Depressive symptoms in the last days of life

– by Elene Janberidze

Depression and depressive symptoms in general are burdensome, especially for patients Elene portrettwith advanced stage cancer. Many of those patients have poorer prognosis and poorer quality of life. The prevalence of depression and depressive symptoms in those patients vary from 2% to 56% which could be due to that we as health care providers are not good enough to identify depression and depressive symptoms. We may think this is a normal part of having cancer and also part of the dying process. However, some patients experiencing depressive symptoms and/or depression can be treated and thus both the patients and their families may have better quality of life. Therefore it is important to study these patients.

The main reason for choosing patients with end-stage cancer in their last 24 hours of life was that patients in this very last period of life are not so well investigated. This might be due to the fact that many are too ill to be included in studies. As there were data available in this large population based study form the Netherlands, it was an opportunity to learn more about cancer patients at the very end of life. Usually we recommend to ask the patients to report about their subjective symptoms, however at this stage, such information in most cases has to be collected by asking relatives or by letting health care providers report about the symptoms as it was in this study.

Our findings showed that according to attending and treating physicians more than one third of the patients were experiencing depressive symptoms in the last 24 hours of life. It seems like that patients older than 80 years had less severe depressive symptoms than the younger. Physicians working in nursing homes in the Netherlands reported patients to have more severe symptoms of depression than general practitioners and physicians in other specialties. In patients with more severe symptoms of depression also pain specialists or palliative care consultants and psychiatrists or psychologists were involved in the care. Patients having depressive symptoms were also having other symptoms such as fatigue, confusion, and anxiety.

Diagnosing depression is challenging, especially in patients with somatic illnesses such as cancer. Symptoms such as fatigue can be related to the cancer, its treatment or interpreted as a sign of depression. Depressive symptoms could be viewed as a normal part of the dying process or could also indicate presence of depression. To be able to screen for and to recognize depressive symptoms is an important task for health care providers requiring evidence based knowledge and skills in order to offer appropriate care. If depressive symptoms are recognised early, patients can be offered adequate treatment. Doctors should investigate the patient further and recommend psychological interventions as needed. However, at the very end of life (last hours and days), it is normal that patients are withdrawing as part of the dying process.

The article which describes the study was recently published online in BMJ Supportive & Palliative Care: Janberidze E, Pereira SM, Hjermstad MJ, Knudsen AK, Kaasa S, van der Heide A, Onwuteaka-Philipsen B; Depressive symptoms in the last days of life of patients with cancer: a nationwide retrospective mortality study, on behalf of Euro Impact; 2015.

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