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Palliative care for older people: the psychiatrist's role

  • Victor M. Aziz (a1) and Rugiyya Saeed (a2)

In this overview we discuss the palliative psychiatric care of older people towards the end of life. We briefly consider ethics, dementia care, delirium, depression, anxiety, grief and physician-assisted suicide. We also discuss hope, dignity, spirituality and existentialism. We hope that this article will encourage clinicians to reflect on the effects of terminal illnesses on the mental health of dying people and the current provision of palliative psychiatric care.


  • Appreciate that patient-centred care builds on providing individualised care for the dying person to meet their needs and wishes
  • Understand the collaborative role of psychiatry in assessing the aetiology and appropriate response to patients presenting with problems of loss, grief, anxiety, depression, hopelessness, suicidal ideation, personality change and confusion
  • Recognise that maintaining hope and living with hope is a way for terminally ill patients to endure and cope with their suffering



Corresponding author
Correspondence Dr V. M. Aziz, OPCMHT, Cynon Valley Hospital, Cwm Taf University Health Board, Mountain Ash, Wales CF45 4DG, UK. Email:
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Abbey, JG, Rosenfeld, B, Pessin, H, et al. (2006) Hopelessness at the end of life: the utility of the hopelessness scale with terminally ill cancer patients. British Journal of Health Psychology, 11: 173–83.
Beauchamp, TL, Childress, JF (1994) Principles of Biomedical Ethics (4th edn). Oxford University Press.
Bolam v Friern Hospital Management Committee [1957] 1 WLR 582 (QB).
Boston, P, Bruce, A, Schreiber, R (2011) Existential suffering in the palliative care setting: an integrated literature review. Journal of Pain and Symptom Management, 41: 604–18.
Breitbart, E, Rosenfeld, B, Pessin, H, et al. (2000) Depression, hopelessness and desire for hastened death in terminally ill patients with cancer. JAMA, 284: 2907–11.
Burns, M, McIlfatrick, S (2015) Palliative care in dementia: literature review of nurses’ knowledge and attitudes towards pain assessment. International Journal of Palliative Nursing, 21: 400–7.
Candy, B, Jackson, KC, Jones, L, et al. (2012a) Drug therapy for delirium in terminally ill adult patients. Cochrane Database of Systematic Reviews, 11: CD004770 (doi: 10.1002/14651858.CD004770.pub2).
Candy, B, Jones, L, Varagunam, M, et al. (2012b) Spiritual and religious interventions for well-being of adults in the terminal phase of disease. Cochrane Database of Systematic Reviews, 5: CD007544 (doi: 10.1002/14651858.CD007544.pub2).
Centre for Policy on Ageing (2017) The Assessment and Management of Pain in Older People. Centre for Policy on Ageing (
Chochinov, HM, Hack, T, Hassard, T, et al. (2002a) Dignity in the terminally ill: a cross-sectional, cohort study. Lancet, 360: 2026–30.
Chochinov, HM (2002b) Dignity-conserving care – a new model for palliative care: : helping the patient feel valued. JAMA, 287: 2253–60.
Cook, I, Kirkup, AL, Langham, LJ, et al. (2017) End of life care and do not resuscitate orders: how much does age influence decision making? A systematic review and meta-analysis. Gerontology & Geriatric Medicine, 3: 117.
Dignity in Dying (2015) Lord Falconer's Assisted Dying Bill (2014). Dignity in Dying ( Accessed 1 July 2018.
English, T, Ribeiro, B (2018) Should doctor assisted dying be legal? BMJ, 360: k562.
Etlers, L, Goodall, D, Harrison, BE (2008) Caregiver burden among dementia patient caregivers; a review of the literatures. Journal of the American Academy of Nurse Practitioners, 20: 423–81.
Fong, TG, Tulebaev, SR, Inouye, SK (2009) Delirium in elderly adults: diagnosis, prevention and treatment. Nature Reviews, Neurology, 5: 210–20.
Ford, JA (2016) The complexity of assessment and treatment for anxiety in patients with a terminal illness. Journal of Hospice and Palliative Nursing, 18: 131–8.
Fox, S, FitzGerald, C, Harrison Dening, K, et al. (2017) Better palliative care for people with a dementia: summary of interdisciplinary workshop highlighting current gaps and recommendations for future research. BMC Palliative Care, 17, 9.
General Medical Council (2010) Treatment and Care towards the End of Life: Good Practice in Decision Making. GMC.
General Medical Council (2013) Guidance Relating to Assisting Suicide. GMC ( ). Accessed 16 May 2018.
Gold Standards Framework Team (2016) The Gold Standards Framework Proactive Identification Guidance (PIG) (6th edn). Gold Standards Framework ( Accessed 1 July 2018.
Handzo, G (2011) Spiritual care for palliative patients. Current Problems in Cancer, 35: 365–71.
Haw, C, Stubbs, J (2010) Covert administration of medication to older adults: a review of the literature and published studies. Journal of Psychiatric and Mental Health Nursing, 17: 761–68.
Herr, K, Bjoro, K, Docker, S (2006) Tools for assessment of pain in nonverbal older adults with dementia. A state-of-the science review. Journal of Pain and Symptom Management, 31: 170192.
Hey, J, Hosker, C, Ward, J, et al. (2015) Delirium in palliative care: detection, documentation and management in three settings. Palliative & Supportive Care, 13: 1541–5.
Heyland, DK, Allan, DE, Rocker, G, et al. (2009) Discussing prognosis with patients and their families near the end of life: impact on satisfaction with end-of-life care. Open Medicine, 3: e10110.
Hinton, J (1994) Can home care maintain an acceptable quality of life for patients with terminal cancer and their relatives? Palliative Medicine, 8: 183–96.
Hlubocky, FJ, Rose, M, Epstein, RM (2017) Mastering resilience in oncology: learn to thrive in the face of burnout. American Society of Clinical Oncology Educational Book, 37: 771–81.
Hølen, JC, Saltvedt, I, Fayers, PM, et al. (2007) Doloplus-2, a valid tool for behavioural pain assessment? BMC Geriatrics, 7: 29.
Husebo, BS, Ballard, C, Sandvik, R, et al. (2011) Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ, 343: d4065.
Kiriakidis, SP (2015) Elderly suicide: risk factors and preventive strategies. Annals of Gerontology and Geriatric Research, 2: 1028.
Kirtley, A, Williamson, T (2016) What is Truth? An Inquiry about Truth and Lying in Dementia Care. Mental Health Foundation.
Lee, A (2016) ‘Bolam’ to ‘Montgomery’ is Result of Evolutionary Change of Medical Practice Towards ‘Patient-Centred Care’. Postgraduate Medical Journal, 93: 4650.
Lichtner, V, Dowding, D, Esterhuizen, P, et al. (2014) Pain assessment for people with dementia: a systematic review of systematic reviews of pain assessment tools. BMC Geriatrics, 14: 138.
Lloyd-Williams, M, Hughes, JG (2008) The management of anxiety in advanced disease. Progress in Palliative Care, 16: 4750.
Marks, S, Heinrich, T (2013) Assessing and treating depression in palliative care patients. Current Psychiatry, 12(8): 3540.
Massie, MJ (2004) Prevalence of depression in patients with cancer. Journal of the National Cancer Institute: Monographs, 32: 5771.
McAuliffe, L, Brown, D, Fetherstonhaugh, D (2012) Pain and dementia: an overview of the literature. International Journal of Older People Nursing, 7: 219–22.
McClain, CS, Rosenfeld, B, Breitbart, W (2003) Effect of spiritual well-being on end-of-life despair in terminally-ill cancer patients. Lancet, 361: 1603–7.
Mental Welfare Commission for Scotland (2014) Good Practice Guide: Covert Medication. Mental Welfare Commission for Scotland (
Meier, EA, Gallegos, JV, Montross Thomas, LP, et al. (2016) Defining a good death (successful dying): literature review and a call for research and public dialogue. American Journal of Geriatric Psychiatry, 24: 261–71.
Merel, S, DeMers, S, Vig, E (2014) Palliative care in advanced dementia. Clinics in Geriatric Medicine, 30: 469–92.
Milner, S (2017) How should nurses assess pain in people with advanced dementia? Ageing and Health, 21: 20–4.
Mitchell, SL, Morris, JN, Park, PS, et al. (2004) Terminal care for persons with advanced dementia in the nursing home and home care settings. Journal of Palliative Medicine, 7: 808–16.
Mitchell, AJ, Chan, M, Bhatti, H, et al. (2011) Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies. Lancet Oncology, 12: 160–74.
National Institute for Health and Care Excellence (2010) Delirium: Prevention, Diagnosis, and Management (Clinical Guideline CG103). NICE.
National Institute for Health and Care Excellence (2011) End of Life Care for Adults (Quality Standard QS144). NICE.
National Institute for Health and Care Excellence (2017) Care of Dying Adults in the Last Days of Life (Quality Standard QS144). NICE.
National Institute on Aging (2017) What Is End-of-Life Care? NIA ( ). Accessed 1 July 2018.
Neufeld, KJ, Yue, J, Robinson, TN, et al. (2016) Antipsychotics for prevention and treatment of delirium in hospitalized adults: a systematic review and meta-analysis. Journal of the American Geriatrics Society, 64: 705–14.
Ng, K, Marchington, K, Algu, K, et al. (2016) Feeding Choices for Patients with Advanced Dementia. University Health Network.
Okajima, Y (2015) Why do psychiatrists face difficulties when treating dying patients and their family members? [Article in Japanese], Seishin Shinkeigaku Zasshi, 117: 978–83.
Park, SA, Chung, SH, Lee, Y (2016) Factors associated with suicide risk in advanced cancer patients: a cross-sectional study. Asian Pacific Journal of Cancer Prevention, 17: 4831–6.
Payne, DK, Massie, MJ (2000) Anxiety in palliative care. In Handbook of Psychiatry in Palliative Medicine (eds Chochinov, HM, Breitbart, W): 6374. Oxford University Press.
Pullman, D (2002) Human dignity and the ethics and aesthetics of pain and suffering. Theoretical Medicine and Bioethics, 23: 7594.
Sanjida, S, Janda, M, Kissane, D, et al. (2016) A systematic review and meta-analysis of prescribing practices of antidepressants in cancer patients. Psycho-Oncology, 25: 1002–16.
Singh, AR (2008) Covert treatment in psychiatry: do no harm, true, but also dare to care. Mens Sana Monographs, 6: 81109.
Snyder, SL, Mueller, PS (2017) Ethics and the legalization of physician-assisted suicide: an American College of Physicians position paper. Annals of Internal Medicine, 167: 576–8.
Somasundaram, RO, Devamani, KA (2016) A comparative study on resilience, perceived social support and hopelessness among cancer patients treated with curative and palliative care. Indian Journal of Palliative Care, 22: 135–40.
Spiller, JA, Keen, JC (2006) Hypoactive delirium: assessing the extent of the problem for inpatient specialist palliative care. Palliative Medicine, 20: 1723.
Spira, JL (2000) Existential psychotherapy in palliative care. In Handbook of Psychiatry in Palliative Medicine (eds Chochinov, HM, Breitbart, W): 197214. Oxford University Press.
Treloar, A, Beats, B, Philpot, M (2000) A pill in the sandwich: covert medication in food and drink. Journal of the Royal Society of Medicine, 93: 408–11.
van der Steen, JT, Radbruch, L, Hertogh, CM, et al. (2014) White paper defining optimal palliative care in older people with dementia: a Delphi study and recommendations from the European Association for Palliative Care. Palliative Medicine, 28: 197209.
van der Steen, JT, Sampson, EL, Van den Block, L, et al. (2015) Tools to assess pain or lack of comfort in dementia: a content analysis. Journal of Pain and Symptom Management, 50: 65975.e3.
Wion, RK, Loeb, SJ (2016) End-of-life care behind bars: a systematic review. American Journal of Nursing, 116: 2436.
World Health Organization (2017) WHO's cancer pain ladder for adults. WHO ( Accessed 16 May 2018.
World Health Organization (2018) WHO Definition of Palliative Care. WHO ( Accessed 1 July 2018.
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Palliative care for older people: the psychiatrist's role

  • Victor M. Aziz (a1) and Rugiyya Saeed (a2)
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