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Psychological and Medical Issues in the Final Days or Weeks

By Roger C. Bone, MD, reprinted with permission

Page Two of Three Pages

Psychological Concerns

In a sense, this entire book [Reflections: A Guide to End of Life Issues for You and Your Family] is meant to be about the psychological issues of learning you are terminally ill. We all use euphemisms to talk about mental problems. For example, this book describes how "to get your house in order" or "to find peace of mind." It is also designed to help your family and friends come to an understanding of what you are facing emotionally. However, your mental state cannot be minimized by cliches. There exists a great amount of pressure on all involved, including health care professionals, and depression, anxiety, or denial can interfere with the effectiveness of your treatment.

Up front, all participants-----meaning the patient, family members, friends, and health care professionals-----must be aware that the disease itself or the treatment protocol can cause a psychological reaction. In this case, I am not speaking of being depressed because you are told you have cancer. Terminal diseases and the medical weapons used to combat them, namely drugs, are known to have a very serious impact on the body. Psychotic reactions can manifest themselves in delusions, uncontrollable depression, hysteria, excessive anger, or any other of a multitude of symptoms. Your behavior will be difficult to predict, although most physicians, nurses, and medical social workers are trained to know what to expect in these situations. It is possible that you will not suffer from any mental abnormalities. However, it is rare that a terminally ill patient progresses through his or her disease without experiencing some psychological reaction due to medication or treatment plans.

It is naturally very distressing if a patient suddenly turns on a spouse with excessive anger, which may even evidence itself with physical or verbal abuse. In addition, the dying individual may attempt to hurt himself or herself. My best advice as a physician who has seen patients react in such a manner is to discuss drug or chemotherapy treatment thoroughly beforehand with your health professionals. Nurses particularly have insight into the tell-tale signs that may precede psychotic episodes.

The fortunate news is that in the vast majority of cases these episodes pass rather quickly. Often, treatments can be adjusted, modified, or discontinued and the problem will fade. Otherwise, scheduling a consultation with a psychologist or psychiatrist may prove helpful to both the patient and family members. For some individuals, a drug may be prescribed to specifically counter the psychological reaction.

The advice in the above paragraph also applies to finding a solution to psychological problems that patients naturally face when they learn they have a terminal illness. Often, their personal difficulties emerge as relatively minor understandable changes in behavior and progress into severe and complex psychiatric issues. A short list includes stress, worry, depression, anger, and fear. Here are some more points to consider:

1. Obviously, almost everyone-the sick and non-sick-experiences these problems to some extent throughout life. Yet, the terminally ill are vulnerable to having them escalate into more serious psychological episodes. What are the warning signs to alert family and friends? The terminally ill patient may initiate unplanned and/or impulsive actions, such as withdrawing all of his or her money from a bank account or disappearing for a weekend-before becoming incapacitated. He may withdraw from social interaction or appear not to enjoy some formerly favorite activities. Appetite suppression, suicidal thoughts, moodiness, agitation, and sleeplessness are also common signs of depression and/or anxiety.

2. Terminally ill patients may become abusive to themselves or to family members. Drinking excessively or taking addictive drugs can contribute to a violent situation at home.

3. Excessive stubbornness or rebelliousness may also prove to be warning signs. This is particularly noticeable in relation to health care professionals who can become "the enemy" to the terminally ill patient for no apparent reason.

It is up to family members to seek counsel from caregivers when they notice these signals. In some cases, religious figures are also able to provide support and advice. Sometimes old friends or distant relatives who have been involved in a similar situation can be of assistance.

Euthanasia, Suicide, and Assisted Suicide

Although never officially sanctioned by church, state, or the medical profession, taking one's own life to avoid pain and suffering is often considered by the terminally ill patient. The widely publicized assisted suicides performed by Dr. Jack Kevorkian within the past decade have created several ethical questions over the legality of such activities. In addition, there are societies and organizations that advocate what they call a "peaceful death."

As a physician, I am pledged to honor the integrity of human life and will never advocate any form of suicide as an "easy way out." Besides being morally opposed to it, I realize that there are too many factors that exist for the terminally ill patient that preclude resorting to such tragic measures. For example, have all treatment protocols run their course? Is the patient psychologically stable? How will suicide impact the family and its finances?

The only positive effect that the assisted suicide debate has had on the medical community is a renewed focus on making the terminal patient comfortable in the very final stages of death. Suicide advocates are correct in emphasizing that patients who have absolutely no medical hope should not be put through useless and painful treatment procedures. When everything reasonable has been done and the disease course has not been significantly altered, physicians must inform the patient, if he or she is conscious, and the family so appropriate action can be taken.

CONCLUDED on Page Three

© Copyright 1997, National Kidney Cancer Association — Return to Page One