Mental Health Issues in Palliative Care

The World Health Organization defines palliative care as an approach to care that improves the quality of life of patients and their families facing problems associated with life threatening illness, through the prevention and relief of suffering by means of early identification , impeccable assessment and treatment of pain and other problems. The ultimate goal of palliative care is the achievement of the best quality of life for patients and their families. The core principle of this form of care is that it begins at the diagnosis of a life threatening condition, continuing through death and bereavement. It is not just an end of life crisis management but an innovative, proactive and a deliberate care plan. Contemporary palliative care is based on a model developed in response to the needs of cancer patients by the hospice movement in the UK. It aims to make death a pain-free process which includes support, comfort and relief of symptoms, making it possible for people to die with dignity often called ‘good death’.

Apart from cancer, advanced HIV illness and other chronic illnesses are associated with pain and varied psychological distresses.  The HIV epidemic especially in most developing countries has led to increased need for palliative care which is at a rudimentary stage in Nigeria. Efforts at providing home care exist but this model is unable to provide the pain relief and treatment of other distressing symptoms that are needed to prolong life and ease dying. Pain control is one of the crucial components of palliative care because it allows patients to come to terms with their approaching death and make arrangements for the future of others who depend on them. Access to pain- control drugs through policy modification for authorized competent staff is crucial. Only recently our minister of health initiated the procurement of more morphine to cater for the huge unmet need for pain relief in Nigeria. Beyond the issue of pain control, there is the need to culturally adapt the contemporary palliative care that originated from a hospice movement. Care for the dying is not new, and different cultures have different approaches to helping people at the end of their lives.  There is the African view of death and dying which may pose some challenges to palliative care in Nigeria. Traditionally, elderly ones look forward to dying where children and other loved ones surround them as they give final instructions and prayers.  There is also the desire of Africans to have a peaceful transition without pain or distress which may explain their preference for home care rather than institutionalized care for the dying patient.   

Palliative care is an innovative   involvement in the process of dying not just the parochial concept of a peaceful death without pain that our culture seems to overemphasize. Herbalist may prescribe certain rituals, concortions and consultation with certain gods which may not effectively alleviate physical symptoms especially pain. However the psychosocial issues may be effectively handled within the purview of tradition and culture.  Psychiatry as a medical discipline has always employed a bio psychosocial model in patient management which appears to be the underlying principle of palliative care. However the overemphasis of the biological aspects especially pain manage ment to the exclusion of psychosocial-spiritual aspects may rob it of its inherent values. In my opinion the background of modern palliative care originating from the hospice model may be responsible for its strong biological bias which is compatible for the Europeans. Contemporary palliative care requires a multidisciplinarian coordination that would exhaustively explore the bio psychosocial- spiritual dimensions of the African patient. By the time patients reach the palliative care stage; they have gone through a process of investigation, diagnosis and treatment with varying degrees of pain and trauma, dependency and disfigurement.  

Kubler-Ross argues there are five stages to patient’s reaction to a terminal diagnosis; denial, anger, bargaining, depression and acceptance. It is now recognized that these emotions can occur simultaneously which pose great mental health challenges to the patient. A good number of them experience existential concerns as they ask questions such as ‘why me’? Or ‘what have I done to deserve this’? Or ‘why did God allow this happen to me’?  Spiritual issues about meaning can have a significant effect on mood and patients might express these spiritual concerns to doctors, who frequently may need to involve appropriate religious instructors.  There are also social problems such as abandonment, marital issues, stigma, financial difficulties and writing a will.   There is increased risk of suicide, depressive illness, adjustment disorders and delirium. Despite this enormous mental health issues in palliative care; there is little involvement of the mental health experts. There is the   need to build on the home care strategy with a linkage to hospital palliative care endowed with all the relevant professionals.

Dr Adeoye Oyewole

adeoyewole2000@yahoo.com

+2348034905808(Whatsapp only)