Anxiety, Depression, Caregiver Burnout, Grief, Anger, Frustration in End of Life Care

Anxiety

• According to the DSM-5, anxiety disorders are those that share features of excessive anxiety and fear with related behavioral disturbances.
• These disorders differ from normal fear and anxiety in their being excessive and persisting beyond developmentally appropriate periods, typically lasting 6 months or more
• Types of anxiety:
  1. Separation anxiety – anxiety or fear about separation from an attachment figure
  2. Selective mutism- consistent failure to speak in social situations
  3. Social anxiety – fear or anxiety about social interactions or situations
  4. Panic disorder -recurrent panic attacks
  5. Phobias- fear of a specific object or situation
  6. Generalized anxiety disorder- persistent or excessive anxiety and worry about various domains.
• Treatment:
  • Nonpharmacological interventions
    1. Establish a trusting relationship
    2. Be aware of any anxiety that you as a nurse may have that may be picked up on
    3. Do not leave a person experiencing an anxiety disorder exacerbation alone
    4. Maintain a calm, nonthreatening, manner-of-fact approach
    5. Keep stimuli minimized
    6. Use simple words and brief messages that are calmly and clearly explained
    7. Discuss the reality of the situation
    8. Include person on decision-making to feel more in control
    9. Encourage exploration of underlying feelings that contribute to irrational fears
    10. Teach and reinforce stress management /relaxation techniques
  • Pharmacological interventions

Depression and anxiety disorders likely remain under recognized in the terminally ill patient. Almost all patients experience sadness, sleep disturbance, and worry sometime in the course of terminal illness. In the absence of psychosis or severe psychological impairment, it is primarily the severity and duration of anxiety and depressive symptoms that determine whether a patient needs further evaluation and treatment. Some argue that the overlap between the physical symptoms of depression (weight loss, sleep disturbance, fatigue) and serious chronic illness make those symptoms unhelpful when it comes to screening. Several straightforward tools exist for anxiety and depression screening in the patient with life-threatening illness.

With the progression of life-threatening illness comes significant change as patients are forced to face declines in physical health and the ability to care for themselves. It is common for patients to feel as though they are burdening family caregivers. The hospice nurse can assist patients and families with this sense of burdening with a variety of strategies. Patient can be encourage by palliative care providers to openly discuss their fears and concerns about burdening loved ones; this allows providers to both provide psychosocial support to the patient and to identify support services that may be helpful in alleviating patient and caregiver stress. The nurse can remind the patient that genuine expression of appreciation for the care that loved ones provide are usually very welcome and can decrease caregivers’ sense of burden. It can be helpful for the nurse to remind patients how important it is for caregivers to have a break and encourage utilization of other help (e.g., other home hospice staff). This is often very difficult for loved ones to express directly to the patient.

Grief in the Dying patient

Dying patients experience grief as they anticipate the dying process and personal mortality. Patients who are psychologically aware of their terminal status and consider themselves “at peace” have less distress. Active listening and honest communication facilitate healthy grief in dying patients. Encouraging life review/ reminiscence process where the patient reflects on the life lived and its meaning is often helpful.

The hospice nurse will encounter a wide variety of family structures, dynamics, and coping styles in his/her career. What works well for one family in dealing with the serious illness and death of a loved one may not be helpful for another family. Assessment of the patient’s family care providers and assistance with the inevitable caregiver stress that accompanies end-of-life care are important skills for the hospice nurse to be comfortable with. Attitudes that caregivers may need more evaluation or intervention include fault-finding, prolonged feelings of powerlessness, reluctance to receive suggestions or support, refusal to allow other family members to be involved in the patient’s care, rigid adherence to their way of doing things, and exclusively negative expression of feelings (e.g., anger, frustration).

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