Some psychological distress will occur with any life-limiting illness . The
ability to recognize and relieve this is an essential skill in palliative care.
Factors predisposing to psychological distress
! the disease
o rapidly progressive, clinical features changing frequently
o present and anticipated disabilities, disfigurement, dependency
o physical dependence
o protracted illness with physical and psychological exhaustion
! the patient
o not fully understanding the disease, treatment or what lies ahead
o made worse when no simple explanations are given
o fear of pain, dying, disfigurement
o loss (or fear of loss) of control, independence, dignity
o helplessness, hopelessness, dependency
o insight regarding (or fear of) poor prognosis
o anxious personality, pre-existing personality traits
o pain and doubts whether suffering can be relieved
o lack of confidence in medical and nursing attendants
o unrelieved pain
! symptoms
o uncontrolled or poorly controlled symptoms
o perceived lack of interest in medical attendants
o unaware of the cause of different symptoms
! treatment
o diagnostic delays, multiple failed treatments
o side effects of therapy
! treatment team
o poor communication
o lack of continuity of care
o exclusion of family, carers
! social
o loss (or fear of loss) of job, social position, family role
o feels isolated (actual or perceived)
o feels a burden on family and carers
o unfinished business: personal, interpersonal, financial
o financial hardship
o fears for family
! cultural
o cultural differences in attitude to sickness, suffering, loss, and death
o language barriers
! spiritual
o religious issues
o spiritual issues, e.g. remorse, guilt, unfulfilled expectations,
meaninglessness, sense of life and suffering having no meaning
Clinical features
• psychological distress is often described in terms of anxiety or depression but
most patients suffer a range of other emotional problems
• these do not necessarily or commonly reflect psychopathology and some, like
denial, are best regarded as the clinical manifestations of coping
mechanisms
• agitation, restlessness and mood swings are particularly common
Examples of psychological distress
anxiety denial sadness, misery, remorse
depression guilt withdrawal, apathy
anger, frustration, irritability fear inappropriate compensation (joyful)
hopelessness, despair grief lack of co-operation with carers
helplessness passivity unresponsive pain
regression avoidance
Denial
! is the most frequently seen coping mechanism
! does not necessarily indicate the patient has not had everything explained
! is not necessarily abnormal or pathological
o it is so common that it could be regarded as a normal feature of lifethreatening
illness
! allows patients time to come to terms with their situation
! an alternative description is ‘suppression of information’ which
emphasizes its protective function
! should not prompt team members to force information on the patient, but
alert them to a defence mechanism
! is often cited by relatives as evidence that the patient does not know or
does not want to know and that information should not be forced upon
them
! may result in the patient behaving differently with different people—with
close relatives they may appear to know nothing of the illness or its
seriousness, but are able to discuss it openly with another relative or a
professional carer
The level of psychological distress depends on patients’ ability to cope
Factors predictive of poor coping
! personal
o anxious or pessimistic personality
o poor coping with previous illnesses, stresses, losses
" most patients cope better than might be expected from their
previous history of coping
o adverse experiences with cancer in relatives or friends
o history of recent personal losses
o low personal esteem
o multiple family problems, obligations
o marital problems
o history of psychiatric illness
o personality disorder
o history of alcohol or substance abuse
! social
o few social supports, resources; isolated
o lower socioeconomic class
o sense of not being valued or understood
! cultural
o certain cultural traditions, usually related to stoicism, showing
emotions, being undemonstrative
! spiritual
o not religious; no alternate value system
Treatment
Treat underlying causative factors before rushing to prescribe anxiolytics
or antidepressants
! general measures
o caring, considerate, unhurried, non-judgemental approach
o good listening, good communication
o reassurance about continuing care
o respect for the person and individuality
o allow discussion of fears regarding future suffering, life expectancy
" even patients ‘in denial’ appreciate such discussions
! control pain and physical symptoms
o most psychological distress lessens when physical suffering is
competently relieved
! social
o address social issues, encourage social supports
o provide support for family and carers
o their support needs are usually different from those of the patient
o many carers say they did not receive all the information they felt
they needed
! cultural
o respect cultural differences: diet, rituals, customs
! spiritual
o address religious or spiritual concerns and respect belief systems
! other measures
o general supportive counselling
o support groups
o relaxation therapy
o meditation
o distraction
o socialization
! psychological therapies
o stress management techniques
o coping skills training
o cognitive therapy
o anxiolytics, antidepressants (as a last resort)
o supportive psychotherapy
Effective treatment of psychological distress in patients with lifethreatening
illness may greatly improve the quality of life
Time spent listening is never wasted. A truism of palliative care is that
‘nothing is trivial’. Everything the patient says, everything they
experience, is worthy of our attention.