END-OF-LIFE CARE: -Part 4
ARE NURSES EDUCATIONALLY PREPARED?

Anxiety

Anxiety is common in the dying, as patients face their fears and concerns about their impending death. However, anxiety is not a normal, inevitable consequence of dying and should be managed aggressively. Risk factors for anxiety include organic mental disorders, concurrent life events or social difficulties, lack of support and understanding from one's family and friends, and apprehension and worry.

The treatment of anxiety requires an adjunctive approach of spiritual- psychosocial support and pharmacotherapy. Providing support and a safe environment for discussing one's concerns and fears is very important.

Anxiety may respond to acupuncture and guided imagery with inclusion of relaxation therapy. In cases of intractable anxiety, a psychiatric consultation utilizing drug therapy may prove beneficial. Benzodiazepines are generally the medication of choice based upon the desired half-life. The longer half-life medications have a more sustained effect (Tomko, 2001).

Delirium

One of the most difficult symptoms to manage in the dying patient is delirium. It is hard to diagnose and to treat, but it remains the most frequent neuropsychiatric disorder that affects the dying. Delirium is a state of decreased cognitive abilities. It usually has a quick onset and is considered to be a potentially reversible process. Changes in patients sleep and wake cycle occur with fluctuating levels of consciousness. Delirium can be divided into two categories: hypoactive and hyperactive. In hypoactive, patients become withdrawn, experience difficulty attending to tasks, or have acute problems with memory. In the hyperactive phase, patients experience psychosis with delusions, paranoia, and hallucinations. Patients with delirium have a higher morbidity rate than those without delirium. Approximately 30% of patients with delirium will experience improvement back to baseline. However, most will not have a found etiology and treatment will not improve their outcome.

The focus of care is often patient comfort. The first line of therapy will involve neuroleptics. Terminal anguish is a combination of delirium, anxiety, and debilitation that can occur shortly before death. It can be frightening for the patient and disturbing to the family. Keeping the patient comfortable, calm, and sedated should be the major goal of treatment. In this case, pain medication and anxiolytics should be used (Tomko, 2001).

Depression

Sadness is common in patients with life-threatening disease. It is a myth that feeling helpless, hopeless, and depressed is inevitable. Sadness usually responds to supportive interventions. Depression, on the other hand, is a pathologic state marked by greater cognitive impairment and generally requires more aggressive therapy. One should not discount the importance of therapy and counseling in the treatment of the depressed, dying patient.

The most frequently used drugs for depression are SSRI's but the patient may have to wait weeks to develop a therapeutic effect. Benefits of a class of drugs called psychostimulants are now being prescribed with more prevalence since they are safe and the rate of onset of action is very fast (Kirchhoff, 2000).

Communication

There is evidence that communication with the dying and their families is less than optimal, and that few nurses receive adequate training in appropriate communication skills. It has been concluded that nurses may neglect their communication with patients who are very ill, tending to rely instead on families to communicate with the dying. (Ross, 2000). The tendency to quietly forget to communicate with family and patients, once patients are stigmatized with the label “incurable”, can bring on a terrible sense of desolation. Patients and family members may become overwhelmed with hopelessness, withdrawing into loneliness and depression. Unfortunately, most nurses are uncomfortable counseling patients and families around EOL decisions because of barriers identified including: lack of knowledge, lack of practical experience, mistaken belief of emotional distress for patients and families associated with a discussion, and time limitations. Patients stated, "They are more comfortable with EOL discussions initiated by their caretakers than with eliciting the conversations themselves" (Ross, 2000).

Signs that the end may be approaching include: terminal breathing patterns, decreased urine output, inability to take in food and fluids, and declining cognitive status (Tomko, 2001). Talking to the patient and family members, letting them know how the patterns has changed, and giving them the opportunity to be with their loved ones and say goodbye or “I love you” is an important role that is often overlooked.

                                                                       Cont'd

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