Aiming for dignity in death

Doctors should know when to stop curative care and begin palliative care, so that terminally ill patients can die with dignity, suggests Dr Pallavi A Joshi

This decade has brought a significant change in a doctor’s point of view. Many of us have changed the focus from ‘only care’ to ‘cure and comfort’ to ‘only comfort,’ when cure is impossible.

Although doctors should strive to extend life and decrease suffering, they must also accept death as a defining characteristic of life. Sometimes, so-called heroic methods may lead to needless suffering instead of preventing death. So, when the incurability of a disease is confirmed, there begins the journey of palliative care to make the end of life easy, and assuring the patient of a dignified death.

A shift from curative to palliative is sometimes difficult for everyone concerned, as it suggests that the patient is nearing death. This might be one of the reasons for the continuation of curative care until the patient’s death.

But a well-planned transition to palliative care often decreases anxiety, and relatives can go through an appropriate anticipatory grief reaction. A positive emotional outcome is much likely if physicians and psychiatrists project a conviction that palliative care will be an active, involved process without any hint of withdrawal or abandonment.

When we hear the term palliative care, what springs to mind? Pain and symptom control? For many health care providers that has been the traditional focus. But the field is recognising that end-of-life care also encompasses psychological, social and spiritual concerns — areas where psychiatrists and other mental health professionals can play a key role.

Palliative care traditionally refers to providing relief from the suffering caused by pain or other symptoms of terminal diseases. However, recently many surgical and medical interventions plus psychotherapies have fallen under this umbrella as they can make the patient more comfortable. Palliative care ideally tends to be a multidisciplinary field, with doctors, nurses, social workers, psychologists, pastoral care workers, psychiatrists and other professionals participating in palliative care programmes and psychosocial oncology services, wherever needed.

Aggressive chemotherapies and radiotherapies for cancers and various invasive procedures are usually discontinued in this approach. Palliating the pain and palliating psychiatric symptoms like sleeplessness, confusion, suicidal ideations, depression, anxiety, overt psychosis and treatment of other complaints like nausea, diarrhoea, anorexia, mouth sores, decubitus ulcers are given priority.

Pain and sleep management are considered subspecialties for psychiatrists. Psychiatric drugs like antidepressants, anticonvulsants and opioids are found to be much more superior than conventional analgesics in treating all types of pains like somatic, visceral, neuropathic and psychogenic. Sleep management is very important so as to maintain the quality of life. It is granted that sedatives as well as opioids are addictive but we must consider these options without hesitation when the aim is only to comfort in incurable diseases like advanced cancer.

Dr John Shuster, a founder of the University of Alabama’s Palliative Medicine Program, highlights key goals for psychiatry in palliative care: helping people feel they are not abandoned; facilitating their achievement of spiritual and emotional peace; providing comfort through the relief of physical symptoms; helping restore and maintain harmony in important relationships; and assisting people in achieving life completion, including understanding what their life has meant, particularly to others. Elements of care are more in the domain of mental health, but pain and symptom control are still top priorities. “You have to clear the decks in terms of intolerable pain, nausea, anxiety and shortness of breath,” says Shuster. “Otherwise you can’t focus on things relating to meaningful relationships and wholeness.”

Dr Harvey Chochinov, Canada Research Chair in Palliative Care says “We all have aspects of our lives that we see as being self-defining, and if those things become threatened by illness, it raises the existential issue — am I still me? Despite my various losses, am I able to maintain some essence of who I am? Near the end of life, such challenges are extremely common, so one task of the mental health provider is to help patients navigate that difficult, existential landscape.”

So the role of psychiatrists in end-of-life care is very important and goes beyond only pain and sleep management. It involves taking care of psychiatric symptoms and involves not only psychotherapy to patients but also to relatives. Relatives can be offered supportive psychotherapy with the chance of venting out their feelings in group. They get the feeling that they are not alone by virtue of group psychotherapy comprising the family members of various patients, and they can discuss the problems encountered commonly and effective ways of coping.

Spiritual ascendancy is encouraged in patients as it helps in accepting death and other miseries related to it in a more positive manner. Patients can actually view death as a part of life. The options of home care and hospice care can also be provided to relatives.
To summarise, doctors should realise when to give a full stop to curative care in terms of the condition of the patient and concentrate towards death with dignity with palliative care. What doctors aim these days is “quality” rather than only the “quantity” of life. Ultimately what we want is the same thing depicted in this old saying – A doctor should: do no harm, cure sometimes and comfort always.”

(The writer is Consultant Psychiatrist and Assistant Prof of Psychiatry, VIMS & RC, Bangalore.)