Clinical practice guidelines for the management of psychosocial distress at the end of life

Abstract

After years of neglect, care at the end of life is receiving increasing attention and concern. It is then that the body is consumed by a progressive and mortal illness, and the person must cope not only with the bodily symptoms, but also with the existential crisis of the end of life and approaching death. As the body suffers, the mind is indeed “commanded … to suffer with the body,” as Shakespeare so well described. Thus, suffering near the end of life encompasses both the mind and the body. Providing optimal symptom relief and alleviation of suffering is the highest priority. However, evidence suggests that we continue to fall far short of this ideal (American Society of Clinical Oncology, 1996; Cassem, 1997; Cassel & Foley, 1999; Carver & Foley, 2000). Although pain management guidelines have been the most widely disseminated, we know that many patients continue to suffer not only from pain, but other troubling physical symptoms in their final days (American Nursing Association, 1991; Carr et al., 1994; American Pain Society, 1995; American Academy of Neurology, 1996; American Board of Internal Medicine, 1996; Ahmedzai, 1998). Despite clear advances in the identification and treatment of psychiatric disorders, we continue to underdiagnose and undertreat the debilitating symptoms of depression, anxiety, and delirium in the final stages of life (Carroll et al., 1993; Hirschfeld et al., 1997; Holland, 1997, 1998, 1999; Breitbart et al., 2000; Chochinov & Breitbart, 2000). And, beyond these physical and psychological symptoms, we fall even shorter of our goals of alleviating the spiritual, psychosocial, and existential suffering of the dying patient and family (Cherny & Portenoy, 1994; Cherny et al., 1996; Fitchett & Handzo, 1998; Karasu, 2000). And this is in spite of the ethical imperative “to comfort always” (Pellegrino, 2000).