Mohammed T. Abou-Saleh

CARE OF THE DYING PATIENT 777patient. Any attempt by the therapist to impose the stages as astructure can be an undue burden placed on the dying.Psychotherapeutic CarePsychotherapeutic approaches vary widely but, in general, thepsychodynamic modes employ open-ended methods throughwhich the patient gains insight. Underlying this approach is thebelief that by better understanding the emotional pain of terminalillness, the patient will gain some relief from it 15 . The therapistpays careful attention to the patient’s defenses, such as denial,displacement, counterdependency and dependency, and those thatare felt to be adaptive are gently reinforced. If the defense ismaladaptive, the question becomes whether the patient couldtolerate an attempt to change it. Denial is felt to be the mostcommon defense encountered in clinical practice, and it can be themost difficult to navigate for those who do not commonly workwith the dying. The decision of whether or not to confront denialplagues psychiatrists, primary physicians and families alike.Stedeford 15 recommends that denial is a problem only when it isthe sole or prominent defense. It then blocks communication withfamily and friends and prevents making suitable plans for thefuture. Often denial serves an important role in allowing thepatient time to assimilate gradually information that would beoverwhelming if absorbed all at once. Connor 18 believes that mostdenial is used to preserve interpersonal relationships. In thismodel, patients use denial primarily to cope with guilt about theeffect of their condition on others, to protect others from theemotional stress they might feel if the patient were to openlyacknowledge his/her condition and feelings, or out of fear ofabandonment. He devised an intervention for this type of denialthrough a structured set of questions displayed in Table 138d.1.Some other techniques are especially appropriate with dyingolder patients. Problem-solving therapy is a brief treatment thatattempts to alleviate emotional symptoms by focusing on thesocial and practical difficulties faced by patients 19 . These problemsare linked to the patient’s symptoms, and the patient is helped tosolve the problem by breaking it down into stages as follows:(a) clarification and definition of the problem; (b) setting ofachievable goals; (c) consideration of alternative solutions;(d) selection of a preferred solution; (e) clarification of thenecessary steps to implement the solution; (f) evaluation ofprogress. The advantages of this therapy are its brief format,which is sometimes necessary to fit the time frame of dyingpatients, as well as its accessibility to patients, who are sometimesTable 138d.1Structured psychosocial intervention for denial1. Different people experience different kinds of difficulties when they areill. What, for you, have been some of the most difficult aspects ofhaving your illness?2. Are there any things you do, or that other people do, that make thesedifficulties easier to deal with?3. Is there anything you or other people do, that make these difficultiesharder to deal with?4. Do you believe you will or will not recover from this illness?5. Have you had any close encounters with death?6. What effect has your illness had on your family and close friends, andhow have they reacted to it?7. How do you feel about the way in which your family and friends havebeen affected by or have reacted to your illness?8. Is there anything good that has come out of your having your illness?9. Are there any other thoughts or feelings about your illness or thequestions I’ve asked that you’d like to talk more about?From Connor 18 , with permission.uncomfortable with the jargon of psychotherapy. Cognitive andbehavioral techniques are widely used to address specificsymptoms, such as anxiety and phobias, through progressivemuscle relaxation, imagery exercises or cognitive restructuring 9 .Guided imagery and trance states have also been successfully usedto treat cancer pain. Education is often overlooked as a highlytherapeutic tool to combat anxiety, since much of a dyingpatient’s fear is generated by the unknown. The resources to assistin this education of the patient and family are growingexponentially and are available through varied media.Psychological Benefits of Hospice CareThe first modern hospice was founded in 1967 in England toaddress concerns about the poor training of physicians to dealwith terminal illness. Since then, the hospice movement has grownand spread to the USA, where roughly 20% of all deaths are nowaccounted for by patients who use hospices. The hospice approachseeks to improve the quality of the end of life by focusing on thewhole patient, including his/her medical, pain relief, emotionaland spiritual needs. Hospices employ a number of the abovedescribed therapeutic interventions through varied disciplineswith a distinctive commitment to a team-based approach. Alongwith the psychological benefits for the dying patient in receivingthis interdisciplinary, psychologically sensitive care at the end oflife, there appears to be a psychological benefit to survivors ofpatients who use hospices; McNeilly and Hillary found survivorsof hospice patients less likely to regret not having more openlyexpressed feelings to the person they cared for than those whoused a home health care group 20 . Hospices can be seen as anintentional aid to the patient in his/her psychological journey atthe end of life in its explicit commitment to helping the patient‘‘die well’’, as he/she understands and interprets it, whilemaintaining an abiding commitment to the family and othersurvivors.Although psychiatric care of the dying older patient embodiesmany challenges, it is full of rewards for the physician, patient andthe patient’s families. The reciprocity inherent within the relationshipwith dying patients is profound in its implications foreducating us about life, suffering and adaptation. The morecapable we become of caring well for the dying during thistransition in their lives, the better we will be at understanding andcaring for all of our patients.REFERENCES1. Breitbart W, Bruera E, Chochinov H, Lynch M. Neuropsychiatricsyndromes and psychological symptoms in patients with advancedcancer. J Pain Sympt Managem 1995; 10: 131–41.2. Breitbart W, Jacobsen PB. 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