Psychological Issues in Terminal Illness and Dying

Learning Objectives
- Manging the terminally ill
o Alternative to hospital care
 Hospice care
 Institutions for the dying that encouraged personalized warm, palliative care
o Encouraged to bring their personal items (curtains etc)
o Restrictions to visits are removed as far as possible
 Acceptance of death in a positive manner
 Home care (most commonly chosen)
 Choice of care for many terminally ill patients
 Sometimes problematic for family members
o Financial and time problems, burnout
o Medical Staff
 Nature of terminal care
 Palliative care
o Enabling patients to be as comfortable as possible
o Lots of unpleasant custodial work (feeding, bathing etc)
 Caregiver burn out
 May withdraw into crisply efficient manner rather than warm and
supportive
 Curative care1
o Curing diseases
 Hospital staff are significant to the patient
 Patient may be in need for trivial things as they are unable to do so themselves
 Patient do not need to put up a positive outlook when interacting with medical staff
 Less time spent on terminally ill as more time spent to help those that can cured
 Avery Weisman’s goals for the staff
 Informed consent
o Patient told nature of condition and treatment, be involved in it
 Safe conduct
o Staff should provide guide for progressing through the tough period
 Significant survival
o Try their best to make good use of their remaining time
 Anticipatory grief
o Prepare patient and family members for future loss of patient
 Timely and appropriate death
o Patient should have a say in when they want to die
o Individual Counselling
 Thanatologists
 Those who study death and dying
 Different from typical psychotherapy
 Duration will be short lived
 Patients set their own agenda
o What they want/don’t to talk about
 With terminally ill children
 Hardest death to accept
 Death can be physically painful
 Children and parents are confused and fearful
 Children may not directly express their concern
o Therapists can takes cues about what to discuss from the child
- Death across the life span
o The most likely cause? And how is it?
 Past
 Infectious disease
 Today
o Death in infancy and childhood
 SIDS (Sudden Infant Death Syndrome)
 Infant stops breathing without obvious reasons
o Most were found dead during sleep
 Children’s understanding of death
 They think of death as a long sleep and is often curious rather than frightened or
saddened by it
o Death in adolescence and young adulthood
 Takes a realistic view of death
 Death of young adult is considered tragic
 Waste of life
 Robbed of a chance to develop and mature
o Death in middle age
 Just live with it
 Mid life crisis
o Premature Death
 Death that occurs before the projected age of 70
 Mostly sudden deaths due to heart attack or stroke
 Disadvantage of not allowing people to prepare of exit
o However, individuals do not have to cope with physical deterioration and
family members do not have to go through emotional torment of patient’s
worsening conditions
o Death at old age
 Relatively easier for elderly to die
 Elderly themselves might already have some mental preparation
 Poor mental heath and reduced life satisfaction predict decline amongst elderly
o Sense of purpose tied to a longer life
- Psychological issue in dying
o Self-, social-, treatment-related issues
o Changes in patient’s self-concept
 Difficult maintaining control of biological functions (drooling, incontinence, shaking)
 Mental regression, difficulty concentrating
 Could also be due to effects of painkillers and other medications
o Issues of social interaction
 Fear that their condition will upset visitors
 Possible to ask family members to prepare the visitors
 Withdrawal may occur for multiple reasons
o Communication issues
 Often feel that it is a taboo topic and not to bring it up
o Treatment issues
 Turn towards dubious remedies offered from informal health care systems
 Hoping to a miracle cure
o Rights to death
 Patient self determination act: DNR / DNAR (DN attempt R)
 DNR more familiar to all
o Misimpression that attempt is likely to succeed
 o Can make patients or family think they are deciding whether to live or die
even if all roads led to death at end of life situation
 DNAR
o Clearer language
o Not familiar to all
 Euthanasia
 What if patient was mentally impaired?
 patient needs to be conscious and triple checked(make request 3 times)
o life expectancy less than 6 monthslife expectancy less than 6 months
o must be informed about alternative care methods
 Living will (advance medical directive)
 We should be able to have a say about what treatment we want
- Survivors adjustments
o Kubler’Ross 5 stages
 Denial
 Subconscious blocking out of full realization of reality and implications
o A mistake has been made
 Anger
 Showing resentment to anyone that is healthy
o Harder response for family members to deal with
 Why me
 Bargaining
 Abandon anger for a different strategy
o Pact with god, charity
 Depression
 Coming to terms with lack of control, “anticipatory grief”
o Mourning the prospect of their own death
 Acceptance
 Tired, peaceful (not always pleasant), calm descends
 Evaluation
 Pros
o Chronicled nearly full array of reactions to death as those who work with
dying will be quick to acknowledge
o Points out counselling needs of the dying
o Breaks through silence and taboo of death
 Cons
o Not all patients get to acceptance
o Patients can jump from one stage to another
 Gives public opinion that it is a trend when it is not
o Anxiety is completely over-looked here
 Worries are still present for terminally ill patients but is not
addressed at all
- Problems of survivors
o Survivor’s routine
 Resumed the interrupted activities
o Grief (may go on for months)
 A response to bereavement involving a feeling of hollowness
 Often marked by preoccupation with the dead person
 Expressions of hostility towards others
 Guilt over death
 Restlessness and inability to concentrate on activities
  Emotional avoidance and positive appraisals actually lead to better adjustment in the wake
of a death
 More aggravated in males and in sudden, unexpected death
o Issues for child survivors
 May expect the dead to return
 May believe a parent left because the child was “bad”
 May feel “responsible” for a sibling’s death
- Death education
o Education
 Programs designed to inform people realistically about death and dying
 Purpose is to reduce terror and avoidance connected with topic of death
o College courses are a viable means of death education
o Tuesday with Morrie was a best seller
- Treatments may have debilitating side effects
o Advanced diabetes
 Amputations of extremities, such as fingers or toes
o Advanced cancer
 Removal of an organ, such as a lung
o Patients feel they are being disassembled
o Whether to continue treatment may become an issue

Alternative to AMD – Advanced care planning

AMD vs ACP
Advance Care Planning is an on-going communication process to help patients make informed decisions regarding
future healthcare wishes. It is not a legal process in itself. An Advance Medical Directive (made in accordance with
the Advance Medical Directive Act) is a legal document that one completes stating that one does not wish to receive
extraordinary life-sustaining treatment to artificially prolong life in the event of terminal illness where death is
inevitable and impending. One can make an Advance Medical Directive and also undergo the advance care planning
process. The existence of an Advance Medical Directive should be documented during ACP discussions. To find out
more about an Advance Medical Directive, go to [Link]