How do you manage anxiety in palliative care?

During the time of someone dying, the time can vary from months to weeks to days, anxiety is an all too common trait that is apparent in every patient and family member  we see at the hospice. Managing the anxiety of a patient and a family member can cause a fraught relationship between the nurse and patient at times,  I remember taking care of a hospice patient with advanced COPD, where shortness of breath and frequent bouts of breathlessness exacerbated through panic were a common occurrence and one I found really difficult to keep under control whilst this patient was coming to the last days of their life

I imagined talking to my previous patients with similar health conditions in hushed tones, comforting them , and medicating their pain and breathlessness away while the entire family gathered around as they breathed their last breath. I would continue to help others  have a beautiful dying experience.

Anxiety is the feeling of dread or overwhelm that comes when something is not quite right. It is often connected to uncertainty and loss of control. Dr. Edmund Bourne, Ph.D. specializes in the treatment of anxiety disorders and reports that anxiety is a normal human reaction that helps us to “cope with situations that are demanding, unfamiliar, or potentially threatening.” Caring for your loved one at the end of their life is all of these.

Anxiety is normal when taking care of a hospice patient. Your life has turned upside down physically and emotionally. Family and friends watching their loved one talking their final breaths will only increase their anxiety and it’s trying to empathise with them whilst they go through this is vital for their grieving process. 

Take a breath and honor this state of overwhelm. It’s legitimate. 

Families and friends of the patients own expectations and own desires sometimes can cause further anxiety. We cannot control another person's experience in death or in life for that matter. To minimize your feelings of overwhelm, focus on what you can control. You can take care of yourself so you can love and nurture your loved one.

Do not strive for perfection abs I think being honest with the family and friends about this is also a poignant truth that they will appreciate you sharing with them, don’t promise them the world of a peaceful and organised death because sometimes it doesn’t work that way. 

You will find yourself in some surprising, awkward, and clunky situations while caring for a hospice patient: cleaning out the commode, washing vomit off shoes, and sweating profusely as you try to give a bed bath, all whilst ensuring you keep a cool and collected demeanour. Caring for a patient or   loved one will not be perfect, but it will be one of the most loving things you can do for them, which is the most important thing that why I think it is important to allow family members or friends to be as involved as they want to be, this can relieve anxiety. 

I find that sometime the worse thing to heighten anxiety is time and waiting. I find it’s helpful to encourage family members or friends to fill  their well in whatever ways are healthy and sustainable during this time. 

Netflix and food deliveries to the hospice  are short-term solutions. Leaving the hospice is good for you. Mindfulness, breathing, meditation, massage, exercise, and nature are all spiritually refreshing. Learning to sit with your uncomfortable feelings may allow them to soften. Allow yourself to feel depleted, you will pick yourself back up again. 

Now let's talk about the patient’s anxiety. There are so many reasons for a patient to feel anxious, and sometimes it's not easy to suss these out. They are losing control, independence, energy, and time; all of these are causes for alarm. 

Look for any underlying physical symptoms. 

Sometimes, the hospice patient has underlying physical symptoms causing the anxiety such as shortness of breath, nausea, and pain. Ask the hospice team for help in finding and fixing any underlying issues. 

Help them tend to unfinished business. 

If they are nearing the end of their life, is there any unfinished business they may need to tend to? Do they fear death, dying in pain, or do they have unresolved guilt or conflict with a family member? Hospice social workers or chaplains are excellent resources and especially skilled at leading these conversations.

Collaborate to create a calm environment. 

Let family and friends know the patient is anxious and brainstorm ways to mitigate environmental stressors. Dim the lights, speak in hushed tones, turn on soothing music, and limit visitors. 

Get some anti-anxiety medication. 

Medications such as lorazepam or diazepam are frequently used for anxiety. Call the hospice team for medication guidance and orders based on their disease and tolerance. Start with the smallest dose to see if it helps. I think medications are a great way to soften the intensity of this process. One 0.5 mg tablet of Ativan will not take away their anxiety but may give them some temporary relief.

Find some distractions from the stress and uncertainty. 

Consider reading a prayer, a guided meditation, or a poem to the patient; sometimes this is a helpful distraction. 

Some hospices offer massage, reiki, and acupuncture. Ask if these are available for the patient. 

Changing the scenery in any way may be helpful. Taking a walk in nature, driving to the country, or pushing your loved one around the block in a wheelchair may offer a perfect diversion and some relief. 

Some patients may fear being alone. Have a chair near the patient to sit and read, knit, or watch TV with them. Presence, and often silent presence, is what they need most. 

Feelings of dread and overwhelm are normal and anticipated states for a hospice patient and their caregiver. Of course nothing feels right. We have spent our entire lives figuring out how to live, and now we suddenly have to think about death and dying.

Take a breath and honor these intense feelings.