Nijole Hunter RN (Center of Hospice)

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Those who work in Hospice care will encounter some major spiritual and emotional issues the terminally ill patients experience as death nears and one of the major issues is anxiety.

In facing death, people typically experience a wide range of anxieties and related emotions like fear, dread, panic and agitation.

An analysis of the anxiety of the dying person identifies several central concerns.  Surely, everyone confronts death in a unique way dependent on one’s individual needs, personality, culture, and social situation, but the majority of dying persons experience intense feelings of anxiety and agitation.

For some patients, the anxiety can quickly escalate to hostile behaviors. In my work as a nurse, I have seen many caregivers and staff nurses kicked by patients due to anxiety and agitation.

 The symptoms of anxiety and agitation vary. Sometimes, it is manifested through misinterpretation of reality. I remember one patient who had not walked in a very long time due to increased weakness and disease process demand, “I want to walk out of here.” Another patient called the police and reported that he was being held hostage.

Another major symptom is confusion/ delirium. Delirium is very common towards the end of life, and can be very distressing for patients and those close to them. One day, one of the patients was pulling her IV lines out and was seeing non-existing objects. She said, “I thought someone was sitting on my arm and trying to hurt me.”

There are three different types of delirium depending on the main symptoms:

• Hyperactive delirium – the person is restless and agitated, they have heightened arousal and occasionally may be aggressive.
• Hypoactive delirium – the person is withdrawn, quiet and sleepy, and may be pleasantly muddled or stubborn and suspicious.
• Mixed delirium – the person has a mixture of hyperactive and hypoactive symptoms.

The symptoms of hypoactive delirium can be more difficult to recognize than hyperactive delirium. It is sometimes mistaken for depression or fatigue or it might not be noticed at all, so it’s very important to be aware of the symptoms.

Agitation in itself is not a disease. It’s a complex of symptoms which arrives from, a medical condition, that disrupts usual thinking flow. Usually the human brain is able to manage anxiety on a daily basis, but when it is overwhelmed, it fails.

The amygdala, which is part of the limbic system of the brain is responsible for processing of emotions and survival. When there is no danger, the amygdala remains quiet. Experiments have been done on animals to prove function of the amygdala. Results show that after it’s removal, fear disappeared.

Here’s how the amygdala creates fear. We know that the brain is the most powerful, life changing force. When the amygdala decides that there is a threat, it sends nerve impulses, to the forebrain called the hypothalamus, which directs a number functions.  Woken up hypothalamus, activates the pituitary gland, and the pituitary gland activates the adrenal gland. The adrenal gland secretes special hormones like adrenaline, noradrenaline and cortisol, which trigger fear and flight response. 

Practical Tips to help reduce anxiety and agitation

When agitation in hospice patients is noted, make sure that patients are safe. If they are in bed, put the side rails up. Create a calm comfortable environment

Investigate possible causes of the agitation and have a corrective action to address causes if possible.

Involve family in the patient’s care. Due to the challenges of the terminal illness, sometimes patients feel isolated from family and community. Help the patient to sustain their sense of connectedness to family. Also having photos of the family members surround the patient can bring so much comfort and encouragement.

Sometimes for hospice patients, favorite food can be recommended if consumption of nutrition is altered due to nausea and vomiting.

In addition, TV can also be a good source of distraction. It can help divert or shift attention from negative to positive. Each patient should have access to his/her favorite channels, be helped to find his/her favorite movies. Favorite shows and movies provide the perfect escape from reality.

You can also play the patient’s favorite songs. Music occupies attention. Smooth music and harmonious sound is able to stabilize people, especially with mood disorders, also effective to adjust psychological functions like slowing the heartbeats, breathing, also has the power to bind conscious with the unconscious. I remember seeing a violinist play to a hospice patient by his bedside. The performance seemed to help the patient put aside his pain, escape his thoughts from reality. He became so peaceful.