Editor—Ellershaw and Ward are to be commended for their useful review of “evidence-based guidelines on symptom control, psychological support, and bereavement... to facilitate a 'good death.'”1 Their recommendations for diagnosing dying are concrete, thorough, and practical.
By contrast, they write only two sentences about the provision of psychological care: “Patients' insight into their condition should be assessed. Issues relating to dying and death should be explored appropriately and sensitively.” Both statements relate to the patient's understanding of, and reactions to, being terminally ill; neither relates to an assessment of the patient's psychological symptoms or disorders—for example, depressive and anxiety related symptoms and disorders—or to ways to treat mental illness when it is present. The under-recognition and undertreatment of psychic distress in dying patients prove unfortunate omissions in terminal care for several reasons.
Firstly, psychiatric disturbances are highly prevalent—for example, an estimated 20-50% of terminally ill patients meet established criteria for depression.2
Secondly, it is almost axiomatic to state that mental illness diminishes a patient's quality of life at the end of life, thereby compromising an ability to achieve a good death.
Thirdly, psychiatric disorders can be diagnosed reliably within minutes, and effective, non-contraindicated treatment is readily available.3-5 Thus, with little additional burden to the healthcare system, the quality of life of dying patients could be vastly improved by detecting and treating their psychiatric problems.
Recommendations for a good death miss a critical aspect of wellbeing and care if they ignore the mental health of dying patients. If they are truly interested in promoting a good death, doctors need to overcome a prejudice against attending to mental, in contrast with physical, illness in patients who are terminally ill.
Competing interests: None declared.
References
- 1.Ellershaw J, Ward C. Care of the dying patient: the last hours or days of life [with commentary by J Neuberger]. BMJ 2003;326: 30-4. [PMC free article] [PubMed] [Google Scholar]
- 2.Rosenblatt L, Block SD. Depression, decision making, and the cessation of life-sustaining treatment. West J Med 2001;175: 320-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Breitbart W, Jacobsen PB. Psychiatric symptom management in terminal care. Clin Geriatr Med 1996;12: 329-47. [PubMed] [Google Scholar]
- 4.Kugaya A, Akechi T, Nakano T, Okamura H, Shima Y, Uchitomi Y. Successful antidepressant treatment for five terminally ill cancer patients with major depression, suicidal ideation and a desire for death. Support Care Cancer 1999;7: 432-6. [DOI] [PubMed] [Google Scholar]
- 5.Block SD. Assessing and managing depression in the terminally ill patient. ACP-ASIM End-of-Life Care Consensus Panel. American College of Physicians-American Society of Internal Medicine. Ann Intern Med 2000;132: 209-18. [DOI] [PubMed] [Google Scholar]