1. Section IV: Psychosocial Issues
Depression
Anxiety
Post-Traumatic Stress Disorder (PTSD)
Delirium/agitation/confusion

2. Depression Ranges from sadness to suicidal
Often unrecognized and undertreated
Occurs in 25-77% of terminally ill
Distinguish normal vs. abnormal
Should not be dismissed
Cluster
Fulcher, 2014; Pasacreta et al., 2015

3. Causes of Depression Disease-related Psychological Medication-related
Treatment-related
Social issues

4. Assessment of Depression
Situational factors/symptoms
Previous psychiatric history
Other factors (e.g., lack of support system, pain)
Pasacreta et al., 2015

5. Suicide Assessment Risk factors for suicide
History of declining functionality
Psychiatric evaluation

6. Pharmacologic Interventions for Depression
Goal: Focus on symptom control
Antidepressants (e.g. Amitryptiline- may take 4-6 weeks to be effective)
Steroids (e.g. Dexmethasone)
Pasacreta et al., 2015

7. Non-Pharmacologic Interventions for Depression
Promote autonomy
Grief counseling
Draw on strengths
Use cognitive strategies

8. Anxiety Subjective feeling of apprehension
Often without specific cause
Categories of mild, moderate, severe

9. Causes of Anxiety Physiological changes Medications and substances
Pre-existing anxiety pre-diagnosis
Uncertainty
Pasacreta et al., 2015

10. Assessment of Anxiety Physical symptoms Cognitive symptoms
Questions for assessment
APA, 2013

11. Pharmacologic Interventions for Anxiety
Benzodiazepines (e.g. Diazepan)
Anticonvulsants (e.g. Carbamazepine)

12. Non-pharmacologic Interventions for Anxiety
Empathetic listening
Assurance and support
Concrete information/warning
Relaxation/imagery

13. Post-Traumatic Stress Disorder (PTSD)
PTSD is characterized by persistent/severe reaction to a traumatic event
Combat
Terrorist attacks
Sexual or physical assault
Accidents
National/natural disasters
Symptom clusters
Avoidance
Re-experiencing the event
Hyperarousal
Implications for EOL

14. PTSD and End-of-Life Care
Illness/death can be a PTSD activator
Challenges social ties
Delirium or flashbacks?
Medication
GOAL: Reduce PTSD symptoms and create an emotionally safe environment
Grassman, 2015

15. Delirium/Agitation/Confusion
Delirium - Acute change in cognition/awareness
Agitation or withdrawal - Accompanies delirium
Confusion - Disorientation, inappropriate behavior, hallucinations
Heidrich & English, 2015

16. Delirium/Agitation/Confusion: Causes
Medications
Infection
Hypoxemia
Bladder distention
Unrelieved pain
Other

17. Delirium/Agitation/Confusion: Assessment
Physical exam
History
Spiritual distress
Other symptoms
Heidrich & English, 2015

18. Delirium/Agitation/Confusion: Treatment
Maintain Safety
Pharmacologic
Neuroleptics
Monitor for side effects, withdrawal
Eliminate non-essential/contributing medications
Reorientation
Relaxation/distraction
Hydration