careful evaluation for illness or medication-related causes: neuroleptic-induced akathisia, corticosteroids, hypoxia or hypercarbia, glucose imbalance, bronchodilators, drug intoxication or withdrawal, and metabolic changes. All must be considered when failure of vital organs is occurring. Explanation of symptoms and preparation of the patient and family for approaching death are important. Communication about fears plays an essential role in modulating patient and family anxiety and distress. Assessment of patients’ safety and supportive psychotherapy, with or without an anxiolytic or antidepressant medication, is indicated.

Generalized anxiety disorder with distressing phobias and panic symptoms, usually antedating the illness, requires titrating medication to control symptoms, along with giving psychological support. Post-traumatic stress disorder (PTSD) may be present at the end of life in patients who have undergone extensive, aggressive treatment with prolonged, poorly controlled pain. Supportive psychotherapy is indicated for these patients along with medication to treat anxiety and sleep problems.

Obsessive-compulsive disorder (OCD) is a type of anxiety disorder that complicates end-of-life care. These patients are often fearful of accepting psychotropic and usually pain medications, have trouble making decisions about treatment and care, and as a result, often suffer more because of inadequate treatment of their symptoms. Family support of decisions and psychotherapy from a mental health professional are of value. End-of-life anxiety guidelines are needed and could be developed by modifying more general anxiety guidelines (see Table 7-2).

Personality Disorders

Patients nearing the end of life may have difficulty in controlling emotions, and underlying personality problems may emerge that require evaluation and intervention. Patients may become angry and hostile, uncooperative and demanding, overly fearful and dependent, indecisive and ambivalent about care, or manipulative and creating conflicts among team members. Such symptoms are best evaluated and recommendations made by a mental health team member. In addition to intervening directly with the patient, a mental health professional can assist staff in managing clinical problems— negotiating behavioral changes, maintaining appropriate boundaries, and addressing conflicts among staff members that arise around caring for such challenging patients. Both the APA Clinical Practice Guidelines for management of personality disorders in physically healthy individuals and the NCCN guidelines for management of distress in ambulatory cancer patients should be revised to provide guidelines for their management in palliative care (see Table 7-2).



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