6 General adult psychiatry6.3 Liaison psychiatry
6.3.5 Care of dying patients and bereaved people
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Written by Resident Doctor Committee · Published
Distress in advanced illness
Total pain, Cicely Saunders's term, means physical, psychological, social and spiritual suffering acting together, so assess every domain before calling distress psychiatric.
Depression near death
Fatigue, poor appetite, weight loss, slowing and poor sleep may come from the illness itself, so rely more on psychological features.
Feature | Points to depression | Explained by the illness |
|---|---|---|
Anhedonia | Little pleasure even when comfortable | Engagement returns as symptoms ease |
Hopelessness | Global, covering all remaining life | Limited to the poor prognosis |
Guilt | Excessive, pervasive or delusional | Specific regrets |
Psychostimulants can lift depression within days, so they suit patients whose life expectancy is shorter than the time a standard antidepressant takes to work.
Specialist regimens are methylphenidate 5 to 30 mg daily or dexamfetamine 2.5 to 20 mg daily.
Mirtazapine helps when prognosis allows standard treatment and poor sleep or appetite comes with the depression.
Demoralisation is helplessness, hopelessness and loss of meaning with enjoyment of the present preserved, and antidepressants are not established for it alone.
Delirium near death
Delirium near death is common, usually multifactorial and often hypoactive, so it is mistaken for depression, withdrawal or sedation.
Causes include opioid accumulation in renal impairment, hypercalcaemia, hyponatraemia, infection, urinary retention, constipation, hypoxia, corticosteroids and cerebral metastases.
Delirium in the last days is sometimes irreversible, so investigate only as far as the goals of care justify.
In the Agar trial of 247 palliative patients, risperidone and haloperidol both worsened delirium scores over 72 hours and caused more extrapyramidal effects than placebo did.
Haloperidol was also linked to poorer survival, so antipsychotics do not reliably resolve delirium; treat causes and the environment, and keep medication for severe distress.
Normal grief
The three-phase model of grief runs through these phases in turn:
The first phase is shock and disbelief.
The second phase is acute distress and withdrawal, with pining, searching and fleeting perceptions of the dead person.
The third phase is restitution and reorganisation.
Continuing bonds, such as talking to the dead person or sensing their presence, often comfort people, and detachment is not required.
Ask about cultural and religious mourning practices before reading expression or restraint as illness.
Telling grief from depression and psychosis
Feature | Normal grief | Suggests depression, psychosis or abnormal grief |
|---|---|---|
Perceptions | Brief, of the dead person, held with insight | Hallucinations of other people |
Activity | Social withdrawal | Psychomotor retardation |
Thoughts | Pining and searching for the dead person | Guilt about matters beyond the death, global worthlessness and suicidal intent |
A current moderate depressive episode after a bereavement, in someone with a past severe episode, counts as depression: treat it with an antidepressant, not with support alone.
Prolonged grief disorder
Criterion | ICD-11 (6B42) |
|---|---|
Time since death | At least 6 months |
Core feature | Persistent longing for or preoccupation with the dead person |
Further symptoms | Intense emotional pain, such as anger, guilt or disbelief |
ICD-11 requires grief beyond cultural norms with significant impairment, and grief-focused therapy can help.
Bereaved people carry raised risks of suicide, self-harm and psychiatric illness for at least ten years, highest in the first year and after sudden death.
Treat coexisting depression, post-traumatic stress disorder and substance problems separately.