Overview
Anxiety in terminally ill patients is poorly understood with regards to prevalence and relationship to other aspects of distress. Terminal illness does not just mean cancer but all progressive chronic illnesses such as progressive organ failure: lung, heart kidney, liver, brain and other areas. Causes of anxiety in terminal illness are multiple and include:
- Fear of death
- Fear of pain
- Fear of loss of bodily autonomy and independence.
- Economic fears
- Fears of isolation and loneliness
- Fear of being a burden on others
- Fear of being mistreated by relatives.
- Iatrogenic causes of anxiety i.e. fear of being harmed by the proposed treatment, medical personnel or the medical system. E.g., uncaring staff or denial of treatment,
What We Know
Anxiety worsens the symptoms of all medical conditions. Numerous studies show it decreases life expectancy in cancer patients and accelerates the progression of the disease, or can even cause disease e.g., tako-tsubo cardiomyopathy, also known as “broken heart syndrome”. (Heart failure caused by severe grief).
Studies show patients with strong belief systems and those who have a supportive family have a much better outcome than those who do not, which almost certainly is because they are less anxious.
Research And Breakthroughs
There have been no major medical breakthroughs in the treatment of anxiety in relation to terminal illness. Standard medical treatment remains analgesic medication, anxiolytic and antidepressant medication, and psychological counselling. The drugs used today are the same drugs used for the last 40 years. Opiates are now used much more often and earlier on but they produce the side effects of dependence and sedation.
A growing trend for the relief of anxiety in terminally ill patients is euthanasia. It is important to note that it is not a medical treatment which is defined as “management and care to prevent, cure, ameliorate, or slow progression of a medical condition” by merriem-webster dictionary. The approach has been available in the State of Victoria for about 5 years now. It is claimed by its proponents that it is especially suitable for those patients who fear (anxiety) loss of control at the end of their lives and are greatly comforted by having a bottle of a very strong anaesthetic agent, sodium pentobarbital, at their bedside which they can take if they want to end their life.
Treatment
The treatment of anxiety in terminal illness is to remove the underlying cause if possible.
1. FEAR OF DEATH
There is no medical treatment for this apart from major sedation with opiates. Sometimes psychostimulants such as dexamphetamine are used.
Psychological and spiritual support provided by a qualified professional plays an important part in helping the patient through this incredibly difficult period. Another issue the medical profession needs to change is telling the patient how long they have to live which causes a great deal of harm to the patient.
General Practitioners witness this issue as a regular occurrence. After seeing a specialist (usually) who has told the patient that they have a certain period to live, the patient feels some burden of their disease but is ambulant and independent. However, because a timeframe has been introduced they are now completely deflated, and feel all hope has gone. Doctors must explain to these types of patients that even the smartest doctor in the world has no idea when they will die. Many patients exceed the doctor’s prediction, often by a significant time.
An example to this point is a male patient who had a severe lung condition (primary pulmonary hypertension) and needed to have continuous oxygen by nasal prongs and an infusion of prostaglandin by a pump under his skin. The patient was able to walk short distances and lived at home. His specialist (a Professor of respiratory medicine at a major teaching hospital) told him he had only limited time to live and the infusion was not helping and he was advised to have it removed. He was admitted for this and he was told he would to die shortly thereafter, if fact probably the next day. His family maintained a bedside vigil. He was still alive a week later to the bewilderment of the respiratory department. After another three weeks he was discharged to a hospital closer to his home as it was difficult for the family to travel across town to the major hospital. He spent 3 months in the local hospital in the palliative care wing and was then transferred to a local nursing home where he received care for the next 2 years when he finally went peacefully in his sleep. It is recommended not to give the patient this information unless they ask and then only with significant qualifications otherwise the psychological damage to the patient can be devastating and is akin to “pointing the bone.”
2. FEAR OF PAIN
The patient should be reassured that severe pain can always be controlled with medication and/or surgery.
3. FEAR OF LOSS OF BODILY AUTONOMY AND INDEPENDENCE
Unfortunately, there is not much that can be done to prevent this. Good nursing care is the mainstay here and unfortunately due to our aging population it is becoming difficult to provide. For example, due to lack of appropriate care in some Aged Care facilities during the COVID crisis in Victoria in June -Sept 2020, patients were given palliative care rather than more active care and this caused a spike in deaths in this area resulting in 8-900 deaths in Aged care facilities out of a total of about 1200 throughout the state.
4. ECONOMIC FEARS
Obviously medical care is very expensive if you must pay for it privately. The public system is often inadequate due to long wait times.
5. FEARS OF ISOLATION AND LONELINESS
This is where family and community are most important. Unfortunately, families and communities in across society are experiencing hardship and fractured relationships. Community and Church groups likewise are stretched. Today, many people live alone. In 1961, 10% of people lived alone. This increased to 25% in 2016 (ABS)
6. FEAR OF BEING A BURDEN
This has increased as the number of those who look after the sick, e.g., family members, volunteers, community, charitable and church groups have decreased in numbers.
7. FEAR OF BEING MISTREATED BY RELATIVES
Many medical practitioners and health professionals have witnessed relatives inappropriately asking for increased and unnecessary doses of opiate analgesia. In one instance they asked the locum doctor to administer a lethal dose of morphine to their aged relative. The patient will be powerless if there is no doctor or advocate to protect them.
8. IATROGNEIC CAUSES OF ANXIETY
Doctors. E.g., pronouncing a death sentence as described above. Much more commonly not explaining treatment to the patient and not answering the patient’s questions.
Nurses. Uncaring attitude or even denying the patient care. In one extreme instance a nursing home patient was chocked to death by the nurse. The patient was a middle-aged male and suffered from spacticity due to a head injury. He was still able to read and communicate using a keyboard. They thought it better for the patient to let this happen rather than intervene or call an ambulance because they thought clearing the throat would be too traumatic for the patient. They called the patient’s GP after the patient had died. The GP reported the case to the coroner, but nothing was done.
Integrative (Holistic) Care Options
It is important to offer psychological treatment to help relieve anxiety e.g., relaxation exercises and hypnosis. Adequate nutrition is crucial too.
Disclaimer
The contents in this condition report is under copyright and cannot be used as a promotional tool. It is intended solely for educational purposes to aid medical and health professionals to advance their duty of care and provide outstanding service and care to their patients.
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