• not fully understanding the disease, treatment or what lies ahead
• fear of pain, dying, disfigurement

• loss (or fear of loss) of control, independence, dignity
• helplessness, hopelessness
• insight regarding (or fear of) poor prognosis
• anxious personality, pre-existing personality traits

• pain
• unrelieved pain
• symptoms
• uncontrolled symptoms
• social
• loss (or fear of loss) of job, social position, family role
• feels isolated (actual or perceived)
• feels a burden on family and carers
• unfinished business : personal, interpersonal, financial
• financial hardship
• fears for family
• cultural
• cultural differences in attitude to sickness, suffering, loss, and death
• language barriers
• spiritual
• religious issues
• spiritual issues, e.g. remorse, guilt, unfulfilled expectations, meaninglessness
• treatment
• diagnostic delays, multiple failed treatments
• side effects of therapy
• team
• poor communication
• lack of continuity of care
• exclusion of family, carers

• lower socioeconomic class
• sense of not being valued or understood

• cultural

• certain cultural traditions

• spiritual

• not religious; no alternate value system

• control pain and physical symptoms
• social

• address social issues, encourage social supports
• provide support for family and carers

• cultural
• respect cultural differences
• spiritual
• address religious or spiritual concerns

• other measures
• general supportive counselling
• support groups
• relaxation therapy
• meditation
• distraction
• socialization
• psychological therapies
• stress management techniques
• coping skills training
• cognitive therapy
• anxiolytics, antidepressants
• supportive psychotherapy

Significant symptoms of depression are reported to occur

• in about 25% of patients with advanced cancer
• the incidence is probably higher in patients with advancing disease, increasing physical disability, or troublesome pain

In palliative care

• many patients with depression are not diagnosed or treated appropriately
• some are started on antidepressants during the last few weeks of life when there is insufficient time for the medication to have any therapeutic effect

The American Psychiatric Association’s DSM-IV criteria for diagnosis of depression in physically healthy individuals requires

• at least one of two core symptoms—depressed mood and anhedonia (decreased interest or pleasure)
• at least four other symptoms from the list
• each symptom needs to be
• severe (most of the day, nearly every day)
• durable (more than two weeks)
• be judged to cause clinically significant distress or impairment
• not be attributable to the patient’s medical condition or therapy.

In palliative care

• the significance of somatic symptoms is questionable as all may be attributable to the disease or treatment

• they might be considered significant if clearly out of proportion to the physical illness

• other criteria that have been advocated as indicators of depression in the terminally ill

• does not respond to support, understanding, caring or distraction

• correlates with a desire for death in the palliative care population

• organic brain syndromes
• patients with acute confusion (delirium) or early dementia may exhibit features of depression
• mental state examination will reveal evidence of organic brain dysfunction
• delusional thoughts and hallucinations, features of psychotic depression, may occur

• exclude adverse effects of drugs and drug interactions

• treat any causative or aggravating factors
• pain, other physical symptoms, social, cultural, spiritual

• general support
• caring and empathy
• reassurance of continued care and interest
• provision of any information about the illness requested by the patient
• explore patients' understanding and fears about illness, prognosis
• encourage, strengthen family and social supports
• brief, supportive psychotherapy
• resolution of issues regarding disease, treatment, future, coping, etc.
• family, group therapy
• behavioural techniques

• antidepressants
• other drugs: hypnotics, anxiolytics, neuroleptics

• different TCAs are more suited to certain situations
• patients with agitation or insomnia are treated with a sedating drug such as amitriptyline or doxepin
• patients with psychomotor slowing require a less sedating drug such as desipramine
• patients with problems related to intestinal motility or urinary retention need a drug with less anticholinergic effect such as desipramine or nortriptyline
• TCAs are usually started at a dose of 25-50 mg at night and increased gradually over several weeks
• 2 to 4 weeks is required for clinical response
• adults without physical illness require doses of 150-300 mg/d
• elderly or debilitated patients may only be able to tolerate much lower doses
• a systematic review of RCTs of TCAs given at low dose (<100mg/d) showed
• these drugs are effective at lower doses when compared to placebo
• that increasing to standard doses did not improve the response rate but did produce more adverse effects

Selective serotonin re-uptake inhibitors (SSRIs)

• have little sedative, anticholinergic or cardiac side effects
• can cause transient anxiety, insomnia, nausea and diarrhoea for the first few weeks
• sertraline is possibly the best drug for patients with physical illness
• paroxetine is more likely to cause drug interactions
• fluoxetine has a slow onset of action
• a Cochrane review of antidepressants in patients with medical illness showed that TCAs might be more effective than SSRIs but were associated with more adverse effects

• non-selective MAOIs should not be used in palliative care because of the need for dietary restrictions and the frequency of interactions with other drugs
• less drug interactions occur with the reversible inhibitor of mono-amine oxidase-A, moclobemide, but there is little to recommend its use in palliative care.

• mirtazapine was effective in a small trial of patients with advanced cancer
• acts more quickly than traditional TCAs
• adverse effects are sedation, dry mouth and weight gain.

• venlafaxine does not have the sedative, anticholinergic or cardiac effects of amitriptyline and acts more quickly
• adverse effects are dizziness, dry mouth, nausea and insomnia

• methylphenidate has been used for patients with advanced disease and a life expectancy of weeks to a few months
• it is effective in the majority of patients
• serious adverse effects are uncommon
• should be given earlier in the day (5mg PO at 0800 and 1200h) to avoid insomnia
• effect is often seen within two to three days
• it has the beneficial side effects

• counteracting opioid-related sedation
• improving appetite
• improving cognitive function
• counteracting the feelings of weakness and fatigue
• promoting a sense of general well being

• is extract of Hypericum perforatum
• is a popular over-the-counter antidepressant
• some studies report activity equivalent to other antidepressants with fewer adverse effects
• there are three RCTs that report it to be no better than placebo

Abnormal (maladaptive) anxiety is distinguished from normal anxiety by

• anxiety out of proportion to the stress
• persistence of symptoms for more than two weeks
• severe physical symptoms or recurrent panic attacks
• disruption to normal functioning

• panic disorder
• repeated sudden, unpredictable attacks of intense fear and physical discomfort
• attacks follow a crescendo pattern, reaching a maximum in a few minutes
• may occur in many different situations.

• phobic anxiety
• anxiety provoked by exposure to a specific feared object or situation
• usually results in an avoidance response.

• organic anxiety syndromes
• uncontrolled pain
• hypoxia, respiratory distress
• hypoglycaemia
• any uncontrolled or severe physical symptoms
• acute confusional state or delirium
• drug adverse effects: corticosteroids, metoclopramide, bronchodilators
• drug withdrawal: opioids, barbiturates, benzodiazepines, alcohol, nicotine

• exclude adverse effects of drugs and drug interactions

• treat other factors that may cause or aggravate anxiety
• pain, other physical symptoms, social, cultural, spiritual

• distraction therapies
• music therapy, art therapy, socialization

• drug therapy: anxiolytics, hypnotics, antidepressants, neuroleptics

• they may cause or aggravate pain and psychosocial problems
• they can cause an anguish all their own

• recognition and successful management of spiritual and existential problems is an important part of palliative care

Spiritual and existential problems encountered by the terminally ill can be broadly grouped

• relating to the past

• value and meaning of a person's life
• worth of relationships
• value of previous achievements
• painful memories or shame
• guilt about failures, unfulfilled aspirations

• relating to the present
• disruption of personal integrity
• physical, psychological and social changes
• increased dependency
• meaning of a person's life
• meaning of suffering
• relating to the future
• impending separation
• hopelessness
• meaninglessness
• concerns about death
• relating to religion
• strength of their faith
• whether they have live according to, and not disgraced, their faith
• existence of after-life

• some will not discuss it
• others just need the presence of a sympathetic person to listen (not necessarily a religious person or a pastoral care worker)

• spiritual care is person-centred and begins at the level of the patients' own insight
• most people are helped by knowing that the questions and doubts that are troubling them are shared by many others

• believers are comforted
• that there is something after death
• that their wrong doings can be forgiven and their good deeds be credited
• families sharing the same faith
• may help them cope better looking after a terminally ill relative
• may be a source of comfort to the dying patient, confident that faith will help those left behind
• people with a deep religious faith often find it grows as death approaches
• for those with a less well-developed/less tested faith, impending death can be a major challenge to their faith

• when these are not forthcoming they may
• blame their religion or even their God
• direct their anger or disappointment against their professional carers

• the patient or family should be asked about religious matters including prayer, diet, and routines of personal hygiene
• sacred practices including prayer, sacraments, anointing with oils, the burning of incense, periods of fasting or self-denial, special diets, baptism and many others are both respected and facilitated

• the manner in which individuals practise their religion must be respected

• a patient's religious needs are assessed on an individual basis

• no two people of the same faith are likely to have exactly the same religious needs

• facilitate arrangements for their priests and teachers to visit them
• support them when their faith feels inadequate for what they are experiencing
• reassure them that the rites of their religion and culture will be fully respected after their death

Good care of the patient helps the relatives cope, but they also have their own needs and anxieties that must be addressed, including:

• to do with the patient's illness and care - relatives may be anxious to know about
• what exactly is wrong with the patient
• why the patient is receiving certain treatment
• whether his illness is infectious or contagious
• whether they will be able to care for the patient at home
• how long they will be able to care for the patient at home
• whether their health will be adequate for them to do this caring
• whether they will know how to speak to the patient if he asks about dying and death, particularly if the relatives have tried to keep the truth from him
• whether they will cope with any emergencies that might arise
• when to call the doctor and what help or advice to ask for
• how to give medications
• whether they are giving he patient the right food and drinks
• visiting in hospital
• talking to children and friends about the patient's illness
• to do with their own personal feelings and needs - relatives are often anxious about
• their own health but feel they cannot mention it
• family tensions and how to deal with them
• unresolved interpersonal problems from the past
• unresolved grief from a recent bereavement
• how they will manage when the patient dies - where will they live, who will care for them, where will the money come from
• to do with the society where they live - relatives may be anxious about
• whether it is right to keep the patient at home
• what other people think about their caring
• whether they are demonstrating their religious faith
• whether they should be accepting the unsolicited advice being offered by friends or neighbours
• who to invite to the funeral
• how to behave after the death
• whether they are " doing the right thing "