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~ Coping may be either adaptive by reducing stress and promoting psychological adjustment or maladaptive preventing necessary adjustments
~ Coping Strategies
~ Seeking information
~ Keeping busy / distress tolerance
~ Redefining options/Examining alternatives / Create a win-win
~ Expressing feelings
~ Taking time away to recharge
~ Getting support / synergize
~ Mindfulness
~ Purposeful action
~ Antidepressant therapy is usually relatively well-tolerated
~ Expert consensus statement recommends a low threshold for initiating treatment.
~ Psychostimulants, SSRIs, and tricyclic antidepressants are the main pharmacologic treatment modalities for depression at the end of life.
~ Sertraline, paroxetine, mirtazapine, and citalopram have demonstrated effectiveness for fatigue and depression in patients at the end of life
~ Cochrane review concluded that there is no systematic evidence of the effectiveness of pharmacologic treatment of anxiety in the palliative care setting
~ Identify what the client and family already know about the prognosis and whether there are gaps and doubts to be resolved
~ Diagnosis: Nature, extent, trajectory
~ Meaning and impact of illness
~ Explanation of symptoms
~ Handling of emergencies
~ Financial concerns
~ Legal issues
~ Death and dying
~ Options (DNR, burial/cremation/donation)
~ Process (see physical)

~ Intra-family conflict situations call for a family reunion with the health team to negotiate with the family: Respecting the patient's wishes and establishing a consensual plan of actions
~ It is important to make written notes of the points discussed and the agreed plan
Cognitive Interventions
~ Counseling strategies that combine emotional support, flexibility, appreciation of the patient’s strengths, warmth and genuineness, life-review and narrative therapy, and exploration of fears and concerns
~ Continuity of care
~ Structure and process of care
~ Supplies and accommodations for client and caregivers
~ Community resources (Shopping, cleaning, transportation)
~ Pay attention to sensory stimuli
~ In the hospital / LTC facility
~ At home
~ Community support
~ Peer support
~ Spiritual guidance
~ Willingness to accept help: You cannot do everything yourself
~ Let others share the load for the dying person, for you, for themselves
~ Increased desire to have loved ones close (or not)
~ Not wanting people to be around (no energy; remember me as I was; not wanting to impose)
Children and Death
~ Children respond to death:
~ Denial, shock and confusion
~ Anger and irritability
~ Inability to sleep or nightmares
~ Loss of appetite

Children and Death
~ Don’t try t o protect them from grief
~ Communicate in concrete developmentally appropriate ways
~ Let children discuss their fears and educate when possible
~ Validate feelings
~ Provide choices about how to memorialize the person and express their feelings
~ Be sensitive that they may not want to talk or think about the deceased because it is too painful.
~ Explain the person loved them and would want them to be happy.
~ Remind your child that not everyone who gets sick will die.
~ Reassure him of your health.
~ Let him know how many people in his life care for him.
~ Take care of yourself and make sure you have support.
Resources / References
~ Psychological Issues in End-of-Life Care by Susan D. Block MD Journal of Palliative Medicine
~ Assessment Tools for Palliative Care
~ Clinical Practice Guidelines for Quality Palliative Care
~ End of life care often involves multiple providers, the client and caregivers
~ It is essential to consider all biopsychosocial needs with a focus on integrative care
~ “Stress” and distress will increase HPA-Axis activation, impair sleep and immunity and contribute to worsening of health and wellbeing of both the patient and caregivers.
~ Children will need different approaches depending on their developmental level.

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