Collaborative Approach in Psycho-Oncology and Palliative Care

Psycho-Oncology and Palliative Care
APM Resident Education Curriculum
Revised 2019: 
Dustin DeMoss, DO
, Assistant Professor, Univ. North Texas HSC
Anthony Nguyen, DO
, John Peter Smith/Univ. North Texas HSC
Revised 2013: 
Ryan Kimmel, MD
, Assistant Professor, Univ. of Washington
Revised 2011: 
Kristen Brooks, MD
, Assistant Professor, UCSF
Original version: 
Bradford D. Bobrin, MD
, Medical Director, ACT Program, Division Chief, Psychiatry
Consult Service, The Reading Hospital and Medical Center, Reading, PA
Version of March 15, 2019
Learning Objectives
Review potential psychiatric comorbidities in the palliative care and psych-oncologic
patient population
Become familiar with diagnostic challenges and modalities commonly used in
palliative care and in psycho-oncology
Review current evidence based treatment guidelines for those with psychiatric
diagnoses in the palliative care and psycho-oncologic patient population
Appropriately identify and screen individuals with risk of substance use disorders
2
Palliative Care and Psychosomatics
Hospice began in France in 1840s
Involves all stages of life-threatening illness
Includes psychological, social, spiritual, and cultural issues
World Health Organization defines palliative care as:
An approach that improves the quality of life of patients and their families facing the problem
associated with life-threatening illness through the prevention and relief of suffering.
3
James L Levenson, M.D., 2005.
Palliative Care and Psychosomatics
Palliative care:
Affirms life and regards dying as a normal process
Neither hastens nor postpones death
Provides relief from pain and other symptoms
Integrates the psychological and spiritual
Offers support system to help patient live as actively as possible
Helps family cope
Utilizes a multidisciplinary approach to address the needs of the patient and their
families
Is applicable early in the course of illness in conjecture with other therapies that
are intended to prolong life.
4
James L Levenson, M.D., 2005.
Psychiatry and Palliative Care
Working Together Towards a Common Goal
Palliative care’
s goal is to relieve symptoms and suffering and improve the
quality of life for the patient and their families.
Palliative informs psychiatry
Assessment and treatment of pain
Bereavement
Anticipatory loss
Psychiatry informs palliative care
Assessment of psychiatric illness and mental status changes
Evaluation of capacity
Psychiatric treatment
Insight into personality structure and communication issues
Conflict resolution
Patient physician relationship
Recognize the formation of an attachment as a consequence of working towards a
common goal
5
JLSpeiss, 2002; Tan et al., 2005, Fairman 2013
Psychiatric Aspects of Cancer Treatment
Chemotherapy
Drug interactions
Procarbazine is a weak MAOI
Paroxetine , fluoxetine, duloxetine and bupropion are strong 2D6 inhibitors and may decrease the
efficacy of tamoxifen due to enzyme inhibition , thus reducing levels of tamoxifen’s active
metabolite (endoxifen).
Venlafaxine likely the safest antidepressant and can help with tamoxifen induced hot flashes
Citalopram and escitalopram are reasonable as well.
Radiation
Increased fatigue, N/V, and anxiety
Bone Marrow Transplant
Depression and anxiety, N/V, fatigue, adjustment d/o, dependence (dependent needs are
associated with poorer survival), neurocognitive deficits due to CNS toxicity
6
James L Levenson, M.D., 2005, SLB Mueller 2005, Desmarais 2010
Psychiatric Issues Following Cancer Treatment
3-55% get depressed following breast cancer treatment
Cognitive problems include disturbed consciousness, cognitive problems, executive
problems. In a study of 8,921 women with breast cancer
Women who got surgery and chemo had increased rates of adjustment d/o and fatigue
Mood disorders were similar in chemo and non-chemo groups
No issues with cognitive disorder
7
JR Sattin 2009, SLB Muller 2005, Takechi 2003
Common Psychiatric Issues In the Psycho-oncologic and Palliative Care
Population
Anxiety
Bereavement and Grief
Depression
Delirium
8
James L Levenson, M.D., 2005, Wyszynski, 2005
Depression and Cancer
May lead to poor treatment adherence and possibly decreased survival
Increased rates of depression in cancer patients over the general population
25% rate overall
Differs for different cancers
Orophargngeal 22-57%
Pancreatic 33-50%
Breast 1.5-46%
Lung 11-44%
Depression appears to be less common in colon cancer, gynecological malignancies and
lymphoma
9
CP van Wilgen 2006, JL Levinson 2005,  KM Brintzenhofe 2009
Depression and Cancer Progression and Mortality
Depression found to be a small but significant predictor of mortality
26% greater mortality with depressive symptoms
39% greater mortality with MDD
Depression may be independent risk factor for mortality
Depression not associated with cancer progression
Chronic inflammation is associated with stress and may underlie depression
symptoms.
Biomarkers for pro-inflammatory cytokines are increased in cancer patients
10
JR Satin 2009, Sotelo 2014
Assessing Depression in the Terminally Ill
Diagnosis often relies more on psychological or cognitive symptoms than physical
complaints
Hopelessness that is pervasive with despair and despondency likely indicates
depression
Suicidal ideation, even mild or passive, more likely to indicate significant depression
11
James L Levenson, M.D., 2005, Takechi 2003
Treatment of Depression in Terminally Ill
Prognosis and time frame affect medication choice
SSRIs for person with several months
Low dose stimulants for those with several weeks
Sedatives or narcotic infusions for those with hours to days
Start antidepressants at half the usual starting dose
Methylphenidate 2.5-5mg in morning and noon
Maximum dose is usually less than 30mg/day.
Psychotherapy
Mixture of supportive, CBT and medications.
Newer modalities such as meaning-centered psychotherapy and dignity-conserving care have also
been found to be helpful
Music therapy
Shown to reduce pain, decrease anxiety and depression and improve quality of life
12
James L Levenson, M.D., 2005, Wyszynski 2005, Gao 2018,
Somatic Symptoms and Depression in Cancer
Somatic symptoms of depression in cancer patients
Appetite changes and decreased ability to think coincided with anhedonia
Sleep disturbance and fatigue not significantly associated with non-somatic symptoms
Appetite changes associated with increased severity of depression
13
Takechi 2003, Van Wilgen 2006 Mueller 2005
Mixed Depression/Anxiety in Cancer Patients
8,265 patients with cancer
Mixed symptoms in 12.4%
Depression in 18.3%
Anxiety in 24%
70% had neither
Mixed symptoms in stomach, pancreatic, head and neck and lung cancers
Lower rates in those with breast cancers
Mixed symptoms in 2/3 of depressed cancer patients
14
KM Brintzenhofe-Szoc 2009
Suicidal Ideation and Cancer
Passive SI common
Relative risk of suicide was 12.6 within first week of cancer diagnosis
Relative risk is 3.1 within the first year of diagnosis
Risk factors
Regular risk factors for suicide in the general population
Advanced disease and poor prognosis
Delirium
Pain
Physical, social, and/or financial exhaustion
Need for control
15
James L Levenson, M.D., 2005, Fang 2012
Suicide and Suicidal Ideation in Palliative Care
3-20% have pervasive and sincere wish to die.
Risk Factors
All regular risk factors for suicidality are important to consider
Age, race, history of suicide attempts, psychiatric illness, means, etc
Advanced stages of the disease
Hopelessness
Uncontrolled pain
Confusional states (delirium)
Loss of control and sense of helplessness
 Fatigue of all forms
Physical
Financial
Social support
Suicidal ideation needs to be addressed, but psychiatric  hospitalization may not be
indicated in some cases
16
James L Levenson, M.D., 2005, Wilson 2015
Desire for Hastened Death
States that allow physician assisted death
Oregon, Washington, Vermont, California, Montana, Colorado, Washington DC, Hawaii
Risks
Depression plays a role in requests for hastened death
Patients with depression were noted to have a 4x higher likelihood of desire for hastened death
Depression and hopelessness are the strongest predictors of desire for hastened death in terminally ill
patients
These patients have higher levels of pain and less support
Psychological distress, social factors, spiritual distress and feeling like one is a burden contribute
Management of physical and psychological distress is likely the best treatment
Increasingly legalized but still relatively rare. Primary involves cancer patients.  
Main motivations for physician assisted death
Loss of autonomy and dignity, decreased quality of life, Mental distress
17
James L Levenson, M.D., 2005, Emanuel 2016
Depression and Cancer
SSRI remains the first line treatment
Possibility of inflammation as a cofactor or even etiological reason for depression. SSRIs found to
have anti-inflammatory properties  on microglia.
SSRIs may even have anti tumor effect. There have been in vitro studies that show SSRIs having
apoptotic effects in hepatocellular carcinoma cells
Concurrent depression and cancer related symptoms
Mirtazapine: Helps with insomnia, nausea and anorexia.
Bupropion : Helps with fatigue, poor concentration, or nicotine dependence
Venlafaxine, Duloxetine or low dose TCA: Helps with neuropathic pain
Venlafaxine and SSRI: Helps alleviate hot flashes from hormone therapy
18
SM Thekadi 2015
Depression in Palliative Care
Prevalence 13-20%
Loss of meaning and lower spiritual well-being lead to higher levels of depressive
symptoms
Pain and functional status also factors in increased rates of depression
Underlying medical conditions may also contribute to depressive symptoms
CNS lesions, metabolic-endocrine complications and paraneoplastic syndromes
Treatment of medical conditions may also induce depressive symptoms
Whole brain radiation, corticosteroids, vincristine, vinblastine, asparaginase, intrathecal
methotrexate, interferon, amphotericin
19
James L Levenson, M.D., 2005, Mitchell 2011
Demoralization vs. Depression
Demoralization
Characterized by 
various degrees of helplessness, confusion and subjective
incompetence
 to adversity.
 Shorter duration than depression
 Reactive to family and supports
 Specific to stressors
How would you be coping if this went away?
20
Slide adapted from Mitch Levy, Univ of Washington
Demoralization
Diagnostic Criteria
1. Patient experiences emotional distress such as hopelessness and losing life’s purpose
2. A general attitude of helplessness, failure pessimism, and lack of worthwhile future
3. Reduced coping to respond differently
4. Social isolation and lack of social support
5. Persistence of the above for 
>
2 weeks
6. Features of major depression are not superseded as primary disorder.
21
Kissane, 2000
Treatment Targets for Brief Psychotherapy for Demoralization:
Existential Postures of Vulnerability and Resilience
Vulnerability
• Confusion
• Isolation
• Despair
• Helplessness
• Meaninglessness
• Cowardice
• Resentment
22
Griffith and Gaby,, 
Psychosomatics, 
2005
Resilience
• Coherence
• Communion
• Hope
• Agency
• Purpose
• Courage
• Gratitude
Overall Psychological Treatment Goals
Help patients maintain control of their lives
Assist in developing healthy coping strategies
Help control
Anger
Denial
Panic
Despair
Fears of rejection and abandonment
Help establish self-respect by assisting with resolution of guilt, shame and self-blame
Help with communication and the maintenance of support systems
23
James L Levenson, M.D., 2005,  JL Speiss, 2002, LW Roberts 2004
Overall Psychological Treatment Goals
Help maintain interpersonal relationships
Help develop strategies to deal with real and anticipated crises
Help identify and address 
unfinished business
Work with patient to explore meaning of death
Help manage depression and anxiety or other psychiatric symptoms that may result
from psychological issues or effects of treatment
24
James L Levenson, M.D., 2005
Dignity Conserving Treatment
 
Dignity therapy
Treatment is based on strong association with undermined dignity and:
Depression
Anxiety
Desire for death
Hopelessness
Feeling of being a burden on others
Overall poorer quality of life
Some studies even suggest that psychosocial and existential issues may be of
greater concern than pain and physical symptoms
Chochinov, H,  2007
Dignity Conserving Treatment
Dignity therapy
Primary themes of dignity:
Generativity
Life has stood for something
Continuity of self
Maintain one’
s essence is intact
Role preservation
Being able to maintain a sense of identification with roles previously held
Maintenance of pride
Ability to sustain positive self-regard
Chochinov, H,  2007
Dignity Conserving Treatment
Dignity therapy
Primary themes of dignity (cont.):
Hopefulness
Ability to find and maintain a sense of meaning or purpose
Aftermath concerns
Worries or fears concerning the burden death will impose on others
Care tenor
Attitude and manner with which others interact with the patient either promotes or diminishes
dignity
Many of these are also essential to a patient maintaining a sense of control and
integrity in any setting
Chochinov, H,  2007
Dignity Conserving Treatment
Dignity therapy (provider):
Treatment of the provider consists of an A, B, C, D approach to teaching interactions
The hope is to allow care givers, institutions, and families a way to better interact with
patients to achieve the desired effect
Our thoughts about an interaction with a patient shape the interaction itself
Engagement Model
Chochinov, H,  2007; Bennington-Davis, M, 2005 
Dignity Conserving Treatment
Dignity therapy (provider):
A—Attitudes
How would I feel in this situation?
What leads me to think that way?
Am I aware of how I might be affecting the patient?
Chochinov, H,  2007
Dignity Conserving Treatment
Dignity therapy (provider):
B—Behaviors
Treat contact with patients as you would any important intervention
Always ask permission to do something
Act in a professional and respectful way at all times
Examples
Knock on the patient’
s door
Use the patient’
s proper name and title unless given permission to do otherwise
Chochinov, H,  2007
Dignity Conserving Treatment
Dignity therapy (provider):
C—Compassion
Very difficult to 
train
Medical Humanities in school
Considering the personal stories
D—Dialogue
What should I now about you as a person to help me take the best care of you that I can?
Who else (or what) will be affected by what
s happening?
Chochinov, H,  2007
Promoting Resilience
• Assess for prior strengths and life challenges.
 
–What have you overcome previously like this?
 
–What has helped in the past?
 
–How do you cope with adversity?
• Engage the family and members of the treatment team.
32
Slide adapted from Mitch Levy, Univ of Washington
Anxiety in Palliative Care
Ranges from 6.8-13.2% and is most often comorbid with depression
Prevalence increases with advanced disease and decline in physical status
Includes fears of clinical course, treatment outcomes, death, social stigma, and/or
physical symptoms (such as dyspnea or pain)
Women, more physical impairment and younger patients with advanced cancer were
more likely to develop anxiety disorders
A trusting physician-patient relationship is critical to minimize patient shame,
humiliation, and power imbalance
33
James L Levenson, M.D., 2005, Wyszynski, 2005, LW Roberts 2004, Spencer 2010, Mitchell 2011
Causes of Anxiety in Palliative Care
Preexisting anxiety disorder
Anxiety symptoms can be caused by various untreated medical complications
Hypoxia
Pain
Medication side effects
Substance withdrawal
Pulmonary embolism (PE)
Electrolyte imbalance,
Dehydration
Fear of isolation and separation of death
34
James L Levenson, M.D., 2005,Wyszynski 2005
Anxiety Treatment in Palliative Care
Benzodiazepines
Multiple routes of administration (PO, IV, IM or PR)
Neuroleptics may be safest when there is a concern of respiratory depression
Multiple routes of administration (PO, IV, or IM)
Supportive psychotherapy, guided imagery, and hypnosis
SSRIs of limited value in patient when life expectancy is only a few days to
weeks
There is lack of evidence for effectiveness of drug therapy in this patient
population
35
James L Levenson, M.D., 2005, Salt 2017
Anxiety and Cancer
Common at start of treatment, recurrence, progression or at follow-up
visits
30% 
of patients had clinical anxiety after diagnosis of cancer
3-10% PTSD in patients
 with breast cancer
Multiple potential medical etiologies of anxiety symptoms
Nausea
Akathisia
PE
Pain
36
MH Antoni 2006, JL Levenson 2005, Cardoso 2015
Anxiety and Cancer
Treatment
SSRI remains the primary approach to generalized anxiety and prevention of panic attacks
Short term use of Benzodiazepines are well tolerated, safe and effective drugs for anxiety.
Anterograde amnestic properties help to lessen the negative impact of cancer treatment
experiences.
Short acting BZD may be used for procedure related anxiety, anticipatory anxiety, or specific
phobias
Non-BZD drugs reduce risk of abuse or dependence
Gabapentin, beta blockers, Buspirone and Hydroxyzine found to be helpful for anxiety.
37
SM Thekadi 2015
Mania in Cancer
Recurrence of pre-existing illness
Steroids
Infection
Diencephalic tumors
38
JL Levinson, 2005
Mood Stabilizers
Help with impulsivity, irritability and temper dysregulation.
Also treat neuropathic pain, hot flashes and seizure prophylaxis
Lithium: rarely started in the cancer context
Risk of dehydration, electrolyte abnormalities, renal dysfunction, and drug interactions.
Valproic acid and Carbamazepine: helpful for mood stabilization. Carry risks of
hematological suppression and hepatotoxicity
39
SM Thekadi 2015
Mood Stabilizers
Gabapentin or Pregabalin:
Helps manage hot flashes, neuropathic pain and postherpetic neurolgia
Has anxiolytic and sedative effects
No Cyp450 interaction. Cleared renally.
Oxcarbazepine: Recent open label study showed it may be helpful in
prevention of oxaliplatin-induced neuropathy.
40
SM Thekadi 2015
Psychosis and cancer
Primary psychosis
Delirium
Psychosis due to medical condition
Medication induced psychosis
41
SM Thekadi 2015
Antipsychotics
Side effects of select antipsychotics can help target symptoms common to
cancer patients. Symptoms include anxiety, nausea, hiccups, loss of appetite,
and insomnia.
Haloperidol continues to be gold standard for delirium
New RTC shows that lorazepam + haloperidol provides superior control to agitated delirium
in advanced cancer patients
Aripiprazole may uniquely be activating for hypoactive delirium
Recent meta-analysis showed a 50% reduction in postoperative delirium for
elderly patient given prophylactic antipsychotics
42
SM Thekadi 2015
Antipsychotics
Antipsychotics may be preferred to BZD for acute anxiety. Less risk of AMS and
respiratory depression.
Low dose quetiapine or olanzapine may be used for insomnia when sedative
hypnotics are deemed too risky.
Haloperidol and chlorpromazine may be used for intractable hiccups
Haloperidol and olanzapine may help with nausea
Olanzapine is efficacious for chemo induced nausea and vomiting
Olanzapine and quetiapine helpful for weight loss and anorexia.
43
SM Thekadi 2015
Bereavement and Grief
Bereavement: 
Situation in which someone who is close dies
Grief : 
Natural response to bereavement
Feelings: 
Some may experience shock, sadness, anger, anxiety,
disbelief, panic, numbness,.
Physical: 
Insomnia, fatigue, loss of appetite, nausea and pain.
Behaviors: 
Substance use, less attention to self care, impulsive or
harmful behaviors
Stages of Grief:
Denial, Anger, Bargaining, Depression, Acceptance.
44
Bereavement and Grief
Anticipatory Grief
Draws family closer
Acute Grief
Numbness 
 D
istress 
 D
isorganization 
 R
eorganization 
R
ecovery and
progression
Complicated Grief
Complicated by depression, anxiety, and substance use
Chronic Grief
Social withdrawal and isolation along with a fantasy of reunion may lead to
suicidal ideation
Traumatic Grief
Often complicated by the inability to communicate 
good-bye
45
James L Levenson, M.D., 2005, LW Roberts 2004
Delirium in Palliative Care
Prevalence of 
62
-88% especially in the last weeks of life
Rates of cognitive impairment rise just prior to death in up to 62% in cancer patients
Terminal delirium has a 88% prevalence before death
In one study 54% recalled their delirium after recovery
The biggest risk factor for distress during episodes of delirium are the presence of
delusions
Delirium may not be reversible in the last 24-48h of life (terminal delirium)
46
JL Levinson 2005, Y. Alici 2009
Delirium in Palliative Care
There are 2 subtypes of Delirium to consider
Hyperactive
 – Easier and more commonly diagnosed type. Characterized by restlessness,
agitation, hypervigilance, hallucinations and delusions.
Hypoactive
 – More difficult to diagnose. Characterized by psychomotor retardation, lethargy, and
reduced awareness of surrounding. Often misdiagnosed as depression or severe fatigue. 
In a hospi
ce setting 29% of 100 acute admissions were found to have delirium, of
these 86% of them had hypoactive delirium.
Hypoactive subtype has a higher risk of mortality compared to hyperactive subtype. 
47
Y. Alici 2009
Delirium 
(continued)
Variable rates of resolution
One study showed a 68% improvement rate despite 31% mortality in 30 days
Another study a cause was found in 43% and 1/3 improved
Another study showed that 50% of episodes of delirium in the last week of life
were reversible
Potential causes of delirium in the terminally ill often include…
Dehydration
Psychoactive or opioid medications
Hypoxia
Other metabolic derangements
48
JL Levinson 2005
Substance misuse/use disorders in Oncology and Palliative Care
Opiates are frequently used in these populations.
Screenings for substance misuse and or use disorders are infrequent (less than half
according to a recent survey; Tan 2015).
Even fewer palliative care clinics have policies regarding the issue of substance
misuse despite the staff reporting to have received training in managing substance
misuse or use disorders.
49
Substance misuse/use disorders in Oncology and Palliative Care
Passik and Portenoy 1998 have developed guidelines for the management of patients
with aberrant drug taking in terminal and oncologic patients.
Primary goals in these guidelines are harm reduction and patient compliance
Some of their recommendations include
Consideration of a written contract between the team and patient
Inclusion of spot urine toxicology screens to assess compliance
Set expectations regarding attendance at the clinic
Management of medication supplies
50
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Y. Alici & W. Breitbart
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Delirium in Palliative Care, Primary Psychiatry. 
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This educational curriculum emphasizes the importance of addressing psychiatric comorbidities in palliative care and psycho-oncology patients. It covers diagnostic challenges, evidence-based treatments, and screening for substance use disorders. The content also discusses the principles of palliative care, psychosomatics, and the collaborative efforts between psychiatry and palliative care. Language Detected: English


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  1. Psycho-Oncology and Palliative Care APM Resident Education Curriculum Revised 2019: Dustin DeMoss, DO, Assistant Professor, Univ. North Texas HSC Anthony Nguyen, DO, John Peter Smith/Univ. North Texas HSC Revised 2013: Ryan Kimmel, MD, Assistant Professor, Univ. of Washington Revised 2011: Kristen Brooks, MD, Assistant Professor, UCSF Original version: Bradford D. Bobrin, MD, Medical Director, ACT Program, Division Chief, Psychiatry Consult Service, The Reading Hospital and Medical Center, Reading, PA Version of March 15, 2019 ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY Psychiatrists Providing Collaborative Care Bridging Physical and Mental Health

  2. Learning Objectives Review potential psychiatric comorbidities in the palliative care and psych-oncologic patient population Become familiar with diagnostic challenges and modalities commonly used in palliative care and in psycho-oncology Review current evidence based treatment guidelines for those with psychiatric diagnoses in the palliative care and psycho-oncologic patient population Appropriately identify and screen individuals with risk of substance use disorders Academy of Consultation-Liaison Psychiatry 2

  3. Palliative Care and Psychosomatics Hospice began in France in 1840s Involves all stages of life-threatening illness Includes psychological, social, spiritual, and cultural issues World Health Organization defines palliative care as: An approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness through the prevention and relief of suffering. James L Levenson, M.D., 2005. Academy of Consultation-Liaison Psychiatry 3

  4. Palliative Care and Psychosomatics Palliative care: Affirms life and regards dying as a normal process Neither hastens nor postpones death Provides relief from pain and other symptoms Integrates the psychological and spiritual Offers support system to help patient live as actively as possible Helps family cope Utilizes a multidisciplinary approach to address the needs of the patient and their families Is applicable early in the course of illness in conjecture with other therapies that are intended to prolong life. James L Levenson, M.D., 2005. Academy of Consultation-Liaison Psychiatry 4

  5. Psychiatry and Palliative Care Working Together Towards a Common Goal Palliative care s goal is to relieve symptoms and suffering and improve the quality of life for the patient and their families. Palliative informs psychiatry Assessment and treatment of pain Bereavement Anticipatory loss Psychiatry informs palliative care Assessment of psychiatric illness and mental status changes Evaluation of capacity Psychiatric treatment Insight into personality structure and communication issues Conflict resolution Patient physician relationship Recognize the formation of an attachment as a consequence of working towards a common goal JLSpeiss, 2002; Tan et al., 2005, Fairman 2013 Academy of Consultation-Liaison Psychiatry 5

  6. Psychiatric Aspects of Cancer Treatment Chemotherapy Drug interactions Procarbazine is a weak MAOI Paroxetine , fluoxetine, duloxetine and bupropion are strong 2D6 inhibitors and may decrease the efficacy of tamoxifen due to enzyme inhibition , thus reducing levels of tamoxifen s active metabolite (endoxifen). Venlafaxine likely the safest antidepressant and can help with tamoxifen induced hot flashes Citalopram and escitalopram are reasonable as well. Radiation Increased fatigue, N/V, and anxiety Bone Marrow Transplant Depression and anxiety, N/V, fatigue, adjustment d/o, dependence (dependent needs are associated with poorer survival), neurocognitive deficits due to CNS toxicity James L Levenson, M.D., 2005, SLB Mueller 2005, Desmarais 2010 Academy of Consultation-Liaison Psychiatry 6

  7. Psychiatric Issues Following Cancer Treatment 3-55% get depressed following breast cancer treatment Cognitive problems include disturbed consciousness, cognitive problems, executive problems. In a study of 8,921 women with breast cancer Women who got surgery and chemo had increased rates of adjustment d/o and fatigue Mood disorders were similar in chemo and non-chemo groups No issues with cognitive disorder JR Sattin 2009, SLB Muller 2005, Takechi 2003 Academy of Consultation-Liaison Psychiatry 7

  8. Common Psychiatric Issues In the Psycho-oncologic and Palliative Care Population Anxiety Bereavement and Grief Depression Delirium James L Levenson, M.D., 2005, Wyszynski, 2005 Academy of Consultation-Liaison Psychiatry 8

  9. Depression and Cancer May lead to poor treatment adherence and possibly decreased survival Increased rates of depression in cancer patients over the general population 25% rate overall Differs for different cancers Orophargngeal 22-57% Pancreatic 33-50% Breast 1.5-46% Lung 11-44% Depression appears to be less common in colon cancer, gynecological malignancies and lymphoma CP van Wilgen 2006, JL Levinson 2005, KM Brintzenhofe 2009 Academy of Consultation-Liaison Psychiatry 9

  10. Depression and Cancer Progression and Mortality Depression found to be a small but significant predictor of mortality 26% greater mortality with depressive symptoms 39% greater mortality with MDD Depression may be independent risk factor for mortality Depression not associated with cancer progression Chronic inflammation is associated with stress and may underlie depression symptoms. Biomarkers for pro-inflammatory cytokines are increased in cancer patients JR Satin 2009, Sotelo 2014 Academy of Consultation-Liaison Psychiatry 10

  11. Assessing Depression in the Terminally Ill Diagnosis often relies more on psychological or cognitive symptoms than physical complaints Hopelessness that is pervasive with despair and despondency likely indicates depression Suicidal ideation, even mild or passive, more likely to indicate significant depression James L Levenson, M.D., 2005, Takechi 2003 Academy of Consultation-Liaison Psychiatry 11

  12. Treatment of Depression in Terminally Ill Prognosis and time frame affect medication choice SSRIs for person with several months Low dose stimulants for those with several weeks Sedatives or narcotic infusions for those with hours to days Start antidepressants at half the usual starting dose Methylphenidate 2.5-5mg in morning and noon Maximum dose is usually less than 30mg/day. Psychotherapy Mixture of supportive, CBT and medications. Newer modalities such as meaning-centered psychotherapy and dignity-conserving care have also been found to be helpful Music therapy Shown to reduce pain, decrease anxiety and depression and improve quality of life James L Levenson, M.D., 2005, Wyszynski 2005, Gao 2018, Academy of Consultation-Liaison Psychiatry 12

  13. Somatic Symptoms and Depression in Cancer Somatic symptoms of depression in cancer patients Appetite changes and decreased ability to think coincided with anhedonia Sleep disturbance and fatigue not significantly associated with non-somatic symptoms Appetite changes associated with increased severity of depression Takechi 2003, Van Wilgen 2006 Mueller 2005 Academy of Consultation-Liaison Psychiatry 13

  14. Mixed Depression/Anxiety in Cancer Patients 8,265 patients with cancer Mixed symptoms in 12.4% Depression in 18.3% Anxiety in 24% 70% had neither Mixed symptoms in stomach, pancreatic, head and neck and lung cancers Lower rates in those with breast cancers Mixed symptoms in 2/3 of depressed cancer patients KM Brintzenhofe-Szoc 2009 Academy of Consultation-Liaison Psychiatry 14

  15. Suicidal Ideation and Cancer Passive SI common Relative risk of suicide was 12.6 within first week of cancer diagnosis Relative risk is 3.1 within the first year of diagnosis Risk factors Regular risk factors for suicide in the general population Advanced disease and poor prognosis Delirium Pain Physical, social, and/or financial exhaustion Need for control James L Levenson, M.D., 2005, Fang 2012 Academy of Consultation-Liaison Psychiatry 15

  16. Suicide and Suicidal Ideation in Palliative Care 3-20% have pervasive and sincere wish to die. Risk Factors All regular risk factors for suicidality are important to consider Age, race, history of suicide attempts, psychiatric illness, means, etc Advanced stages of the disease Hopelessness Uncontrolled pain Confusional states (delirium) Loss of control and sense of helplessness Fatigue of all forms Physical Financial Social support Suicidal ideation needs to be addressed, but psychiatric hospitalization may not be indicated in some cases James L Levenson, M.D., 2005, Wilson 2015 Academy of Consultation-Liaison Psychiatry 16

  17. Desire for Hastened Death States that allow physician assisted death Oregon, Washington, Vermont, California, Montana, Colorado, Washington DC, Hawaii Risks Depression plays a role in requests for hastened death Patients with depression were noted to have a 4x higher likelihood of desire for hastened death Depression and hopelessness are the strongest predictors of desire for hastened death in terminally ill patients These patients have higher levels of pain and less support Psychological distress, social factors, spiritual distress and feeling like one is a burden contribute Management of physical and psychological distress is likely the best treatment Increasingly legalized but still relatively rare. Primary involves cancer patients. Main motivations for physician assisted death Loss of autonomy and dignity, decreased quality of life, Mental distress James L Levenson, M.D., 2005, Emanuel 2016 Academy of Consultation-Liaison Psychiatry 17

  18. Depression and Cancer SSRI remains the first line treatment Possibility of inflammation as a cofactor or even etiological reason for depression. SSRIs found to have anti-inflammatory properties on microglia. SSRIs may even have anti tumor effect. There have been in vitro studies that show SSRIs having apoptotic effects in hepatocellular carcinoma cells Concurrent depression and cancer related symptoms Mirtazapine: Helps with insomnia, nausea and anorexia. Bupropion : Helps with fatigue, poor concentration, or nicotine dependence Venlafaxine, Duloxetine or low dose TCA: Helps with neuropathic pain Venlafaxine and SSRI: Helps alleviate hot flashes from hormone therapy SM Thekadi 2015 Academy of Consultation-Liaison Psychiatry 18

  19. Depression in Palliative Care Prevalence 13-20% Loss of meaning and lower spiritual well-being lead to higher levels of depressive symptoms Pain and functional status also factors in increased rates of depression Underlying medical conditions may also contribute to depressive symptoms CNS lesions, metabolic-endocrine complications and paraneoplastic syndromes Treatment of medical conditions may also induce depressive symptoms Whole brain radiation, corticosteroids, vincristine, vinblastine, asparaginase, intrathecal methotrexate, interferon, amphotericin James L Levenson, M.D., 2005, Mitchell 2011 Academy of Consultation-Liaison Psychiatry 19

  20. Demoralization vs. Depression Demoralization Characterized by various degrees of helplessness, confusion and subjective incompetence to adversity. Shorter duration than depression Reactive to family and supports Specific to stressors How would you be coping if this went away? Slide adapted from Mitch Levy, Univ of Washington Academy of Consultation-Liaison Psychiatry 20

  21. Demoralization Diagnostic Criteria 1. Patient experiences emotional distress such as hopelessness and losing life s purpose 2. A general attitude of helplessness, failure pessimism, and lack of worthwhile future 3. Reduced coping to respond differently 4. Social isolation and lack of social support 5. Persistence of the above for >2 weeks 6. Features of major depression are not superseded as primary disorder. Kissane, 2000 Academy of Consultation-Liaison Psychiatry 21

  22. Treatment Targets for Brief Psychotherapy for Demoralization: Existential Postures of Vulnerability and Resilience Vulnerability Confusion Isolation Despair Helplessness Meaninglessness Cowardice Resentment Resilience Coherence Communion Hope Agency Purpose Courage Gratitude Griffith and Gaby,, Psychosomatics, 2005 Academy of Consultation-Liaison Psychiatry 22

  23. Overall Psychological Treatment Goals Help patients maintain control of their lives Assist in developing healthy coping strategies Help control Anger Denial Panic Despair Fears of rejection and abandonment Help establish self-respect by assisting with resolution of guilt, shame and self-blame Help with communication and the maintenance of support systems James L Levenson, M.D., 2005, JL Speiss, 2002, LW Roberts 2004 Academy of Consultation-Liaison Psychiatry 23

  24. Overall Psychological Treatment Goals Help maintain interpersonal relationships Help develop strategies to deal with real and anticipated crises Help identify and address unfinished business Work with patient to explore meaning of death Help manage depression and anxiety or other psychiatric symptoms that may result from psychological issues or effects of treatment James L Levenson, M.D., 2005 Academy of Consultation-Liaison Psychiatry 24

  25. Dignity Conserving Treatment Dignity therapy Treatment is based on strong association with undermined dignity and: Depression Anxiety Desire for death Hopelessness Feeling of being a burden on others Overall poorer quality of life Some studies even suggest that psychosocial and existential issues may be of greater concern than pain and physical symptoms Chochinov, H, 2007 Academy of Consultation-Liaison Psychiatry

  26. Dignity Conserving Treatment Dignity therapy Primary themes of dignity: Generativity Life has stood for something Continuity of self Maintain one s essence is intact Role preservation Being able to maintain a sense of identification with roles previously held Maintenance of pride Ability to sustain positive self-regard Chochinov, H, 2007 Academy of Consultation-Liaison Psychiatry

  27. Dignity Conserving Treatment Dignity therapy Primary themes of dignity (cont.): Hopefulness Ability to find and maintain a sense of meaning or purpose Aftermath concerns Worries or fears concerning the burden death will impose on others Care tenor Attitude and manner with which others interact with the patient either promotes or diminishes dignity Many of these are also essential to a patient maintaining a sense of control and integrity in any setting Chochinov, H, 2007 Academy of Consultation-Liaison Psychiatry

  28. Dignity Conserving Treatment Dignity therapy (provider): Treatment of the provider consists of an A, B, C, D approach to teaching interactions The hope is to allow care givers, institutions, and families a way to better interact with patients to achieve the desired effect Our thoughts about an interaction with a patient shape the interaction itself Engagement Model Chochinov, H, 2007; Bennington-Davis, M, 2005 Academy of Consultation-Liaison Psychiatry

  29. Dignity Conserving Treatment Dignity therapy (provider): A Attitudes How would I feel in this situation? What leads me to think that way? Am I aware of how I might be affecting the patient? Chochinov, H, 2007 Academy of Consultation-Liaison Psychiatry

  30. Dignity Conserving Treatment Dignity therapy (provider): B Behaviors Treat contact with patients as you would any important intervention Always ask permission to do something Act in a professional and respectful way at all times Examples Knock on the patient s door Use the patient s proper name and title unless given permission to do otherwise Chochinov, H, 2007 Academy of Consultation-Liaison Psychiatry

  31. Dignity Conserving Treatment Dignity therapy (provider): C Compassion Very difficult to train Medical Humanities in school Considering the personal stories D Dialogue What should I now about you as a person to help me take the best care of you that I can? Who else (or what) will be affected by what s happening? Chochinov, H, 2007 Academy of Consultation-Liaison Psychiatry

  32. Promoting Resilience Assess for prior strengths and life challenges. What have you overcome previously like this? What has helped in the past? How do you cope with adversity? Engage the family and members of the treatment team. Slide adapted from Mitch Levy, Univ of Washington Academy of Consultation-Liaison Psychiatry 32

  33. Anxiety in Palliative Care Ranges from 6.8-13.2% and is most often comorbid with depression Prevalence increases with advanced disease and decline in physical status Includes fears of clinical course, treatment outcomes, death, social stigma, and/or physical symptoms (such as dyspnea or pain) Women, more physical impairment and younger patients with advanced cancer were more likely to develop anxiety disorders A trusting physician-patient relationship is critical to minimize patient shame, humiliation, and power imbalance James L Levenson, M.D., 2005, Wyszynski, 2005, LW Roberts 2004, Spencer 2010, Mitchell 2011 Academy of Consultation-Liaison Psychiatry 33

  34. Causes of Anxiety in Palliative Care Preexisting anxiety disorder Anxiety symptoms can be caused by various untreated medical complications Hypoxia Pain Medication side effects Substance withdrawal Pulmonary embolism (PE) Electrolyte imbalance, Dehydration Fear of isolation and separation of death James L Levenson, M.D., 2005,Wyszynski 2005 Academy of Consultation-Liaison Psychiatry 34

  35. Anxiety Treatment in Palliative Care Benzodiazepines Multiple routes of administration (PO, IV, IM or PR) Neuroleptics may be safest when there is a concern of respiratory depression Multiple routes of administration (PO, IV, or IM) Supportive psychotherapy, guided imagery, and hypnosis SSRIs of limited value in patient when life expectancy is only a few days to weeks There is lack of evidence for effectiveness of drug therapy in this patient population James L Levenson, M.D., 2005, Salt 2017 Academy of Consultation-Liaison Psychiatry 35

  36. Anxiety and Cancer Common at start of treatment, recurrence, progression or at follow-up visits 30% of patients had clinical anxiety after diagnosis of cancer 3-10% PTSD in patients with breast cancer Multiple potential medical etiologies of anxiety symptoms Nausea Akathisia PE Pain MH Antoni 2006, JL Levenson 2005, Cardoso 2015 Academy of Consultation-Liaison Psychiatry 36

  37. Anxiety and Cancer Treatment SSRI remains the primary approach to generalized anxiety and prevention of panic attacks Short term use of Benzodiazepines are well tolerated, safe and effective drugs for anxiety. Anterograde amnestic properties help to lessen the negative impact of cancer treatment experiences. Short acting BZD may be used for procedure related anxiety, anticipatory anxiety, or specific phobias Non-BZD drugs reduce risk of abuse or dependence Gabapentin, beta blockers, Buspirone and Hydroxyzine found to be helpful for anxiety. SM Thekadi 2015 Academy of Consultation-Liaison Psychiatry 37

  38. Mania in Cancer Recurrence of pre-existing illness Steroids Infection Diencephalic tumors JL Levinson, 2005 Academy of Consultation-Liaison Psychiatry 38

  39. Mood Stabilizers Help with impulsivity, irritability and temper dysregulation. Also treat neuropathic pain, hot flashes and seizure prophylaxis Lithium: rarely started in the cancer context Risk of dehydration, electrolyte abnormalities, renal dysfunction, and drug interactions. Valproic acid and Carbamazepine: helpful for mood stabilization. Carry risks of hematological suppression and hepatotoxicity SM Thekadi 2015 Academy of Consultation-Liaison Psychiatry 39

  40. Mood Stabilizers Gabapentin or Pregabalin: Helps manage hot flashes, neuropathic pain and postherpetic neurolgia Has anxiolytic and sedative effects No Cyp450 interaction. Cleared renally. Oxcarbazepine: Recent open label study showed it may be helpful in prevention of oxaliplatin-induced neuropathy. SM Thekadi 2015 Academy of Consultation-Liaison Psychiatry 40

  41. Psychosis and cancer Primary psychosis Delirium Psychosis due to medical condition Medication induced psychosis SM Thekadi 2015 Academy of Consultation-Liaison Psychiatry 41

  42. Antipsychotics Side effects of select antipsychotics can help target symptoms common to cancer patients. Symptoms include anxiety, nausea, hiccups, loss of appetite, and insomnia. Haloperidol continues to be gold standard for delirium New RTC shows that lorazepam + haloperidol provides superior control to agitated delirium in advanced cancer patients Aripiprazole may uniquely be activating for hypoactive delirium Recent meta-analysis showed a 50% reduction in postoperative delirium for elderly patient given prophylactic antipsychotics SM Thekadi 2015 Academy of Consultation-Liaison Psychiatry 42

  43. Antipsychotics Antipsychotics may be preferred to BZD for acute anxiety. Less risk of AMS and respiratory depression. Low dose quetiapine or olanzapine may be used for insomnia when sedative hypnotics are deemed too risky. Haloperidol and chlorpromazine may be used for intractable hiccups Haloperidol and olanzapine may help with nausea Olanzapine is efficacious for chemo induced nausea and vomiting Olanzapine and quetiapine helpful for weight loss and anorexia. SM Thekadi 2015 Academy of Consultation-Liaison Psychiatry 43

  44. Bereavement and Grief Bereavement: Situation in which someone who is close dies Grief : Natural response to bereavement Feelings: Some may experience shock, sadness, anger, anxiety, disbelief, panic, numbness,. Physical: Insomnia, fatigue, loss of appetite, nausea and pain. Behaviors: Substance use, less attention to self care, impulsive or harmful behaviors Stages of Grief: Denial, Anger, Bargaining, Depression, Acceptance. Academy of Consultation-Liaison Psychiatry 44

  45. Bereavement and Grief Anticipatory Grief Draws family closer Acute Grief Numbness Distress Disorganization Reorganization Recovery and progression Complicated Grief Complicated by depression, anxiety, and substance use Chronic Grief Social withdrawal and isolation along with a fantasy of reunion may lead to suicidal ideation Traumatic Grief Often complicated by the inability to communicate good-bye James L Levenson, M.D., 2005, LW Roberts 2004 Academy of Consultation-Liaison Psychiatry 45

  46. Delirium in Palliative Care Prevalence of 62-88% especially in the last weeks of life Rates of cognitive impairment rise just prior to death in up to 62% in cancer patients Terminal delirium has a 88% prevalence before death In one study 54% recalled their delirium after recovery The biggest risk factor for distress during episodes of delirium are the presence of delusions Delirium may not be reversible in the last 24-48h of life (terminal delirium) JL Levinson 2005, Y. Alici 2009 Academy of Consultation-Liaison Psychiatry 46

  47. Delirium in Palliative Care There are 2 subtypes of Delirium to consider Hyperactive Easier and more commonly diagnosed type. Characterized by restlessness, agitation, hypervigilance, hallucinations and delusions. Hypoactive More difficult to diagnose. Characterized by psychomotor retardation, lethargy, and reduced awareness of surrounding. Often misdiagnosed as depression or severe fatigue. In a hospice setting 29% of 100 acute admissions were found to have delirium, of these 86% of them had hypoactive delirium. Hypoactive subtype has a higher risk of mortality compared to hyperactive subtype. Y. Alici 2009 Academy of Consultation-Liaison Psychiatry 47

  48. Delirium (continued) Variable rates of resolution One study showed a 68% improvement rate despite 31% mortality in 30 days Another study a cause was found in 43% and 1/3 improved Another study showed that 50% of episodes of delirium in the last week of life were reversible Potential causes of delirium in the terminally ill often include Dehydration Psychoactive or opioid medications Hypoxia Other metabolic derangements JL Levinson 2005 Academy of Consultation-Liaison Psychiatry 48

  49. Substance misuse/use disorders in Oncology and Palliative Care Opiates are frequently used in these populations. Screenings for substance misuse and or use disorders are infrequent (less than half according to a recent survey; Tan 2015). Even fewer palliative care clinics have policies regarding the issue of substance misuse despite the staff reporting to have received training in managing substance misuse or use disorders. Academy of Consultation-Liaison Psychiatry 49

  50. Substance misuse/use disorders in Oncology and Palliative Care Passik and Portenoy 1998 have developed guidelines for the management of patients with aberrant drug taking in terminal and oncologic patients. Primary goals in these guidelines are harm reduction and patient compliance Some of their recommendations include Consideration of a written contract between the team and patient Inclusion of spot urine toxicology screens to assess compliance Set expectations regarding attendance at the clinic Management of medication supplies Academy of Consultation-Liaison Psychiatry 50

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