suggest that while family caregivers persist in their caregiving role, they are subject to increased illness and mortality.

The same guidelines apply to recognition of distress in the family, and the same obligation exists to recognize and treat it, including management of bereavement after the death of the loved one when the staff who knew the patient will have a relationship and can monitor the need for intervention.

Clinical Practice Guidelines for Management of Common Psychiatric Disorders

Several common psychiatric symptoms or disorders (using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV]) are encountered during end-of-life care (Table 7-2). Psychiatrists and psychologists with expertise in problems occurring at this stage can substantially diminish the distress of patients and their relatives. The American Psychiatric Association (APA) Clinical Practice Guidelines are useful for modification for end-of-life care, as are the NCCN guidelines for the management of these disorders specifically in cancer patients (APA, 2000; Holland, 1997; Holland and Almanza, 1999).


Delirium is a common psychiatric disorder toward the end of life, estimated to affect as many as 85 percent of patients in their final days (Massie and Holland, 1983). The etiology of delirium in the terminally ill cancer patient is often multifactorial including medication side effects, infection, organ failure, metabolic derangement, and direct central nervous system (CNS) involvement. Older individuals who have mild impairment of cognition are especially susceptible to delirium. In the final stages of life, it is unlikely that the cause of the delirium can be resolved, and attention should focus on comfort. All too often, “quiet delirium” is ignored, but patients may be distressed by delusions that frighten them. Patients’ capacity to make health care decisions must be assessed at times and the health care proxy identified. Considerable research has gone into management of delirium by pharmacologic means (see Table 7-2) (Kress et al., 2000).

Delirium is sometimes accompanied by agitation with self-injurious behavior (e.g., pulling out intravenous lines) or less frequently, the risk of injuring others (Johanson, 1993). Sometimes, poor impulse control, confusion, and depression combine to result in poorly planned, impulsive suicide attempts. Loved ones are frightened by a sudden change in behavior, and they need explanation as to the origin—be it related to disease or medication effects or both. Patients also need explanation since they fear, “I’m losing my mind” (Chochinov and Breitbart, 2000).

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