الفهرس 
PSYCHOLOGY OF DYING PROCESSOnly 14 pages are availabe for public view
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Abstract
TERMINAL ILLNESS
Terminal illness is a medical term popularized in the 20th century to describe a disease that cannot be cured or adequately treated and that is reasonably expected to result in the death of the patient within a short period of time. This term is more commonly used for progressive diseases such as cancer or advanced heart disease than for trauma. In popular use, it indicates a disease which will eventually end the life of the sufferer (Bayer, 1984). A patient who has such an illness may be referred to as a terminal patient, terminally ill or simply terminal. Often, a patient is considered to be terminally ill when the life expectancy is estimated to be six months or less, under the assumption that the disease will run its normal course. The six-month standard is arbitrary, and best available estimates of longevity may be incorrect. Consequently, though a given patient may properly be considered terminal, this is not a guarantee that the patient will die within six months (Glare et al. 2003 ).
Elisabeth Kubler-Ross (1969) was a pioneer in the psychological field of death counseling. While working with dying patients she analyzed what goes on in their minds. from her experience-oriented research, she found five specific emotional and mental stages that are consistent with almost all patients, all of which occur because they’re emotionally beneficial in one way or another. Usually the stages require a good amount of time to experience, as with a person diagnosed with a terminal illness. In sudden, unexpected deaths there simply isn’t enough time to be emotionally and mentally affected in too many different ways. These five stages don’t usually follow any particular order, and each can be experienced more than one time. Stage 1: Denial and Isolation, stage 2: Anger, stage 3: Bargaining, stage 4: Depression and stage 5: Acceptance.
At the same time, meeting the physical needs of the dying is aimed at providing as much comfort as possible. The change from curing to caring means providing comfort with the least invasive procedures, while maintaining his/her privacy and dignity. A terminally ill person has many of the same needs as any seriously ill person. With someone who is dying, one of the greatest fears is pain. Every measure should be taken to eliminate pain from the dying process. Pain control options and management plans should be discussed before the person experiences significant pain. Fear of addiction to narcotics is common among families. It is important to understand, however, that the ultimate goal is comfort, which means taking appropriate measures to assure that the patient is free from pain. Many people believe that if a person has been diagnosed with a terminal illness they must be in pain. This is not necessarily the case and, when pain is present, it can be reduced or even prevented. Pain management is an important topic to discuss with the physician ( Karl et al.2001).
Moreover, diagnosis with a terminal illness can be a traumatic event for a patient and his or her family, and is usually accompanied by offers of psychological counseling and similar assistance. At the same time, being informed that medical condition is terminal can be a very intense experience. Most doctors are aware of this and exercise care when informing patients and family members. A terminal illness gives everyone involved a period of time to come to terms with death, which can be very valuable. Moreover, terminal patients need the support and love of their friends and family members-giving comfort for the dying is one of the most important compassionate acts that anyone can perform (Evridiki et al. 2012).
On the other hand, the majority of strategies used by caregivers to cope with the problems of caring were emotionally focused, that is avoidance or denial and wishful thinking, and these were associated with higher levels of burden (Pearce et al. 2006). However, these findings are not consistent with the findings reported by Stajduhar et al. (2008) who claim that caregivers with higher levels of burden and most at risk for negative health outcomes tend to use problem-solving coping strategies rather than emotion-focused strategies. The literature on caregivers and terminal illness coping is rather limited, although as Northfield and Nebauer (2010) and Northouse et al. (2010) point out is rapidly expanding. As this is a limited field the findings of any study are also compared with dementia caregiver research and the rational for doing so lies in the fact that these two distinct diseases require long term, specific and demanding care resulting in similar physical and emotional strains for the persons who assume the role of the caregiver.
Along with the progressive worsening of their illness, terminal patients face an increasingly complex set of care decisions and look to their health care providers to initiate and guide discussions about them (Peppercorn et al. 2011). At the same time, patient-centered care is better accomplished through a comprehensive understanding of patients’ preferences for how they want to live their lives and how they want to influence their own death process. The need to build a model of end-of-life care that begins with the patient’s perspective and proceeds to deal with the conflicts and changes that happen with illness progression (Knops et al. 2005) ,is often in opposition to the difficulties clinicians face when communicating about patient goals and expectations. So the presence of team work between the physician and psychiatrist can be helpful in the context of understanding and being aware of terminal patients needs such as how and when the conversation between the therapist and the patient could begin. On the other hand, physicians should have training courses in how they could observe, prevent and manage psychiatric distress in terminal patients and this requires flexible tools that aid the encounter between clinician and patient and allow explicit inquiries about preferences that are too variable to predict ( Kutner et al. 2009)
Hope is essential for people who are coping with serious and prolonged psychological stress; and hope is not a perpetually self-renewing resource; it has peaks and valleys and is at times absent altogether. The relationship between hope and coping is dynamic and reciprocal; each in turn supports and is supported by the other. This relationship is illustrated with two adaptive tasks common across situations that threaten physical or psychological well-being-managing uncertainty and coping with a changing reality ( Folkman. 2010).
PSYCHIATRIC PROBLEMS IN TERMINALLY ILL PATIENTS&THEIR FAMILY MEMBERS
One of the most significant and potentially remediable impediments to the dying process for terminally ill patients and their families is psychiatric problems near the end of life include depression, anxiety, delirium, hopelessness, desire for hastened death, isolation, grief and suicidal ideation, all of which can emerge during the course of a terminal illness. A number of medical and psychosocial issues can lead to these various disorders, including medication side effects, physical impairments, dependency, bereavement, and family dysfunction, all of which frequently co occur during a terminal illness and can increase the risk of psychiatric difficulties (Breitbart et al. 1998).
Yet despite the importance of identifying and treating psychiatric symptoms near the end of life, mental health clinicians often receive little training or education in the assessment or treatment of mental disorders in people who are dying. The presence of psychiatric distress, even at a mild to moderate level, can have a significant effect on the patient in the last weeks of life. Many patients describe a decrease in their capacity for pleasure, sense of meaning in their lives, and ability to make connections with others and cite these difficulties as having a negative effect on their overall quality of life (Breitbart et al. 1995). For example, a patient’s ability to perform the emotional tasks involved in separating and saying goodbye may become compromised as psychiatric problem increases. Psychiatric problems have also been shown to amplify the perception of pain, at times resulting in the need for more aggressive pharmacological interventions than would otherwise be necessary .In extreme cases, the patient’s ability to make rational treatment decisions may become compromised by psychiatric symptoms, causing particular problems during the late stages of illness because many important medical decisions arise near the end of life. Psychiatric symptoms can also lead to heightened distress and worry among friends and family members, possibly leading to a downward spiral as family distress further fuels patient distress (Block, 2000). Extreme psychiatric problem is a major risk factor for suicidal ideation and suicide attempts as well as for requests for assisted suicide and desire for hastened death (Rosenfeld et al. 2000).
Despite the importance of identifying and treating psychiatric problems near the end of life, a number of obstacles converge to significantly complicate this task (Shuster et al. 1999). First, medical professionals often have difficulty recognizing symptoms and behaviors as reflective of psychological distress. Emotional distress is often viewed by clinicians and family members as a normal, inevitable, and appropriate response to dying, thus obscuring the distinction between normal and more severe or pathological distress. Even when symptoms are recognized, distinguishing between medical and psychological etiologies is often difficult, potentially leading to incorrect or insufficient clinical interventions. In addition, the frequent medical complications that accompany terminal illness may further obscure the process of making accurate diagnoses. Even when a diagnosis has been rendered, many clinicians are reluctant to recommend treatment because of the belief that terminally ill patients will not respond to interventions, leading to an attitude of therapeutic nihilism (Shuster et al. 1999).
Moreover, the commonest psychiatric disorders seen in the terminally ill are adjustment disorders, depression, anxiety and delirium. There are inherent difficulties in estimating the prevalence of depression in the terminally ill, symptoms taken to signify depression such as fatigue, insomnia and loss of weight occur due to physical illness, however taking these factors into account, depression can occur in up to 77% of the terminally ill. Depression is strongly associated with increasing physical symptoms and pain. Anxiety often occurs as part of an adjustment disorder, concurrently with depression, or secondary to a medical complication such as hypoxia. Generalized anxiety was found to occur in 1.1% of patients admitted to a palliative care ward. Delirium becomes increasingly common as a patient’s physical state deteriorates,
and rates as high as 85% have been found in-patients who are terminally
ill. It is important to remember these conditions are not mutually exclusive and can, and often do occur together (Smith et al.2003).
At the same time, desire of hastened death (EUT, PAS) is considered one of the common psychiatric problems in terminally ill patients. Euthanasia (EUT) means a death that is perpetrated or accelerated with the assistance of medicine .Euthanasia has been classified as “active” or “passive”. Active EUT refers to the direct administration of a lethal agent to the patient by another party with a merciful intent but passive euthanasia is defined as withholding medical treatment with the intention of causing the patient’s death (Patelarou et al.2009) . Most people think unbearable pain is the main reason people seek euthanasia, but some surveys in the USA and the Netherlands showed that less than a third of requests for euthanasia were because of severe pain. Psychological factors that cause people to think of euthanasia include depression, fearing loss of control or dignity, feeling a burden, or dislike of being dependent. Terminally ill people can have their quality of life severely damaged by physical conditions such as incontinence, nausea and vomiting, breathlessness, paralysis and difficulty in swallowing ( Gesang, 2008). On the other hand, physician assisted suicide (PAS) refers to the patient intentionally ending his or her own life with the assistance of another party. Furthermore, it is not an assisted death in case where the intention is the relief of symptoms and not to hasten a patient’s death ( johansen et al.2005).
PSYCHIATRIC NEEDS OF TERMINALLY ILL PATIENTS&THEIR FAMILY MEMBERS
It is crucial to emphasize one obvious fact the physicians and nurses are frequently unaware of everyone needs support from the social environment. It has been widely discussed that social support is of superior importance among various psychological factors and social conditions that influence the process of dealing with disease (Pilecka, 2004). The research in the Greater Poland Cancer Centre proves that most patients need the help of others and lack this help, but cannot always inform others about these needs. That frequently results from the willingness to avoid dependence on others or misunderstanding. Therefore, ensuring good care with particular respect to the specific nature of support must be individually adapted to each patient. Unfortunately, competent persons who could meet such requirements are often replaced by family and friends. This hypothesis is particularly valid in light of the types of expected and actually received support. Much research has confirmed that emotional support is of the greatest importance. However, instrumental and practical support seems significant for the provision of advice concerning the further life of the patient, ways of dealing with the disease, and factors contributing to improvement of the quality of life. This is a factor that reduces the intensity of negative symptoms, and social contacts offer positive experiences and a feeling that life is more predictable and stable. And despite the fact that everyone seeks a purpose in life. Everyone dreams, thinks and plans. Everyone sometimes does not want or cannot talk about many things, because of the feeling of impossibility inside, the closeness of kindhearted persons gives the feeling of safety and acceptance, helps reduce the fear and helplessness, become a partner in therapy, and accept responsibility for its results (Schwarzer, 2001).
Moreover, Health care professionals who take care of terminal patients should be educated and informed about the benefits of complete truth disclosure. Patients not only need to know the diagnosis, but also need to know when to prepare to go. Knowing that religious belief is an important part of spiritual well-being and the powerful effects of spiritual well-being on end-of-life despair, the role of a hospital chaplain in the hospice care team should be emphasized, especially for patients at terminal stages (McClain et al.2003). On the other hand, the findings of many studies demonstrate that living with hope is a significant factor that assists individuals to adjust to their terminal illness, reduce their psychological distress and enhance their psychosocial well-being and quality of life (Taylor, 2003). hope is the expectancy of good in the future. It plays a role in the successful coping with illness and in improving the quality of a person’s life. In the context of a terminal illness, hope can exist even when time is limited. Such hope is bolstered by appreciating our patients’ value, strengthening and reconciling their relationships with family and friends, helping them to explore spiritual matters, and controlling their symptoms. Although physicians may find it hard to comprehend, when everything seems to be lost, that hope may actually be stronger than ever before (Kylma et al, 2009).
In addressing the complicated needs of a seriously ill patient it can be all to easy to overlook the needs of the caregivers .The pattern of care is important, who is the main caregiver, has one relative been scapegoated to do all the work, or conversely is the family hard to engage in the patients care. There are some caregivers who are so diligent, and spend all their time at the hospital that caregiver fatigue sets in, and they become ill and exhausted themselves. These latter caregivers need counseling and help in how to pace themselves over a long illness. Each family has their own way of communicating and it is important to know whether issues are openly discussed, or if information is being withheld from certain members of the family. In all cases open communication should be encouraged, as this allows for more supportive relationships to develop. Relationships where the caregiver is ambivalent or dependent on the patient, may later lead to a difficult bereavement (Haley et al.2001).
PSYCHIATRIC CARE OF TERMINALLY ILL PATIENTS& FAMILY MEMBERS
Although individuals and cultures since prehistoric times have been
consistently preoccupied with circumstances after death, devotion
to the care of the dying has only recently gained consistent
attention in the human consciousness. Religious institutions were the
main providers of end-of-life care for centuries, and the recipients of that care were mainly those with limited resources and no family members. Therefore palliative care aims to relieve suffering and improve quality of life for patients with serious, chronic, or terminal illnesses and their families. The World Health Organization (2011) adheres to the belief that palliative care is intended for all of the seriously ill, not just the actively dying. In other words, palliative care is a large umbrella that shelters modern protocols of treatment (curative and non curative in nature). Palliative care as a precursor to hospice supports patients and families through diagnosis and side effects of treatment by focusing care on quality of life and patient goals (Ferrell, 2005).
Hospice care (end of life care) focuses on quality rather than length of life. It provides humane and compassionate care for people in the last phases of incurable disease so that they may live as fully and comfortably as possible. The hospice philosophy accepts death as the final stage of life: it affirms life and neither hastens nor postpones death. Hospice care treats the person rather than the disease, working to manage symptoms so that a person’s last days may be spent with dignity and quality, surrounded by their loved ones. It’s also family-centered – it includes the patient and the family in making decisions. Hospice care is used when the patient can no longer be helped by curative treatment, and expected to live about 6 months or less if the illness runs its usual course. Hospice gives supportive or palliative care, which is treatment to help relieve disease-related symptoms, but not cure the disease. Its main purpose is to improve the quality of life. One of the problems with hospice is that it’s often not started soon enough. Sometimes the doctor, patient, or family member will resist hospice because there’s no hope. This is not true. If patient get better or the cancer goes into remission, you can leave hospice and go into active cancer treatment. But the hope that hospice brings is the hope of a quality life, making the best of each day during the last stages of advanced illness (Chang et al. 2006).
All hospices must provide certain services, but they have different approaches to service, staffing patterns, and types of support services offered such as (NHPCO.2010):
Pain and symptom control
The goal of pain and symptom control is to help the patient be comfortable while allowing to stay in control of and enjoy his life. This means that discomfort, pain, and side effects are managed to make sure that terminal patient are as free of pain and symptoms as possible.
Spiritual care
Since people differ in their spiritual needs and religious beliefs, spiritual care is set up to meet patients specific needs. It might include helping look at what death means, helping say good-bye, or helping with a certain religious ceremony or ritual.
Family conferences
Regularly scheduled family conferences, often led by the hospice nurse or social worker, keep family members informed about patient condition and what to expect. Family conferences also gives everyone a chance to share feelings, talk about what to expect and what’s needed, and learn about death and the process of dying.
Coordination of care
The interdisciplinary team coordinates and supervises all care 7 days a week, 24 hours a day. This team is responsible for making sure that all involved services share information. Hospice care assures the patients and their family members that they are not alone and help can be reached at any time.
Bereavement care
Bereavement is the time of mourning after a loss. The hospice care team works with surviving loved ones to help them through the grieving process. A trained volunteer, clergy member, or professional counselor provides support to survivors through visits, phone calls, and/or other contact, as well as through support groups.