Psychiatric Aspects of Terminal Illness

Foundations in Terminal Care - End Game Blues

• Terminal Illness: Incurable disease; death expected within months.
• Palliative Care (PC): Improves quality of life for patients/families with life-threatening illness; symptom relief. Can start early.
• Hospice Care: PC subset; prognosis ≤ 6 months; comfort, dignity focus.
• C-L Psychiatry Role: Manages psychiatric issues (depression, delirium), aids coping, decision-making, grief.
• Goals of Care: Symptom control, comfort, dignity, patient autonomy, shared decisions.

⭐ Palliative care can be initiated early with curative treatments, not just end-of-life; hospice is for prognosis ≤ 6 months.

Psychiatric Syndromes at EoL - Mood & Muddle

• Depression: Common (15-25%); anhedonia, hopelessness. Differs from grief.

• Anxiety Disorders: GAD, panic. Prevalence ~10%. SSRIs, short-term BZDs.

• Adjustment Disorders: Distressed response to illness; common.

• Delirium: Acute confusion; 25-85% (↑ near death). Hyper/hypoactive. 📌 I WATCH DEATH.

  • ⭐ Hypoactive delirium is more common than hyperactive delirium in terminally ill patients but is often underdiagnosed.

• Table: Depression vs. Grief vs. Demoralization

  Feature	Depression	Grief	Demoralization Syndrome
  Core	Anhedonia, pervasive sadness	Emptiness, loss-focused	Loss of meaning/purpose, hopeless
  Self-esteem	Often ↓	Intact	May be ↓, failure sense

• Flowchart: Delirium Assessment (CAM) & Initial Management

Assessment in Palliative Settings - Diagnostic Dance

• Challenges in Diagnosis:
  • Symptom overlap: physical illness symptoms vs. psychiatric ones.
  • Treatment side-effects mimicking mental health conditions.
• Screening Tools:
  • ESAS (Edmonton Symptom Assessment System).
  • Adapted PHQ-2/PHQ-9 (Patient Health Questionnaire).
  • HADS (Hospital Anxiety and Depression Scale).
• Comprehensive Assessment:
  • Detailed clinical interview.
  • Collateral history from family/caregivers.
• Key Distinction: Differentiating normal grief from clinical depression.

⭐ Standard DSM criteria for depression can be challenging due to somatic symptom overlap. Prioritize psychological symptoms: anhedonia, pervasive guilt, hopelessness, and suicidal ideation.## Assessment in Palliative Settings - Diagnostic Dance

• Challenges in Diagnosis:
  • Symptom overlap: physical illness symptoms vs. psychiatric ones.
  • Treatment side-effects mimicking mental health conditions.
• Screening Tools:
  • ESAS (Edmonton Symptom Assessment System).
  • Adapted PHQ-2/PHQ-9 (Patient Health Questionnaire).
  • HADS (Hospital Anxiety and Depression Scale).
• Comprehensive Assessment:
  • Detailed clinical interview.
  • Collateral history from family/caregivers.
• Key Distinction: Differentiating normal grief from clinical depression. (image)[56616bdb-7b2f-4c0f-95de-01c82eb8cb5c]

⭐ Standard DSM criteria for depression can be challenging due to somatic symptom overlap. Prioritize psychological symptoms: anhedonia, pervasive guilt, hopelessness, and suicidal ideation.

Management & Comfort Measures - Soothing the Soul

• Pharmacological Approaches:
  • Antidepressants (depression, anxiety): SSRIs (e.g., Sertraline 25-50mg OD), SNRIs (e.g., Venlafaxine XR 37.5mg OD), Mirtazapine (7.5-15mg HS for sleep/appetite).
  • Psychostimulants (fatigue, apathy): Methylphenidate (2.5-5mg morning/noon).
  • Anxiolytics (acute anxiety, panic): Short-acting Benzodiazepines (e.g., Lorazepam 0.5-1mg SOS).
  • Antipsychotics (delirium, agitation): Haloperidol (0.5-1mg), Risperidone (0.25-0.5mg), Olanzapine (2.5-5mg).
• Non-Pharmacological Therapies:
  • Supportive psychotherapy, Cognitive Behavioral Therapy (CBT).
  • Meaning-centered psychotherapy, Dignity therapy.
  • Spiritual care.
• Palliative Sedation: Considered for refractory, unbearable symptoms at end-of-life.

⭐ Methylphenidate can offer rapid (within days) improvement in fatigue, apathy, and depressive symptoms in terminally ill patients.

Flowchart: Managing Anxiety/Agitation

Ethico-Legal & Communication - Critical Conversations

• Capacity assessment & informed consent: foundational.
• Advance directives (living will): patient autonomy.
• Discussing prognosis & end-of-life preferences.
• Breaking bad news: 📌 SPIKES protocol.
  • S: Setting, P: Perception, I: Invitation, K: Knowledge, E: Emotions/Empathy, S: Strategy/Summary.
• Do Not Resuscitate (DNR) orders.
• Withholding/withdrawing treatment: ethical decisions.
• Euthanasia & PAS; India: passive euthanasia legal (advance directives).

⭐ The Supreme Court of India has recognized the right to die with dignity and legalized passive euthanasia through advance directives (Aruna Shanbaug case as a significant reference).

High‑Yield Points - ⚡ Biggest Takeaways

• Depression is common, not normal grief; screen for suicidal risk.
• Anxiety (fear of death/pain) may require cautious benzodiazepine use.
• Delirium is frequent near death; identify and treat reversible causes.
• Prioritize pain control; address opioid addiction misconceptions.
• Discuss advance directives and palliative care for patient autonomy.
• Clear communication with patient/family on prognosis and goals is vital.
• Differentiate normal grief from complicated grief or MDD.