Treatment
of Those Near the End of Life
Robert
T. Zozus, Jr., Ph.D.- Clinical Psychologist
Introduction:
Psychological
care of those nearing the end of their lives is one of the least
researched areas in psychology. In fact, it is my belief that the best primer for working
with the terminally ill is a book written for the layman,called
“Tuesdays with Morrie” (Albom, 1997).
In it, Morrie Schwartz, the subject of the book (and a dying
man) sagely notes that “ everybody knows they are going to die,
but nobody believes it.”
Denial
is a strong defensive mechanism that may allow us to live more
comfortably. This
comfort has a cost, however. Robert
Firestone (1994), a renowned psychodynamic theorist and clinician,
states that “humans adapt to death anxiety by giving up their life
in the face of death.” In
essence, he sees much of the psychopathology that we treat routinely
in our patients (especially involving depression and addiction) as
arising from death denial. He
wouldn’t get much argument from those with an existentialist bent.
My
point is that much of what this article examines will be familiar.
As Morrie states, “Once you learn how to die, you know how
to live.” An
important difference does exist in that because of the inherent
physical illness involved in your patient’s suffering, an
interdisciplinary treatment approach is even more important than
usual. Another
important difference is that in the treatment of the terminally ill
time pressures may intensify the work (making it more demanding).
An
interesting question crops up when considering the psychological
treatment of the terminally ill.
Are all terminally ill individuals destined to benefit from
these services? It is a
normal and human response to be upset when they are told of their
impending death. In my view, those needing psychological treatment at the end of life are
very much like those who are physically well. They, or those important to them, recognize emotional
difficulty which is significantly interfering with the life they
have remaining in a consistent and enduring fashion.
These emotional symptoms can often be classified in DSM-IV
terms. Research by
Brietbart (EOL Conference, February, 2002), of those suffering from
terminal cancer, found in several studies that from 15 to 20% of
those individuals have a diagnosable depressive disorder.
The most important symptom of depression isolated as
determining poor emotional functioning in the face of death was a
sense of hopelessness (giving up).
Further
guiding efforts identify those who could benefit from psychological
interventions involves research examining those terminally ill who
desire death. While not
always a sign that an individual is suffering from a diagnosable
disorder, it can identify many who suffer mental illness because of
their impending death. Brietbart
((EOL conference, February, 2002), in a factor analytic study of
those desiring death among those found terminally ill with cancer,
found that poor social support and high levels of pain were the most
important predictors of depression (hopelessness), which then
predicted with high accuracy subsequent desire for death.
Another
consideration in work with those nearing the end of life are the
cultural norms they hold dear.
In Greece, for example, it is
normal for the family of the terminally ill to deny the impending
death. It is thought
that this may take place in order to preserve the family unit’s
functioning and strength (Papadatou, EOL
conference, February, 2002)).
The astute clinician, as always, will attempt to understand
the cultural norms of the patient to aid their work.
Unfortunately, space and knowledge constraints will make it
necessary to focus in this article on those embracing the American
culture.
Treatment:
Research
has shown (Brietbart, EOL conference, February, 2002)) that depression is reduced
when clients are thoroughly briefed and educated about their
terminal illness. Their
physician should be the first point of departure for helping those
near the end of life cope. Because
of the loss of felt control that the terminally ill suffer, it is
most important to allow them a sense of autonomy regarding their
treatment. Collaboration
with their physician regarding medical measures taken to prolong
their lives is necessary.
Quality
of life issues are paramount in work with the terminally ill.
Physical comfort, or palliative care, should be at the top of
the list. Pain is very often under treated in this population
(Conner, EOL conference, February, 2002), and, as noted above, often severely
debilitates psychological functioning. Delirium is often thought to be a negative side effect from
pain medication usage, but Brietbart (EOL
conference, February, 2002) reports that this happens only about
10% of the time. He
further goes on to note that neuroleptics have been found to be
useful in controlling delirium in
the terminally ill. Other
etiological factors that may cause delirium involve de-hydration and
constipation. Since delirious patients can not interact well with family,
and may not benefit from psychological care because of their
disorientation, this quality of life issue also needs to be
addressed along with pain management.
Finally, as patients suffering from terminal illness lose
different physical abilities, patients should be educated on
alternative means to keep functioning.
Hospice services are quite adept at providing (or suggesting)
pain management solutions, delirium control, and help with
developing adaptive functioning to their increasing disabilities.
They should be routinely utilized in work with those near the
end of life. A good
resource for finding hospices services is found online, at the
following web page location http://www.nhpco.org/Directory/.
In
an Nightline interview, Morrie Schwartz detailed (Albom, 1997) his
thoughts when first diagnosed with a terminal illness.
The question he posed to himself was “Am I going to
withdraw from the world, like most people do, or am I going to
live?” He goes on to
say “I decided I’m going to live- or at least try to live- the
way I want, with dignity, with courage, with humor, with composure. There are some mornings when I cry and cry and mourn for
myself. Some mornings,
I’m so angry and bitter. But
it doesn’t last too long. Then
I get up and say, ‘I want to live…”
He provides a paradigm of a man who dies (lives) well.
Below I will attempt to address the psychological
interventions that we can use to help the emotional lives of those
terminally ill clients resemble his.
Grief
work, or mourning, is often essential to those afflicted with a
terminal disease. Predictable
responses to their diagnosis can include shock; denial; emotional
release of anger, anxiety, and sadness; along with preoccupation
with their disease. These
responses should be looked upon not as stages, but as recurring
themes that will infuse therapy at different times and levels of
intensity. They will,
however, not block growth as long as the patient processes these
themes and holds hope.
Hope
comes in many forms for the terminally ill, and should be routinely
thought of while working clinically with this population.
If the patient is religious, then those religious leaders
with whom they worship should be an important part of treatment and
provide their own pastoral counseling.
The therapist should support that work and facilitate
religious expression, as well as use religious themes in their work
with the client when appropriate.
Research has shown that spirituality is one of the most
important positive predictors in an individual’s emotional
well-being while coping with a terminal illness.
Hope
should also come in the form of helping the patient find meaning in
their lives. In others
words, if they still breathe, it is not too late to get involved.
Therapy is one such involvement. A very important therapeutic
intervention would involve engagement in narrative work, in which
they review their life. In this review, they may be able to forgive themselves or
others for past deeds, as well as consolidate their internal
understanding of what made their life meaningful to them.
In essence, they gain a sense of inner resolution and closure
that allows them to move on. In
Morrie’s words, he tried to “accept the past as the past,
without denying or discarding it.”
It was present, augmenting, and not blocking his
psychological functioning.
Closely
aligned with the narrative work explained above, involves the
resolution and closure brought about by sharing feelings and
thoughts with those important to the patient.
Here, resolution is further consolidated, and forgiveness and
love can be felt more deeply. This sharing should be encouraged as an ongoing process, and
should strengthen the social support that research has also found to
be an important predictor of emotional well-being while coping with
terminal illness (Breitbart, EOL
conference, February, 2002).
Hope derives both from this emotional sharing and the
narrative work described above, as it should eventually create the
sense of well-being and meaning that sustains life.
So,
grief work, pastoral counseling, narrative therapy, and
interpersonal therapy techniques all would seem to provide a
therapeutic armamentarium to help the individual improve their
emotional well-being and cope with impending death. However, the clinician should also be sensitive to other
issues that will crop up in work with the terminally ill. A danger for the patient involves rumination about their
disease. It is useful
to help them engage in activities that distract them from their
illness- especially activities which provide them with a sense of
pride or accomplishment. Many
patients at the end of their life feel like a burden, and resent the
increasing dependency and loss of functioning that they suffer.
These feelings must be processed and accepted, by both the
patient and therapist. Perhaps
one of the reasons that therapy can be so helpful to this process of
closure is because they act as an important witness to the courage
and dignity of their patients as they face death.
Lastly,
this brings me to two important points regarding the treatment of
those near the end of life. The
existential movement was very astute in its’ ability to discern
how death could bring appreciation of life.
However, in today’s culture, this is counter-intuitive.
It is difficult for the therapist to be empathic
(which I believe to be the most essential element to
successful psychotherapy) to the patient, because the death denial
that Firestone (1994) discusses is pervasive and deeply embedded in
our psyches. If end of
life treatment succeeds, hope, meaning, and resolution will arise
from death’s end. Secondly,
the therapist will realize the demanding nature of this work, and
the stresses placed upon themselves, as well as the patient’s
family. Therapists will
be wise to be sure that they have adequate support when endeavoring
to treat the terminally ill, and also should also work to ensure
that the family of the terminally does not neglect their own needs
and grief in order to care for their loved one.
.
Robert
T. Zozus, Jr., Ph.D.
Clinical
Psychologist
Date:
November 4, 2002
North
Carolina License #2576
HSP-P
Certified
References:
Albom,
M. (1997) Tuesday’s with Morrie- an old man, a young man, and
life’s greatest lesson. New
York: Doubleday.
Breitbart,
W. (2002, February).
Overview of Psychiatric and Psychosocial Issues Near the
End of Life. Paper
presented at the Attending to Psychosocial Issues Near the End Of
Life: A SPSSI-Sponsored International Conference.
Cleveland, OH.
Conner,
S. (2002, February).
Overview of Psychiatric and Psychosocial Issues Near the
End of Life. Paper
presented at the Attending to Psychosocial Issues Near the End Of
Life: A SPSSI-Sponsored International Conference.
Cleveland, OH.
Firestone,
R. (1994). Psychological Defenses Against Death Anxiety.
In Neimeyer, R. (Ed.), Death Anxiety Handbook:
Research, Instrumentation, and Application (pp. 217-241)
Washington, D.C.: Taylor & Francis.
Papadatou,
D. (2002, February).
Overview of Psychiatric and Psychosocial Issues Near the
End of Life. Paper
presented at the Attending to Psychosocial Issues Near the End Of
Life: A SPSSI-Sponsored International Conference.
Cleveland, OH.
Online
Resources:
Hospice
Locator:
http://www.nhpco.org/Directory/.
General
Information:
http://www3.uakron.edu/eol/news_&_links/news_&_links.html
http://www.partnershipforcaring.org
http://www.lastacts.org
|
Happy
ACT Anniversary!
v
Karen
Carlough
celebrating 4
years with ACT as of November 4
Happy
Birthday!
v
Doris Moore
November 1
v
L. Dawn
Allen, PhD
November 5
v
Robert T.
Zozus, PhD
November 22
v
Mary"Jean"
Patel, RN, CRC, LPC
December 7
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