Assessing anxiety in palliative care patients

In part two, Dr Patricia Macnair discusses how assessing anxiety in palliative care patients can help in developing the treatment plan

Anxiety and pain are closely associated in palliative care and need to be managed within holistic context (Photo: SPL)
Anxiety and pain are closely associated in palliative care and need to be managed within holistic context (Photo: SPL)

Anxiety and pain are often subtly intertwined, particularly in palliative care, with pain heightening anxiety, and fear or worries lowering the patient’s pain threshold.

Each needs to be considered with regard to the other, as well as the broader context of the holistic review that is central to palliative care.

It is a mistake to assume anxiety is simply a reaction to a progressive or incurable disease. This ignores underlying factors that can be managed and risks worsening pain, depression and other problems.

The treatment plan
  • Assess pain and anxiety
  • Review the patient regularly
  • Identify specific concerns
  • Agree goals for symptom management with the patient and their family?
  • Start treatment appropriate to symptom assessment
  • Manage side-effects
  • Review progress using assessment tools or outcome measures

Many factors contribute to anxiety in a patient receiving palliative care, from fears about death, physical symptoms and unwanted effects of treatment, to practical problems, such as housing and worry about dependants. Most resolve with help, but 10-20% of patients develop formal psychiatric disorders that require more specific therapy.1

It is important to check psychological symptoms, such as difficulty in concentrating, relaxing or sleeping, irritability, signs of motor tension (muscle aches and fatigue, tremor or restlessness), headaches and worsening of other pains, and symptoms reflecting activation of the autonomic nervous system, such as palpitations, sweating, dry mouth or diarrhoea.

Some assessment tools, such as the Hospital Anxiety and Depression Scale,2 are well established in a general clinical setting, but in palliative care, a more holistic assessment of anxiety, within a wider view of emotional, social or spiritual problems, is important. For example, the Distress Thermometer3 can give a broader picture of the patient’s stress and anxiety, as well as pinpointing the impact on their daily life and providing targets for action.   

Once the impact of pain and anxiety is clear, it is helpful to go through these with the patient and their family, to confirm contributory factors and set realistic management goals. Specific treatments, including non-drug therapies, can then be selected and planned.

Outcome measures

Outcome measures are essential to explain to the patient the real meaning of efforts to control pain and anxiety, and how these are determining their overall wellbeing.

Feedback from the patient on how they feel carries more weight than a score on a symptom scale.  

Outcome measures should be used once a treatment plan has been initiated, to determine its efficacy and guide further development. For example, the Palliative Care Outcome Scale4 includes 10 items on physical symptoms, emotional, psychological and spiritual needs, and provision of information and support.

Patient-led outcome measures are very useful, for example, in reaching the compromise that may be needed between achieving symptom control and managing side-effects, such as  sedation or constipation from opiates, as well as identifying when referral to more specialised support services, such as clinical psychology or pain specialists, may be needed.     

  • Dr Macnair is a hospital doctor working part-time in medicine for the elderly at Milford Hospital in Surrey

References
1. Barraclough J. ABC of palliative care: Depression, anxiety, and confusion. BMJ 1997; 315: 1365.
2. Zigmond AS, Snaith RP. The Hospital Anxiety And Depression Scale. Acta Psychiatr Scand 1983, 67: 361-70.
3. NHS West London Cancer Network. Coping with Stress: The Distress Thermometer.
4. Hearn J, Higginson IJ. Development and validation of a core outcome measure for palliative care: the palliative care outcome scale. Palliative Care Core Audit Project Advisory Group. Qual Health Care 1999; 8(4): 219-27.

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