This advice is sourced from Dr Heather Wells, Clinical Psychologist and Dr Ros Taylor a senior palliative physician
Anxiety is very common in advancing illness.
For many people death is a taboo subject. Unexpressed fears about the end of life can worsen anxiety and impact symptom control and quality of life.
Leaning in to exploring individual worries is key and requires brave empathic communication. Patients can feel overwhelmed and the conversations can't be rushed. Depending on your clinical setting it may require several appointments to explore, and your patient should control the pace.
Causes of anxiety can range from the practical to the spiritual. Some of these worries can be resolved and others can be shared, explored and often become more tolerable over time.
Discussing fears and worries often leads on to identifing goals of care, and can help people to plan how they want to live.
Common worries we see in practice
Pain – people may worry about dying in pain; those with cancer may worry that new pain is a sign of the cancer spreading
End of active treatment – people may struggle to adjust when active treatment of an illness stops e.g. chemotherapy
The process of dying - this can be gently explained
Family worries – for example, worrying about being a burden or being isolated and abandoned
Legal, financial and housing worries - often not explored by clinicians
Spiritual distress
Assessment of severity
A validated tool such as GAD-7 can be helpful to guide treatment
Non pharmacological treatment
- Talking with a trusted professional often helps: In particular active listening and clarifying goals of care
- For many people with mild levels of anxiety, self-help resources may be enough
- Breathing exercises are often a helpful way to manage the symptoms of anxiety
- Practical help – for example, help in making advance care plans, support for housing or financial worries
- Spiritual care - focussing on what gives meaning, legacy, reminiscence and faith if appropriate
- Browsing books can be a gentle way to feel less alone and more in control
Recommended book: Free yourself from Death Anxiety. A CBT Self-Help Guide for a Fear of Death and Dying. Menzies and Veale 2022
Pharmacological treatment
- Benzodiazepines e.g. long acting diazepam or clonazepam or short acting lorazepam. In hospice care we commonly use clonazepam 500 mcg twice daily for anxiety and neuropathic pain
- SSRIs such as sertraline, citalopram or escitalopram are worth trialling if there is a reasonable prognosis
- Citalopram drops 40 mg/ml can be really useful for people with swallowing difficulties or towards the end of life to avoid SSRI withdrawal. The starting dose is 4 oral drops (8mg) which is equivalent to a 10mg tablet
- Other commonly used medications for anxiety include neuropathic agents such as pregabalin and sedative antidepressants such as mirtazapine and trazodone
In palliative practice we have a lower threshold for prescribing anxiolytics and often use benzodiazepines (BDZs) to support titration of antidepressants. BDZs are a useful short term intervention to reduce severe anxiety so that patients can engage with other non pharmacological strategies. Concerns about addiction do not apply.