Thus, appropriate intervention in delirium includes steps to ensure early identification, safety of the patient, interventions (to treat both the delirium and its underlying cause, if possible), and education of patient and family to decrease distress associated with this disturbing symptom (see Table 7-2).

Depression and Depressive Symptoms

Depressive symptoms are common at the end of life, often at the subsyndromal level or as part of an adjustment disorder (Wilson et al., 2000) (Table 7-2). The etiology must first be determined, ruling out metabolic, illness-, or drug-related causes. Irrespective of the etiology, attention is directed to the treatment of the depressive symptoms. A prior history of bipolar disorder or dysthymia suggests a longstanding problem that may be exacerbated during end-of-life care. Evaluation of suicidal ideation and risk is essential, as well as of the capacity to make decisions. The role of depression in requests for physician-assisted suicide makes this a critically important aspect of evaluation and treatment (Burt, 1997). The presence of hopelessness appears to be a separate but related factor, along with depression, in suicidal wishes (Breitbart et al., 2000). The notion that depression is an ordinary aspect of the end of life has been dispelled by careful longitudinal studies by Chochinov and colleagues, who found a high level of fluctuation in suicidal wishes day-to-day, suggesting caution in acting on a patient’s stated wish at a particular time (Chochinov and Breitbart, 2000; Passik et al., 1998, 2000; Razavi et al., 1990).

Meeting criteria for true major depression (DSM-IV criteria) is not common, but when major depression is present, it should be treated as aggressively as any physical symptom, with psychological support, psychotherapy, and medication. Antidepressants and psychostimulants are of proven value. Existential forms of psychotherapy are under development by the authors and colleagues. Guidelines for treating end-of-life depression are still needed. A start could be made by modifying more general depression treatment guidelines (see Table 7-2). Education for clinical staff about depression, anticipatory grieving, and bereavement is essential for appropriate implementation of guidelines.

Anxiety Disorders

Anxiety is the most common symptom of distress near the end of life. It often stems from fears about shortness of breath, fear of pain, unremitting symptoms, and uncertainty about the future. Reactive anxiety symptoms alone, or mixed with depressive symptoms, constitute the mildest DSM-IV psychiatric disorder, adjustment disorder (APA, 2000). The patient requires



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