manual of Mental Disorders (DSM) IV and International Classification of Diseases (ICD-10) diagnostic criteria for adjustment disorder are imprecise and nebulous.⁴ Though a relatively commonly used diagnosis, the relationship of adjustment disorder to other psychiatric disorders is unclear and there is a lack of research data to support its utility.⁵ Conceptually, adjustment disorder may be a subthreshold form of post-traumatic stress disorder,⁵ or merely be a diagnostic creation to satisfy the American health insurers and permit financial return to health professions. By DSM definition, within 1–3 months of a triggering event, emotional disturbance (marked distress in excess of expected) and behavioural changes (impairment of social/occupational functioning) occur, which are not able to be diagnosed as another mental disorder. Anxiety, depressed mood and conduct aberrations are often the prominent symptoms, yet not of the intensity or persistence to meet the specific diagnostic criteria for these conditions. Adjustment disorder refers to someone who is distressed and ‘not coping’, having recently experienced a stressor, such as a malignant diagnosis, a treatment complication or the awareness of impending death. If the identified stressor is a ‘traumatic event’ (according to DSM-IV criterion A) a post-traumatic diagnosis is preferred.⁵

Adjustment disorder is reported in 32% of cancer patients, and 35% of cancer sufferers are clinically significantly distressed.⁶ These would appear to be surprisingly low figures, for at stages it is probable that all cancer patients struggle with their emotions and coping. ‘Distress’ is not defined in the medical literature. Rather than attempting to differentiate adjustment difficulties from sadness, sorrow, grief, subclinical anxiety, depression and Axis-1 DSM-IV diagnoses, it may be more useful to use the term ‘distress’. Distress rather than the medical condition of adjustment disorder would avoid psychiatric stigmatisation and acknowledge an expected and normal reaction to an unsettling life event. Risk factors including low ego strength, passive or avoidant coping style, inadequate or inappropriate information, lack of social support, communication problems, treatment-related stressors, number of unresolved c...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Foreword to the second edition
• Preface to the second edition
• About the author
• Contributor
• 1 Psychiatry and palliative medicine
• 2 Adjustment and anxiety
• 3 Psychological issues and dying
• 4 Families and caregivers
• 5 Psychiatry, spirituality and palliative medicine
• 6 Pain and psychiatry
• 7 Other symptoms and the psyche
• 8 Depression
• 9 Delirium
• 10 Sleep, sedation and coma
• 11 Neoplasms
• 12 Cognitive dysfunction and dementia
• 13 Terminal neurological disorders
• 14 Chronic mental illness and dying
• 15 Euthanasia and psychiatry
• 16 Psychopharmacology
• Index