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Managing Grief andDepression at the
End of Life
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Abstrak
Psychological distress is common in terminally ill persons and can be a source of great suffering. Grief is
an adaptive, universal, and highly personalized response to the multiple losses that occur at the end of
life. This response may be intense early on after a loss manifesting itself physically, emotionally,
cognitively, behaviorally, and spiritually; however, the impact of grief on daily life generally decreases with
time. Although pharmacologic interventions are not warranted for uncomplicated grief, physicians are
encouraged to support patients by acknowledging their grief and encouraging the open epression of
emotions. !t is important for the physician to distinguish uncomplicated grief reactions from more
disabling psychiatric disorders such as ma"or depression. The symptoms of grief may overlap with those
of ma"or depression or a terminal illness or its treatment; however, grief is a distinct entity. #eelings of
pervasive hopelessness, helplessness, worthlessness, guilt, lack of pleasure, and suicidal ideation are
present in patients with depression, but not in those eperiencing grief. Psychotherapy and
antidepressant medications reduce symptoms of distress and improve $uality of life for patients with
depression. Physicians may consider psychostimulants, such as methylphenidate, for patients who have
depression with a life epectancy of only days to weeks.
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Grief
% #or most patients, grief is an appropriateand adaptive response to loss and illness.
&ymptoms of grief may include denial,
anger, disbelief, yearning, aniety, sadness,helplessness, guilt, sleep and appe' tite
changes, fatigue, and social withdrawal.
% Grief'related distress typically diminishes
over time, corresponding with an increase
in acceptance ofloss.
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Treatment
% Physi cians can help patients who are grieving by encouraging them to use eterna l
sources of support, including family , friends, and faith communities. Physicians
should acknowledge the loss and the associated grief, actively listen to and
eplore patients( concerns.
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)epression
% The ma"ority of patients with advanced
illness are not depressed, although they
may complain of a depressed mood or
other depressive symptoms. Although
sadness is common in patients who are
terminally ill.
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)iagnosis
% The Diagnostic and Statistical Manual of Mental Dis orders, *th ed. +)&'!-
describes a ma"or depressive episode as at least two weeks of depressed
mood or loss of interest accompanied by at least four additional symp toms of
depression +sleep disturbance; guilt and feelings of worthlessness; lack of
energy; loss of concentration and difficulty making decisions; anoreia or weight
loss; psy chomotor agitation or retardation; and suicidal ideation
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!ndications for ental /ealth 0eferral in
Patients with Advanced !llness
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% A meta'analysis of si randomized controlledtrials of supportive'epressive group therapy 1
2.3ognitive behavioral therapy, and4.Problem'solving therapy for persons with
advanced cancer concluded that psycho'therapy has significant beneficial effect on the
treatment of depressive symptoms.
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P/A0A35T/60AP7
% A meta'analysis of ** studies involving 8,894 adults with
depression and physical illness revealed that selective
serotonin reuptake inhibitors +&&0!s and tricyclic
antidepressants +T3As were more effective than
placebo within four to five weeks of treatment.