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Psychotherapy Casebook

The "End of Life" Stage

The “End of Life” Stage

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EDITOR’ S NOTE

Through this column, we hope that practitioners in general medical settings will gain more complete knowledge of the many patients who are likely to benefit from brief psychotherapeutic interventions. A close working relationship between primary care and psychiatry can serve to enhance patient outcome.

Dr Schuyler is a psychiatrist with a part-time private practice and a part-time job on the Geriatric Unit at the Ralph H. Johnson Veterans Administration Medical Center, Charleston, South Carolina.

Prim Care Companion CNS Disord 2012;14(1):doi:10.4088/PCC.11f01331

Published online: February 9, 2012.

Potential conflicts of interest: None reported.

Funding/support: None reported.

Disclaimer: The views herein are those of the authors and do not necessarily reflect the views of the Veterans Administration.

Corresponding author: Dean Schuyler, MD, Geriatrics/Extended Care, Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC 29401 (deans915@comcast.net).

One of the more important books that I have read talks about the different segments of one’s life.1 The concept of life stage has been useful for treating a variety of people at different times of their lives. When puberty or the calendar ushers in adolescence, a new life stage begins. When schooling ends, when someone is hired to work, when the employed man or woman retires, or when a marriage takes place, a new life stage may begin. When a married couple has a child, a new stage of life often starts, and when the last child leaves home, a married couple may begin a new life stage.

Similarly, when serious illness (eg, cancer) brings restrictions, a new life stage can be said to follow. Once defined, I have found it useful to ask the patient to describe how he or she wants to spend this stage. A Veterans Administration colleague recently gave me an article2 to read that calls attention to the “homelessness” that typically results when an older person is admitted to a nursing home. It seems to me that one approach to the institutionalized elderly man or woman at the end of life is to define the problem as the onset of a new life stage and encourage the individual to plan for this time.

I have been working on a palliative care team at a local Veterans Affairs hospital now for nearly 2 years. As part of that work, I treat patients who have been admitted to our nursing home unit. Although every case is different, and the problems presented may vary, I utilize the concept of a new life stage with practically every veteran that I treat. The loss of a home is one of many events that challenge the older person’s need to have some control over his or her life. The event forces the individual at the end of life to make a plan for this period.

In a manner similar to those individuals who are admitted to hospice, some patients who learn to call our nursing home unit their home outlive their commitment. When they leave the place where they expected their life to end, a new life stage can also be said to begin.

CASE PRESENTATION

Mr A is a 70-year-old man who has been married for 40 years. He is the father of 3 sons and 2 daughters, all grown. There are 10 grandchildren and 5 great grandchildren. His military service was accomplished in the navy during the Vietnam War.

Born in rural South Carolina, Mr A is a high school graduate. His original family had 2 younger sisters, a mother, and an alcoholic, abusive father. Mr A’s childhood home was a continuing source of stress for him. Posttraumatic stress disorder was a consequence of Mr A’s combat experience, and depression manifested itself several times when he was a young adult. Suicidal ideas were a constant preoccupation.

Two years ago, Mr A had the onset of severe abdominal pain. This pain led to multiple visits to the emergency room and to multiple surgeries. A ruptured intestine proved to be a stubborn problem, and multiple fistulae never adequately healed. With loops of bowel prominent alongside his abdomen, Mr A was admitted to our nursing home unit at the end of life, anticipating death. He told me at our first meeting, “At one time, I gave up hope.”

PSYCHOTHERAPY

I was able to form an engagement bond with Mr A by taking a detailed history. Mr A credited the 20-bed unit with showing him men in worse shape than he was. He spoke about significant people in his life who had given up on him. I emphasized to him that his mindset (how he saw himself and his world) would be central to how he felt and how he functioned. Mr A told me about the example of some family members who had maintained their motivation despite demanding life events.

In our second session, we labeled this time in his life as a new life stage. I challenged Mr A to come up with a plan for how he would live this new stage of life. We spoke about different strategies and different options. Mr A noted that planning to eventually go home would entail his taking significant risks.

A blood clot in Mr A’s leg was an obstacle to his progress. He was admitted to the hospital, was treated for a week, and then returned to the nursing home. Mr A acknowledged spending a lot of his unstructured time thinking about his life plan. At our third session, he once again focused on his ideas for the future and noted that he was doing better with his thinking and that he was more at peace. Originally depressed and despairing, Mr A’s motivation to live was clearly returning.

In our fourth session, we emphasized the need for Mr A to take control of his recovery and his life. We discussed his family’s view of him and how it differed from his own view. In our fifth meeting, we noted that Mr A’s instructions for healing the clot (bed rest) were at variance with his plan for recovery (increased mobility to regain strength). Mr A emphasized how he was becoming increasingly assertive, both with his family and with his fellow ward residents.

Gradually, the swelling in his leg diminished, and Mr A resumed an active plan to increase his endurance. Mr A planned a home visit and began to anticipate his discharge to home. We discussed the care that Mr A would need and options to provide the care. His family was encouraged, he said, by the change in his attitude. Mr A noted having a lot to be thankful for and talked about how he might “give back now to others.”

Mr A spoke about his participation in an outing arranged by the recreational staff and how much it had meant to him. The transformation from a depressed, despairing individual at the end of his life to a functional man planning to go home and rejoin his family was impressive. Mr A seemed very likely to join that small elite group of residents who arrive at the end of their life and “graduate” to a brand new life stage.

REFERENCES

1. Sheehy G. Passages: Predictable Crises of Adult Life. New York, New York: EP Dutton and Co; 1974.

2. Carboni JT. Homelessness among the institutionalized elderly. J Gerontol Nurs. 1990;16(7):32-37. PubMed

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