Psychiatric Aspects of Excellent End-of-Life Care

atrists. The most basic challenge at the end of life that stresses patients and families is loss, which is related to both the disabilities of the illness (that threaten self-esteem) and the patient’s death (that ruptures the direct relationship with the family). Other psychiatric problems and issues commonly seen at the end of life include anxiety symptoms and anxiety disorders, depressive symptoms and depressive disorders, delirium and other cognitive disorders, suicidal ideation, consequences of low perceived family and other social support, personality disorders or personality traits that cause problems in the setting of extreme stress, questions of capacity to make informed decisions, grief and bereavement, and general and health-related quality of life. Spiritual and religious issues, including both personal faith and relationship to a community of believers, are important for most people. Good end-of-life care requires explicit attention to these matters. Studies show that psychiatric morbidity in the setting of terminal illness is exceptionally high. The reported prevalence rates of delirium in terminal cancer and AIDS (acquired immunodeficiency syndrome) patients range from 25% to 85%, 7–11 and the prevalence rates of clinically significant depression range from about 20% to 50%. 7–9,12–15 The prevalence of depression among terminally ill patients with a desire for death is eight times higher than in those without a significant desire for death. 14 Depression is the strongest determinant of suicidal ideation and desire for death in those with serious or terminal illness. 12–15 Psychiatric complications at the end of life are treatable but often go unrecognized and untreated. Several factors or barriers contribute to the underrecognition and undertreatment of psychiatric problems at the end of life. Psychiatric disorders (e.g., anxiety, delirium, depression) are difficult to diagnose with confidence in the setting of significant physical illness, owing to the overlap in the symptoms caused by the psychiatric disorder and the comorbid physical problems. Many patients, family members, physicians, and hospice and palliative care providers hold beliefs in which psychiatric symptoms, especially depression, are viewed as normal parts of the dying process. Many patients and physicians do not understand that patients who have mental disorders at the end of life can respond to treatment. This therapeutic