End-of-Life Care, Death, Dying, and Bereavement



End-of-Life Care, Death, Dying, and Bereavement





I. End-of-Life Care

End-of-life refers to all those issues involved in caring for the terminally ill, and it begins when curative therapy ceases. Palliative care is the most important part of end-of-life care. Also included are other complex issues such as euthanasia, physician-assisted suicide, and ethical issues.


A. Palliative care.

Palliative care (from Latin palliere, “to cloak”) is concerned with treating the dying patient. It is geared to the relief of pain and suffering; it is not designed to cure. While this is most commonly associated with analgesic drug administration, many other medical interventions and surgical procedures fall under the umbrella of palliative care because they can make the patient more comfortable. Such care provides pain relief and emotional, social, and spiritual support, including psychiatric treatment if indicated. Psychiatric consultation is indicated for patients who become severely anxious, suicidal, depressed, or overtly psychotic. In each instance, appropriate psychiatric medication can be prescribed to provide relief. Palliative care physicians must also be skilled in pain management, especially in the use of powerful opioids—the gold standard of drugs used for pain relief. Pain management is discussed in further detail at the end of this chapter.


B. Euthanasia and physician-assisted suicide.

Euthanasia is defined as a physician’s deliberate act to cause a patient’s death by directly administering a lethal dose of medication or other agent (sometimes called mercy killing). It is illegal and unethical. Physician-assisted suicide is defined as a physician’s imparting information or providing means that enable a person to take his or her own life deliberately. Physician-assisted suicide and euthanasia should not be confused with palliative care designed to alleviate the suffering of dying patients.


C. Ethical issues.

Euthanasia and physician-assisted suicide are opposed by the American Medical Association and the American Psychiatric Association. In Oregon, physicians are legally permitted to prescribe lethal medication for patients who are terminally ill (1994 Oregon Death with Dignity Law [Table 28-1]).


D. End-of-life decisions.

The principle of patient autonomy requires that physicians respect the decision of a patient to forego life-sustaining treatment. Life-sustaining treatment is defined as any medical treatment that serves to prolong life without reversing the underlying medical condition. It includes, but is not limited to, mechanical ventilation, renal dialysis, blood transfusions, chemotherapy, antibiotics, and artificial nutrition and hydration.
Patients in extremis should never be forced to endure intolerable, prolonged suffering in an effort to prolong life.








Table 28-1 Oregon’s Assisted Suicide Law




Oregon residents whose physicians determine they have less than 6 months to live are eligible to ask for suicide medication.
A second doctor must determine if the patient is mentally competent to make the decision and is not suffering from mental illness such as depression.
The law does not compel doctors to comply with patients’ requests for suicide medication.
Doctors who agree to provide medication must receive a request in writing from the patient, signed by two witnesses. The written request must be made 48 hours before the doctor delivers the prescription. A second oral request is made just before the doctor writes the prescription.
Pharmacists who are opposed to suicide may refuse to fill the prescriptions.
The law does not specify which medication may be used. Supporters of the law say an overdose of barbiturates combined with antinausea medication would probably be used.


II. Grief, Mourning, and Bereavement

Grief, mourning, and bereavement are generally synonymous terms that describe a syndrome precipitated by the loss of a loved one. Attempts have been made to characterize the stages of grief, which are listed in Table 28-2.








Table 28-2 Grief and Bereavement
































Stage John Bowlby Stage CM Parkes
1 Numbness or protest. Characterized by distress, fear, and anger. Shock may last moments, days, or months. 1 Alarm. A stressful state characterized by physiological changes (e.g., rise in blood pressure and heart rate); similar to Bowlby’s first stage.
2 Yearning and searching for the lost figure. World seems empty and meaningless, but self-esteem remains intact. Characterized by preoccupation with lost person, physical restlessness, weeping, and anger. May last several months or even years. 2 Numbness. Person appears superficially affected by loss but is actually protecting himself or herself from acute distress.
3 Disorganization and despair. Restlessness and aimlessness. Increase in somatic preoccupation, withdrawal, introversion, and irritability. Repeated reliving of memories. 3 Pining (searching). Person looks for or is reminded of the lost person. Similar to Bowlby’s second stage.
4 Reorganization. With establishment of new patterns, objects, and goods, grief recedes and is replaced by cherished memories. Healthy identification with deceased occurs. 4 Depression. Person feels hopeless about future, cannot go on living, and withdraws from family and friends.
    5 Recovery and reorganization. Person realizes that his or her life will continue with new adjustments and different goods.









Table 28-3 Grief Versus Depression



































Grief Depression
Normal identification with deceased. Little ambivalence toward deceased. Abnormal overidentification with deceased. Increased ambivalence and unconscious anger toward deceased.
Crying, weight loss, decreased libido, withdrawal, insomnia, irritability, decreased concentration and attention. Similar.
Suicidal ideas rare. Suicidal ideas common.
Self-blame relates to how deceased was treated. Self-blame is global. Person thinks he or she is generally bad or worthless.
No global feelings of worthlessness.  
Evokes empathy and sympathy. Usually evokes interpersonal annoyance or irritation.
Symptoms abate with time. Self-limited. Usually clears within 6 months to 1 year. Symptoms do not abate and may worsen. May still be present after years.
Vulnerable to physical illness. Vulnerable to physical illness.
Responds to reassurance and social contacts. Does not respond to reassurance and pushes away social contacts.
Not helped by antidepressant medication. Helped by antidepressant medication.

Grief can occur for reasons other than the actual death of a loved one. These reasons include (1) loss of a loved one through separation, divorce, or incarceration; (2) loss of an emotionally charged object or circumstance (e.g., a prized possession or valued job or position); (3) loss of a fantasized love object (e.g., therapeutic abortion or death of an intrauterine fetus); and (4) loss resulting from narcissistic injury (e.g., amputation, mastectomy).

Grief is normal and differs from depression in a number of ways, described in Table 28-3. Risk factors for a major depressive episode after the death of a spouse are listed in Table 28-4

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Jun 8, 2016 | Posted by in PSYCHIATRY | Comments Off on End-of-Life Care, Death, Dying, and Bereavement

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