Improving Care for the End of Life, Online Edition The Palliative Care Policy Center

Sourcebook : Improving Care for the End of Life : 15.0 Depression and Delirium

Depression in dying patients is often dismissed as a natural reaction to knowing that one’s life is ending. Although sadness and grief are normal reactions to such news, these emotions usually give way to others. Clinical depression, however, does not “give way”; instead, it plagues sufferers with guilt, self-doubt and blame, hopelessness, and loneliness. While those who are sad can have times in which they are content and able to enjoy life, those who are depressed are unable to engage in life or to find moments of pleasure. Depression can deplete a person’s quality of life as much as any other disease.

Like most people, clinicians often think that they too would be depressed knowing they had a life-threatening disease. This belief leads some clinicians to disregard or not recognize depression in their dying patients. Cancer patients rarely receive antidepressants, although as many as 20 percent may be clinically depressed (Vachon, 1998). Left untreated, depression causes significant emotional harm, reduces the ability to participate fully in life, reduces the ability to comply with other medical treatments, and can contribute to other medical problems (Strouse, 1997).

Delirium is another common medical complication among dying patients; estimates suggest that anywhere from 25 to 85 percent of dying patients experience delirium at some point in the last year of life. Delirium may be a side effect of some pain medications, and it may be caused by other common end-of-life problems, such as dyspnea, dehydration, and cachexia. Delirium creates terrible distress for patients, families, and professional caregivers.

Both depression and delirium are treatable causes of suffering at the end of life. Although it can be difficult to distinguish between the two, providers can learn to screen and treat patients accordingly.

Strategies to improve screening and treatment include adding common assessments to intake forms, requiring depression screening for dying patients, tracking screening rates and prescribing practices, and setting goals for practice improvement. With these steps, organizations take a critical move in improving the lives of thousands of patients and their families.

In This Chapter

Few organizations have engaged in quality improvement measures that address depression among dying patients. Consequently, this chapter focuses on more general issues, with the hope that teams might engage in relevant quality improvement activities. This chapter provides:

Innovators Need to Know

  • Although people who are told they have a terminal disease are likely to feel depressed and sad, clinical depression is not a healthy response to the diagnosis of terminal illness; depression is a treatable disease.
  • Depression, which robs people of their ability to engage in and enjoy life, erodes the quality of life, impedes healing, and interferes with other medical treatments.
  • Depression and delirium have distinct symptoms and treatments, although the two can be hard to distinguish.
  • Asking patients “Are you depressed?” is a good indicator of how they feel and whether or not they need psychiatric help.
  • People who are depressed are at increased risk for suicide and are more likely to request physician-assisted suicide. Other improvements include tracking prescriptions for antidepressants, educating patients and families about depression and delirium, and forging alliances with community-based mental health organizations.

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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.

For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].

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