Article for "Psychological and Social Aspects of the Elderly" -Dr. Liat Ayalon
Back to website| Page 1 |
10.1177/1534650102250778
ARTICLE
CLINICALCASESTUDIES/April2003
Ayalon/PROVIDINGCAREINTHEENDOFLIFE
Providing Care in the End of Life
Ethical and Therapeutic Considerations
LIAT AYALON
Illinois Institute of Technology
Abstract: As modern technology advances, people live longer and are more likely to face
death later in life from chronic or degenerative diseases. The location of death has also
changed, resulting in more people dying in impersonal settings. The final months in the
lifeofGeorge,aterminallyill89-year-oldCaucasianmalearediscussedfromfourperspec-
tives: existential approach, the stage model of death and dying, the reinforcement model,
and an integrated model. Therapeutic interventions, aimed toward assisting George in
dealing with his medical condition and existential issues, consisted of the following three
major components: family therapy, religiosity, and preparation for death. Ethical and ther-
apeutic considerations related to issues of death and dying are addressed.
Keywords: end of life care, terminal illness, aging, religiosity, family therapy, competency
evaluation
1
THEORETICAL AND RESEARCH BASIS
In 1900, the average life span was 47.3 years; by 1997, it had increased to 76.5
years,againof29.2yearsinlessthanacentury.Theagedistributionofthepopulationin
theUnitedStateshasalsochangeddramaticallyinthepastcentury.Thenumberofpeo-
ple under the age of 65 has tripled, whereas the number of people who are 65 or older
has increased by a factor of 11 (Kevin & Velkoff, 2001). The location and the nature of
death have also changed. Approximately 70% to 80% of the population in advanced
industrial nations face death later in life from chronic or degenerative diseases charac-
terized by late, slow onset, and extended decline. In the past, death occurred in more
personal settings involving family and friends, whereas currently, nearly 60% of all
deaths occur in impersonal settings. These dramatic changes should be taken into con-
sideration when working with terminally ill elderly patients (American Psychological
Association, 2001). The extension of life, at times beyond the physiological capacity of
the body, raises ethical and therapeutic challenges that should be addressed.
107
CLINICAL CASE STUDIES, Vol. 2 No. 2, April 2003 107-126
DOI: 10.1177/1534650102250778
© 2003 Sage Publications
When working with terminally ill populations, it is essential to have a thorough
understandingofthepatient’smedicalconditiontoestablishappropriatetreatmentgoals
andinterventions.George,asweremostpatientsintheparticularhospitaldescribed,suf-
fered from a complex medical condition. The most acute medical conditions with the
greatest impact on George’s medical course at the hospital were Chronic Obstructive
Pulmonary Disease (COPD), followed by a respiratory failure that required connection
to the mechanical ventilator.
COPD
COPD is the fourth most common source of death in patients older than 65. It
affects more than 14 million people in the United States. This is a chronic and progres-
sive disease of the lungs, largely related to smoking behavior, with a preclinical course of
30 to 40 years and a clinical course of approximately 10 years. Symptoms include
increased airflow resistance, difficulty in breathing, and dyspnea (Labbot, 1998; Segal,
1996).
According to Frazer, Leicht, and Backer (1996), depressive symptomatology
occurs in one quarter to one half of COPD patients. Denial and tolerance of symptoms
ofCOPDmayleadtorestrictionofactivitiesandrestrictionofthesocialenvironment.In
addition,guiltassociatedwithprevioussmokingbehavioroftenintensifiesthedepressive
symptoms. Secondary symptoms of COPD, such as fear of not being able to catch one’s
breath,arestronglyrelatedtoanxiety.CognitivesymptomsofCOPDincludeadecrease
in mental alertness and difficulties in tasks that require complex problem solving, motor
coordination, and speed. The cognitive symptoms may be due to oxygen deprivation or
due to CO
2
retention (Acosta, 1987; Frazer et al., 1996).
THE VENTILATOR PATIENT
A mechanical ventilator may be required in case of ventilatory failure due to pul-
monaryorcardiacdiseases.Aventilator-dependentpatientrequiresthemechanicalven-
tilation over an extended period of time due to adaptation to the chronic need for a
mechanical ventilator and due to fear of not being able to catch his or her own breath.
Weaning is the gradual process of removing the patient from the ventilator machine.
Thereareabout11,419chronicventilatorpatientsinhospitalsintheUnitedStates
(American Association for Respiratory Care, 1991). There are no epidemiological stud-
ies describing the characteristics of ventilator patients. The prognosis of ventilator
patients is relatively poor, especially at older age and prior poor functional dependence.
Carson, Bach, Brzozowski, and Leff (1999) reported that of 133 ventilator patients stud-
ied,66diedpriortodischarge.Ofdischargedpatients,70%wereweaned.Oneyearlater,
108
CLINICAL CASE STUDIES / April 2003
77% of all patients had expired, typically after spending the majority of their days in
intensive care units. Only 8% of 1-year survivors were fully functional.
Riggio, Singer, Hartman, and Sneider (1982) suggested that inability of the “venti-
lator” patient to produce sound speech often leads to feelings of loss of control that may
trigger frustration and anger in the patient and the family. Interactions between patient
andfamilyandstaffarelikelytobehamperedbecauseofthecommunicationdifficulties
of the patient. The staff is more likely than the patient or the family to perceive commu-
nication difficulties as problematic. The staff also tends to perceive the patient as more
disoriented and as having more memory problems than perceived by the family. Both
patients and staff notice more anger expressed by patients than family members do
because the staff is likely to be the target of such anger.
Hypnotically induced relaxation has been identified as a beneficial therapeutic
intervention aimed toward assisting with the weaning process (Acosta, 1987; Bowen,
1989).However,researchofthetopichassufferedfromempiricalflaws,focusingmainly
on case studies and involving heterogeneous samples without use of a comparison
group.
OLD AGE
Prevalence of depression among the elderly is between 12% to 15%. Such preva-
lence is relatively similar to prevalence of depression in the general population. How-
ever,oncethefocusshiftstohospitalizedmedicalpatients,betweenonethirdtoonehalf
of the patients older than 60 are diagnosed with depression (Barusch & Abu-Bader,
1999).Latelifedepressionismorelikelytobechronicandisassociatedwithhighermor-
tality rates (Benazzi, 2000).
Physicaldisabilityandmedicalillnessarethemostprominentriskfactorsofdepres-
sion in old age, especially among men. Depression is more likely to occur when a larger
number of medical conditions are present. However, the relation between disability and
depression could go both ways. Because disability may be the first observable feature of
depression,itmaybeastressfulconditionthatincreasestheriskfordepression,ordepres-
sion may be considered as a risk factor for disability (Cadoret & Widmer, 1988).
Bereavementandlossareriskfactorsofdepressioninthegeneralpopulation.How-
ever,itwassuggestedthatatoldage,lossoflovedonesandlossofsocialrolesbecomeless
influential because of their familiarity to elderly people. Gender discrepancies between
males and females diminish with age, possibly because of the fact that medical illness is
moredepressogenicformenthanforwomen.Similarly,therelationbetweendepression
tolowsocioeconomicstatusortofamilyhistoryofdepressiondecreasesinoldagebecause
of the high association between medical condition and depression (Wolfe, Morrow, &
Fredrickson, 1996).
Ayalon / PROVIDING CARE IN THE END OF LIFE
109
2
CASE STUDY
George was an 89-year-old male, Protestant, married, and father of two children.
George retired at the age of 65 from his work as an accountant and was fully independent
priortohospitalization.Whenadmittedtothehospital,hesufferedfromacomplexmedi-
cal condition, including past history of cardiomayopathy, prostate cancer, and COPD.
Most recent medical history included a car accident due to a syncopal episode, pneumo-
nia, respiratory failure, renal insufficiency, and proximal atrial fibrillation.
It is essential to view George’s course at the hospital in a chronological fashion
because the short period of hospital stay incorporated intense medical, emotional, cog-
nitive,andsocialchangesinhislife.Figure1presentsagraphicalillustrationofGeorge’s
course at the hospital. Following the motor vehicle accident, he was transferred to the
hospital for further weaning from the mechanical ventilator. His medical condition had
slightly improved but eventually was followed by a setback associated with delirium.
Duringthisperiod,George’swife,whowashisprimarycaregiver,brokeherhipanddied
several weeks after her injury. George died 15 days after his wife’s death.
3
PRESENTING COMPLAINTS
Georgewasinitiallyevaluatedaspartofthehospitalrequirementstoevaluateevery
new admission. During the initial evaluation, George endorsed feeling depressed and
expressedfeelingsofanhedoniaandguiltoverpastsmokingbehavior.Hedeniedanysui-
cidal or homicidal thoughts or intents. George’s vegetative symptoms included insom-
nia, loss of weight, psychomotor retardation, and loss of energy. Based on the initial eval-
uation, it was decided that George would benefit from supportive therapy. Later, during
the course of his illness, George’s level of awareness to the environment had declined,
and he was placed in wrist restraints. Periods in which George slept throughout the
entire day and was oriented only to type of place and person became more frequent.
4
HISTORY
George denied any personal or familial history of mental illness. Most patients in
this particular hospital, including George, suffer from complex medical conditions and
areunabletotoleratealongevaluationprocess.Ventilatorpatients,inparticular,arelim-
itedintheirabilitytocommunicateandprefertoresorttoclose-endedquestions.Mostof
the initial information about the patient is usually gathered through contacts with other
informants, such as family members and friends. When George was first admitted to the
hospital, no family member or friend accompanied him. Therefore, his evaluation did
not include important details about his history that were essential to development of an
appropriate therapeutic intervention. Only after George’s death was the primary thera-
110
CLINICAL CASE STUDIES / April 2003
pist informed that he was previously married twice. His wife at time of hospitalization
had also been married in the past and had children from a previous marriage. It was
unclear, however, whether George’s biological daughters, who were most influential
in his care, also were the biological children of his wife. Figure 2 represents George’s
family tree.
5
ASSESSMENT
During the initial evaluation, a short neuropsychological screening aimed toward
assessingcognitivedeficits,isusuallyemployed(i.e.,MiniMentalStatusExam)inaddi-
tiontoashortinformalinterview.George’sinitialassessmentdidnotrevealanycognitive
deficitsinhisfunctioning.Hiscognitivefunctioningwasatthesuperiorlevelforhisage.
George was evaluated three additional times toward the end of his life due to men-
talstatuschangesassociatedwithdeteriorationinhismedicalcondition.Thepurposeof
these evaluations was to determine whether George had decisional capacity to make
end-of-lifedecisions.Capacitybecomesanissueinsituationsinwhichapatientrefusesa
recommendedmedicaltreatment,whenself-careisimpaired,whenthereisevidenceof
mentalstatusimpairments,orwhenthefamilydisagreeswiththepatient’swishes.There
are no uniform criteria to assess competency. However, it is suggested that at least two
evaluations should be conducted at different points in time because of possible fluctua-
tionsintheabilityofolderadultstocomprehendandtomakerationaldecisions.Evalua-
tion of capacity incorporates several components: (a) The patient has to demonstrate
abilitytounderstandthepossiblechoicesandtoretaininformation;(b)thepatienthasto
demonstrate rational manipulation of choices; (c) the patient has to understand the
implications of the choices made; and (d) the patient has to communicate a coherent
and consistent choice over time (Mishkin, 1989; Searight & Hubbard, 1998).
During the first two evaluations, George was only able to nod his head in response
to close-ended questions and to follow two-step commands. George indicated that he
wouldprefertogotoanursinghomeconnectedtotheventilatormachineratherthango
through terminal weaning. Based on these evaluations, it was decided that George had
decisional capacity. Following a request of George’s daughters, an additional evaluation
wasconducted.Thedaughters,accompaniedbyacasemanager,assessedGeorge’send-
of-lifedecisionsforthethirdtimeanddeterminedthathewouldprefertogothroughter-
minal weaning.
Ayalon / PROVIDING CARE IN THE END OF LIFE
111
Figure 1: George’s Course at the Hospital
6
CASE CONCEPTUALIZATION
SeveraldifferentDSM-IVdiagnosescouldbeemployedtodescribeGeorge’smen-
tal condition. During the initial stages, the options of adjustment disorder versus mood
disorder due to medical condition versus major depressive disorder were considered.
Due to the fact that George’s presentation met criteria for major depressive disorder, the
other two disorders were ruled out.
Toward the end of George’s life, his presentation met the criteria for delirium due
to multiple etiologies. This diagnosis was supported by laboratory results. The diagnosis
ofmajordepressivedisordercouldnothavefullyexplainedhispresentationatthatpoint.
Because George’s initial evaluation did not suggest existence of cognitive deficits, the
diagnosis of dementia was ruled out.
Several theoretical approaches can explain George’s mental condition during his
initial hospitalization period. The existential approach (Frankel, 1946; Yalom, 1980),
the stage model of death and dying (Kubler-Ross, 1969), and the reinforcement model
(Lewinsohn, 1974) were selected because each explains a different aspect of George’s
condition.
THE EXISTENTIAL APPROACH
The existential approach emphasizes the following four ultimate concerns: death,
freedom, isolation, and meaninglessness. Confrontation with these concerns is inevita-
ble, and it is likely to promote anxiety that increases the use of defense mechanisms
(Yalom, 1980).
Fear of death was George’s main concern. According to the existential approach,
fear of death represents the tension between the inevitable and the wish to continue to
be. Being in the hospital in a critical condition and abruptly losing his independence
served George as a constant reminder of his own mortality. The search for meaning is
ofteninfluencedbythefearofdeath.Thelogotherapyapproachsuggeststhatneurosisis
a failure to find meaning and responsibility in life (Frankel, 1946). George, who faced
112
CLINICAL CASE STUDIES / April 2003
Figure 2: George’s Family Tree
his upcoming mortality, was actively searching for meaning that would account for his
life prior to admission to the hospital and for his upcoming death. God was George’s
sourceofmeaning.PrayingtoGod,talkingaboutGod,talkingwithGod,andexperienc-
ing God provided George with meaning. George perceived himself as blessed because
he “had seen God.” The strong connection with God also increased George’s belief in his
immortality.George,whohadneverattendedchurchbeforehospitalization,becamereli-
giously involved while in the hospital.
STAGES OF DEATH AND DYING
The stages of death and dying, identified by Kubler-Ross (1969), can also explain
George’smentalconditionatthehospital.Themodeldescribesthestagesofcopingwith
death. All stages are considered adaptive and serve as defense mechanisms against death
anxiety.Althoughthisisastagemodel,peoplecangobackandforththroughthestages.
In the case of George, some stages captured a more prominent role during certain
periods, but oftentimes, several stages co-occurred. During the initial stage, denial and
isolation exist. Shock and denial protect the mourner from experiencing the total extent
of reality. Denial is often accompanied by isolation from family and friends (Kubler-
Ross,1969).ItispossibletoviewtheinitialperiodofGeorge’stherapyasrepresentingthe
stage of denial and isolation. During the first period of George’s stay at the hospital, his
communication was extremely limited because he was connected to the ventilator
machine, which prevented him from producing sound speech. George’s hearing prob-
lem also impaired communication. Each of the first four meetings with George lasted
less than 20 minutes. He did not discuss any personal issues, and the conversation
focused mainly on vegetative symptoms of depression. During the fifth session, he had
noticed the therapist’s name tag and commented on the unusual name. Learning that
the unusual name originated from Israel had increased his interest in the therapist
because he apparently had a strong political interest. The fifth session lasted longer than
thefirstfoursessions,andthetopicofdiscussionwasthepoliticalsituationintheMiddle
East. Only during later sessions did George discuss his emotional experience at the hos-
pital. The last period in his life, which was characterized by disorientation and inatten-
tion to the environment, can also be viewed as a period of denial.
During the second stage, anger is present; when denial cannot be maintained, the
question,Whyme?arises.Angerisdisplacedinalldirectionsandreducestheavailability
of social support. Guilt is another common theme at this stage because, often, people
express the feeling that their actions caused or failed to prevent the upcoming death
(Kubler-Ross, 1969). George expressed guilt related to previous smoking behavior and
blamedhimselfforhismedicalcondition.Inaddition,Georgedirectedhisangertoward
his daughters, whom he perceived as not caring for his wife as much as he would have
liked.
Thethirdstage,bargaining,representsanattempttoenteranagreementwithGod
to postpone the inevitable (Kubler-Ross, 1969). George, who was relatively secular
Ayalon / PROVIDING CARE IN THE END OF LIFE
113
before admission to the hospital, reported an increase in religiosity and spirituality fol-
lowing his admission. This can be considered as an attempt to prevent the inevitable.
DepressionwasGeorge’smaincomplaint,endorsedthroughouthisstayinthehos-
pital.Thefourthstagerepresentsasenseoflossthatcannotbedeniedortransformedany
longer. This preparatory grief is aimed toward separation from the world (Kubler-Ross,
1969).
Last,acceptanceoccurswhenthepatientisnolongerangryordepressedabouthis
orherfate.Duringthisstage,thefamilymayneedmoresupportthanthepatient(Kubler-
Ross, 1969). It is possible that the last month in George’s life, during which levels of ori-
entation and attention declined, represents his acceptance of his fate.
Critics of the model argue that it was developed on middle-aged cancer patients
and does not necessarily apply to the elderly. Middle-aged people perceive death as
untimely and have to adjust to the dramatic change in roles, whereas elderly people per-
ceive loss of friends and change in roles as familiar and timely (Retsinas, 1988). Despite
this criticism, the stages of death and dying model describes George’s experiences ade-
quately because he was functionally independent before hospitalization.
THE REINFORCEMENT MODEL
The reinforcement model addresses a different angle of George’s mental condi-
tion. Depression is considered by the model as a response to loss or lack of response-
contingentpositivereinforcements.Insufficientreinforcementsaresaidtoleadtoreduc-
tion in behaviors, whereas other symptoms such as low self-esteem or hopelessness are a
result of reduced level of functioning (Lewinsohn, 1974). Williamson and Shaffer
(2000) studied 228 geriatric outpatients with a variety of illness conditions. They found
that illness and disability are life stressors and depression is a reaction to such stressors.
However, activity restriction is the mediator that connects between life stressors and
depression.Restrictedactivityissaidtopreventpeoplefromobtainingpositivereinforce-
mentsandtolowerpeople’sfeelingsofself-efficacy.InthecaseofGeorge,acombination
of low levels of reinforcements provided by the hospital setting, restricted activity, and
few attempts to obtain available reinforcements were responsible for a reduction in his
functioning level and for an increase in his depressive symptomatology.
AN INTEGRATED MODEL
Figure 3 represents an integrated etiological model of George’s condition. A com-
bination of a deteriorating medical condition and high self-expectations were responsi-
ble for his inability to meet his expectations. This promoted thoughts of worthlessness
and hopelessness. Feelings of self-anger were influenced by these thoughts. George’s
self-anger was then redirected at others, who did not meet his increasing expectations.
The fact that other people did not meet George’s expectations and the hospitalization of
George’s wife, promoted perception of the world as an unfair place. This thought had
114
CLINICAL CASE STUDIES / April 2003
increased George’s hopelessness. Hopelessness and anger had a negative effect on his
medical condition. George’s religious beliefs served as his main coping mechanism,
which slightly ameliorated his thoughts of worthlessness and feelings of anger.
7
COURSE OF TREATMENT AND
ASSESSMENT OF PROGRESS
George’s treatment incorporated the following three main aspects: family therapy,
religiosity, and preparation for death. These aspects do not represent the conventional
treatmentformajordepressivedisorder.However,eventhoughGeorgemetallthecrite-
ria of major depressive disorder, his mental condition was viewed in the context of his
medical condition and existential issues.
FAMILY THERAPY
ItislikelythatthedeathofGeorge’swifewasatleastpartiallyrelatedtothestressors
associated with her role as his primary caregiver. Even when formal care services are uti-
lized, family members remain a crucial component of the overall care plan. The impact
Ayalon / PROVIDING CARE IN THE END OF LIFE
115
Positive relationship
Negative relationship
George's
medical
condition
George's
wife at the
hospital
Cannot
meet own
expectations
"I am a
failure"
Anger at
self
Religious
beliefs
High
expectations
from self and
other
Increased
expectations
from others
"I will not
get over
this"
"The world
is unfair"
Other people
do not meet
George's
expectations
Figure 3: An Integrated Etiological Model
of caregiving is well documented and ranges from loss of financial resources to emo-
tional and physiological stress (Schulz & Beach, 1999).
Thedyingpersonshouldneverbeconsideredinisolation.Treatmentshouldstrive
to improve the health of the patient and the caregivers and to help the family identify
supportive resources. Once the patient receives enough emotional support from the
family, the role of the therapist may end (Stedeford, 1979). Familial conflicts regarding
end-of-lifedecisionsarelikelytooccur.Psychologistscanplayapositiverolebyclarifying
the situation, facilitating discussion, providing support, and helping family members
dealwithfeelingsofguiltorregretovertheirdecisions(AmericanPsychologicalAssocia-
tion, 2001).
Neither George’s wife nor his daughters chose to participate in the weekly family
support group provided by the hospital. George’s family members also chose not to par-
ticipateinfamilycounselingdespitethefactthattheywereoftenthefocusoftheindivid-
ual therapy conducted with George. During therapy, George discussed his concern for
his wife’s welfare and his expectations that his daughters would care for his wife in his
absence. Ways of communicating expectations to his daughters were explored. How-
ever, the fact that his family members preferred not to be involved in therapy hampered
theabilitytochangethefamilydynamics.Anotherimportantfactorthathamperedther-
apy was lack of knowledge about George’s family history.
Oftentimes, end-of-life decisions require involvement of the family. According to
Rothchild(1998),severalvariablesarelikelytoaffectthefamily’sdecision-makingprocess:
1. Thepatient’sroleinthefamily:George’sroleinhiswife’slifewassocrucialthatthewife
decided to reconnect George to the ventilator machine following a deterioration in his
medical condition, despite his initial request not to be reconnected to the ventilator
machine.
2. The developmental stage of the family and the patient: The daughters’ preference that
George would go through terminal weaning was at least partially influenced by the fact
that he was an elderly man.
3. The degree of cohesion of the family: The crisis of a dying family member can bring up
oldloyaltiesandpowerstruggles.ScharlachandFuller-Thomson(1994)interviewed83
adults following the death of one of their parents. The majority of respondents reported
that families were extremely helpful during the grieving process. However, several
respondentsreportedthatconflictsandchildhoodpowerstruggleswerereactivateddur-
ing this process. Discrepancies between George’s wishes, the wishes of his wife, and the
wishes of his daughters were evident. George initially wished not to be placed back on
the ventilator if his condition worsened. However, once his condition had worsened, his
wife, who had power of attorney, decided that he should be placed back on the ventila-
tor. Once George’s wife died, his children wished that he would go through terminal
weaning, despite previous evaluations suggesting that he would agree to move to a nurs-
ing home connected to the ventilator machine. This scenario reflects the lack of cohe-
sioninthefamilyandthedifficultiesofthefamilymemberstoreachmutualdecisions.
4. The structural characteristics of the family: A close system may share little information
with the staff and may strive to protect the patient against the world. In the case of
George,hisfamilymemberschosenottoconsultwiththepsychologyteamatthehospi-
tal as well as not to share information with one another. After the death of the wife, the
116
CLINICAL CASE STUDIES / April 2003
daughtersdecidednottotellGeorgeabouttheevent,despitesuggestionsofthepsychol-
ogy team to the contrary.
5. Denial and guilt or “the daughter from California syndrome”: This concept refers to a
daughter who comes all the way from California and struggles to keep her mother alive
even though she has never been involved in her mother’s care before. Similarly, once
George’s wife had died, a daughter from Arizona, who was estranged from George for
many years, came to the hospital for the first time and argued that George should be
taken off the ventilator.
RELIGIOSITY
A second aspect of George’s treatment plan emphasized religiosity. The impor-
tance of religious issues in the general population is well documented. Of people older
than 65, 52% attend worship services and 75% indicate that religion is very important to
them (Princeton Religious Research Services, 1985). Koenig, George, and Peterson
(1998) studied 87 people older than 60 who came to a medical clinic for treatment.
Intrinsic religiosity predicted shorter time for remission of depression. In addition, one
third of the participants spontaneously and without prompting indicated that religious
aspects (i.e., “God,” “the Lord,” “my faith,” “prayer,” “Jesus,” and so forth) helped them
deal with the stress associated with their physical illness.
According to the American Psychological Association (2001), use of religion may
supplementbutnotreplacetraditionalpsychotherapeuticstrategies.Thepatientshould
be provided with permission to discuss and practice spiritual beliefs (Coward & Reed,
1996). In addition, spiritual involvement of clergy should be encouraged (Moss,
McGaghie, & Rubinstein, 1978). For George, religiosity provided a sense of hope and
self-esteem and helped him accept his death. He was encouraged to talk about his spiri-
tual experiences and the involvement of clergy was also encouraged.
PREPARATION
A third aspect of the treatment focused on preparation for death. When working
withterminallyillpatients,fearsaboutlossofautonomyanddignityandseparationfrom
the world should be addressed. The clinician should be aware of the fact that the suffer-
ing of a dying person may be physical, emotional, social, and spiritual (American Psy-
chological Association, 2001). Loss of independence was extremely distressing for
George, mainly because of his high level of independence prior to hospitalization.
Georgediscussedresponsibilityforhiswife’swelfareandhisperceptionofhisupcoming
death as untimely. George’s feelings of loss of control were expressed as anger directed
toward staff, his daughters, and himself. Therapy attempted to help him gain more con-
troloverhiscarebyintroducingsimpleactivitiesthathewasabletocarryout,suchastak-
ingcareofhisfinancialbusiness.TherapyalsoattemptedtohelpGeorgeunderstandthe
originsofhisanger.Georgewashighlyfunctioningatthetimeofadmissionandhadhad
various ongoing plans and activities that had to be cancelled due to the hospitalization.
Ayalon / PROVIDING CARE IN THE END OF LIFE
117
Therapy encouraged George to talk about his losses and to express the wide variety of
feelings associated with his terminal illness and upcoming death.
Discussion of end-of-life decisions took place only very late in therapy, and
George’s primary therapist was not involved in the discussion because of her role as a
practicum student. The role of mental health professionals in evaluating decisional
capacity and in determining end-of-life decisions has increased in recent years. The
patient self-determination act advocates provision of written material to patients and
their families as to their rights to make medical decisions and advance directives. The
directives become effective if and when the patient is unable to make coherent deci-
sions. Advance directives are used to communicate to family and health care profession-
als what life-sustaining procedures to use under which medical circumstances in case
the patient loses the capacity to decide. Advance directives include the following two
parts: (a) the living will, which contains directions to guide medical decisions if deci-
sional capacity is lost, and (b) durable power of attorney, which assigns decision-making
capacity to a specific surrogate in the event of future incompetence (Weinstock, Leong,
& Silva, 1994).
According to Quill (2000), discussion of end-of-life decisions should include the
following topics: (a) goals, which address the hopes and the fears of the patient; (b) val-
ues, which address the question of what makes life worth living; (c) advance directives,
which address the question of who would best represent the patient’s views; (d) discus-
sion of do-not-resuscitate orders; (e) control of pain and other symptoms; and (f) any
unfinished business that has to be addressed before the patient can let go. According to
Quill (2000), discussion of end-of-life issues has to occur in certain occasions. These
occasions include: situations in which the patient is facing imminent death; the patient
talks about wanting to die; the patient and the family inquire about hospice; the patient
recentlywashospitalizedforasevereprogressivecondition;thepatientsuffersoutofpro-
portion to prognosis; when discussing treatment options with low probability of success;
whendiscussingthehopesandfearsofthepatient;andfinally,whenansweringnotothe
question, Would I be surprised if this patient dies within 6 to 12 months?
InthecaseofGeorge,end-of-lifediscussionwasinitiatedwhenitbecameclearthat
George would not be able to wean from the ventilator machine. He faced the options of
going through terminal weaning or of going to a nursing home connected to a ventilator
machine. The clinical psychologist who evaluated George was under the impression
that he was able to comprehend the implications of his decisions and that he would pre-
fer to stay connected to a ventilator machine. In contrast, George’s daughters had initi-
ated a third discussion in the presence of a case manager and concluded that he would
prefer to go through terminal weaning.
ASSESSMENT OF PROGRESS
As indicated elsewhere in the text, thorough formal measures are less likely to be
employedwithterminallyillpopulations.Instead,informalobservationswereemployed
118
CLINICAL CASE STUDIES / April 2003
toevaluateGeorge’sprogressintherapy.Indicatorsofthepositiveaspectsoftherapywere
expressed by George’s verbal communication. He indicated that therapy sessions were
“refreshing” and stimulating and served as his main comfort at times. Another indicator
ofGeorge’sinvolvementintherapywasthemethodofcommunicationusedduringther-
apy. Initially, he was connected to the ventilator machine and was able to communicate
only by silent speech. George was also severely hard of hearing and therefore written
communication on the side of the therapist was required. After George’s condition had
improved, he was able to use the passive mere valve (PMV), which allowed him to pro-
duce sounds. His family had also brought him a pocket talker, which improved his hear-
ing. George’s insistence on using these two devices during therapy indicated high levels
of involvement in therapy. The content of communication during therapy had also
changed. From discussion of sleep and appetite patterns or political events, George
started to discuss more personal issues, such as his expectations from family members,
his fear of dying, and his spiritual experiences. The length of sessions had also changed
dramatically, indicating his positive experience in therapy. Initial sessions lasted for less
than 20 minutes, whereas later sessions lasted for more than an hour.
The therapy provided to George had several flaws. First, although therapy was
highly focused on preparation for end of life, discussion of advance directives did not
occur early enough in therapy and did not occur with George’s primary therapist. Sec-
ond, lack of involvement of family members hampered therapy, especially because
George’s primary concerns were associated with his family members. Third, failure to
conduct a thorough assessment made therapy more complex because important infor-
mation such as George’s family history was not available. Fourth, termination of therapy
occurred when George was not able to comprehend its meaning due to abrupt mental
status changes associated with a decline in his medical condition.
8
COMPLICATING FACTORS
DIAGNOSIS
Certain symptoms of depression are considered as part of “normal aging”
(Gottfries, 1997). In the 1970s and 1980s, depression in old age was perceived as normal
(Bruce, 2000; Shaffer, 2000). Only in 1991 did the National Institute of Health propose
that late-onset depression could be diagnosed and differentiated from normal aging.
Somatization in the elderly is very prevalent (Grau & Padgett, 1988) because somatic
symptoms are often more acceptable to older patients than psychological complaints.
Somatization results in inappropriate health service utilization and misdiagnosis.
KoenigandKuchibhatla(1998)studiedtheuseofhealthservicesinmedicallyillelderly.
Aftercontrollingfordemographicvariables,theHamiltondepressionscoresignificantly
predicted hospital stay, total inpatient days, and number of outpatient visits in the previ-
ous 3 months. Depressed medically ill elderly patients used more hospital and outpa-
Ayalon / PROVIDING CARE IN THE END OF LIFE
119
tient medical services than nondepressed patients, but they did not utilize more mental
health services than the nondepressed group.
Vegetativesymptomsofdepressionmaybesimilartomedicalsymptoms.Fourcon-
ceptual approaches to the diagnosis of depression in medically ill were suggested. The
inclusive approach includes all symptoms and signs presented by the patient even when
they are secondary to the physical illness. The exclusive approach disregards somatic
symptomssuchasanorexiaanddoesnotallowthemtocontributetoadiagnosisofmajor
depression. The etiological approach determines whether the problematic behavior is
secondary to physical illness or to mental disorder. The substitutive approach suggests
substituting additional cognitive symptoms of depression such as brooding or pessimism
for vegetative symptoms of uncertain or mixed etiology (Cohen-Cole & Stoudemire,
1987). The substitutive approach was employed in diagnosing George. More attention
wasplacedoncognitivesymptomsofdepression,whereasthevegetativesymptomswere
disregarded because of their uncertain etiology.
LACK OF KNOWLEDGE
Working with medically ill populations requires proficiency in medical terminol-
ogy. Without a thorough understanding of medical terminology and of the impact that
certain medical conditions may have on cognitive and emotional functioning, psycho-
therapy is likely to be ineffective.
Lack of social knowledge is another factor that hampered George’s therapy. Dis-
cussing with George his expectations of his daughters occurred under the therapist’s
impressionthatthedaughterswerethebiologicaldaughtersofhiswifeaswell.Onlyafter
George’s death did it become known that he was married twice in the past and that his
daughters might not have been the biological daughters of his wife.
THE SETTING
Professional boundaries are more fluid when working with dying people than in
traditional psychotherapy cases (American Psychological Association, 2001). The thera-
pistconductsthesessioninthepatient’sroom,nexttothepatient’sbedside.Medicalstaff
and family members may interrupt the session at any time. Lack of professional bound-
aries can be manifested by the patient’s requests for a blanket, a glass of water, or for a
respiratory therapist in the middle of a session. For therapists who are used to the tradi-
tional model of psychotherapy, the hospital setting presents a major challenge.
Sessions are likely to be extremely short, determined by the patient’s medical con-
dition. In addition, medical patients in today’s hospitals do not stay in the hospital for
morethanafewweeks.Treatment,therefore,hastobefocusedonthehereandnowand
is likely to be problem-solving oriented rather than insight oriented.
120
CLINICAL CASE STUDIES / April 2003
END-OF-LIFE DISCUSSION
Another complicating factor is end-of-life discussion. The majority of physicians
have never told a patient that he or she was about to die (Moss et al., 1978). When work-
ingwithdyingpatients,thephysicianbecomesmoreawareofhisorherownimpotence.
Physiciansareoftenreluctanttotransmitbadnewsbecausetheyhaveaprofessionalded-
icationtothepreservationoflifeandlackpsychosocialeducationaboutdeathanddying.
The physician holds the notion of being able to cure and is therefore threatened by a
dying patient (Kirchberg & Neimeyer, 1991; Lieff, 1982). The therapist and the physi-
cianarelikelytofacethedilemmaofidentifyingtheappropriatetimetomakethetransi-
tion from rehabilitation therapy to end-of-life discussion and assistance in separation
fromtheworld.Lackofeducationaboutend-of-lifeissuesisevenmoreprevalentamong
psychologists.Thereisnomentionofdyingordeathorend-of-lifedecisionsineitherthe
American Psychological Association accreditation guidelines for psychology programs
or the American Psychological Association Code of Ethics (American Psychological
Association, 2001).
A study of 151 physicians found that most feel the patient must be told of terminal
illness. Older physicians were more negative about offering prognosis. On the other
hand, experienced physicians in issues of death and dying tended to provide prognostic
information(Rea,Greenspoon,&Spilka,1975).Ingeneral,staffwouldbemorelikelyto
giveafavorablepicturewithintheframeworkofreality(Quill,2000).Inthegeneralpub-
lic, however, a survey of 1,555 healthy people found that most people would prefer to be
informed about terminal illness (Blumenfield, Levy, & Kaufman, 1979).
Discussion of end of life should take place with the physician because the physi-
cian has important information about the patient’s medical condition. This discussion
occurred very late in the case of George and did not involve his primary therapist, ham-
pering the level of trust and intimacy.
Our society tries to respect the individual by offering the option of advance direc-
tives. However, the question of whether the current procedures employed promote the
respect for the individual’s wishes has to be asked. Many times, people would refrain
from writing advance directives due to a “not yet” attitude and indecisiveness regarding
mattersthatneedtobedecided(Vandecreek&Frankowski,1996).Thefactthatasignifi-
cant portion of the outpatient population misunderstands end-of-life options is also
likely to be responsible for people’s inclination to make advance directives (Silveria,
DiPiero, Gerrity, & Feudtner, 2000). In addition, as conditions change, advance direc-
tivesmaynotapply(Reilly,Teasdale,&McCullough,1994).Tocomplicatethepicture,
familymembersdonotnecessarilyrepresentthewishesoftheirlovedones.Researchhas
documented no significant correspondence regarding end-of-life decisions between
adult children and their parents (Karel & Gatz, 1996).
Ayalon / PROVIDING CARE IN THE END OF LIFE
121
9
TERMINATING THE PROFESSIONAL RELATIONSHIP
When it became clear that George would not be an appropriate candidate for fur-
thertherapyduetomentalstatuschanges,itwasalreadytoolatetouseso-calledconven-
tionalterminationmethods.Instead,itwasdecidedthattheprimarytherapistwouldtalk
to George about the enriching experience of working with him. The therapist also told
Georgethatanychoicehewouldmakeabouthislifewouldbetherightone.Georgewas
unable to respond at that time, and it was not clear whether he was able to comprehend
thetherapist’scommunication.Theattempttoterminate,however,hadhelpedthether-
apist to do some closure of the therapeutic relationship.
10
FOLLOW UP
Following George’s death, his daughters were offered condolences, but no further
follow-up contact was initiated.
11
TREATMENT IMPLICATIONS OF THE CASE
The importance of communication with all sides involved in the patient’s care is
oneofthemajorimplicationsofthecase.Caringforamedicallyillpatientand,inpartic-
ular, discussion of end-of-life decisions has to occur in the context of consultation with
thephysician(Goldblum&Martin,2000)andfamilymembers.Themedicalcondition
of the terminally ill patient has to be fully considered when developing a treatment plan
as well as when conducting end-of-life discussion. The therapist should also strive to
involve family members in the development of the overall treatment plan and in the
decision-making process. Failure to do so is likely to result in difficulties of the patient
and the family to reach end-of-life decisions.
Anadditionalimplicationofthecaseisthefactthatalthoughinsurancecompanies
require clinicians to provide a DSM-IV diagnosis, the appropriate treatment plan may
not always adhere to the official diagnosis. George’s pathology was not a result of errone-
ous thought process but rather a result of tragic life events and a deteriorating medical
condition. Attempting to reduce depressive symptomatology would have invalidated
George’s experience. Instead, it was essential to help George experience the wide range
of emotions associated with the process of dying.
Finally, use of religiosity as a tool when working with dying patients should receive
morerecognition.Useofreligiosityintreatmentislikelytoposeaproblemformanypsy-
chologistsbecausepsychologyhasabandonedreligioninthenameofscience.The“rest
oftheworld,”ontheotherhand,ismorelikelytoappreciateandtousereligionandspiri-
tuality as coping tools (Koenig, Larson, & Matthews, 1996). For George, as well as for
122
CLINICAL CASE STUDIES / April 2003
many other people, God was an important coping tool. Learning how to utilize this tool
in therapy is essential.
12
RECOMMENDATIONS TO CLINICIANS AND STUDENTS
WORKING WITH ELDERLY PEOPLE
Therapy with an elderly person is complex as patients often have a mixture of mul-
tilevel problems. The therapist should acknowledge his or her expectations from elderly
people and his or her beliefs about the ability of older people to change. If the therapist
doesnotbelievethatolderpeopleareabletochange,theeffectivenessoftherapyislikely
tobehampered.Inaddition,attimesthetherapistmaystruggletoacceptphysicallimita-
tions associated with old age and medical condition whereas the elderly person has
already learned to accept these limitations.
ASSESSING DECISIONAL CAPACITY
During assessment of decisional capacity and discussion of end-of-life decisions,
the therapist must understand his or her own values, be willing to discuss the client’s val-
ues, and to resolve possible value conflict (Goldblum & Martin, 2000). Competency is
not an all-or-none ability. However, determining whether the patient has decisional
capacity is an all-or-none decision and therefore places the therapist in a complex situa-
tion.Thecriterionforassessingcompetencyissubjective,andpsychiatristsoftenusethe
risk-benefit analysis of competence. This criterion determines that the least stringent
tests of competency should be employed with patients consenting to low-risk and high-
benefittreatments,whereasmorestringentstandardsshouldbeusedfortreatmentrefus-
als that carry serious consequences (Weinstock et al., 1994).
Requeststohastendeathshouldbeviewedwithcautionbecausetheymaybeinflu-
enced by numerous factors. Not only should decision-making capacity be considered
but also the physical, psychological, and spiritual suffering of the patient should be care-
fully evaluated when conducting end-of-life discussion (Block & Billings, 1995).
WORKING WITH TERMINALLY ILL PATIENTS
It is important that clinicians who work with terminally ill patients develop skills
and resources for surviving this experience. According to Homer (1984), hospital staff
tend to use a wide array of defense mechanisms when working with terminally ill
patients. Use of defense mechanisms is likely to ease the emotional reaction of the staff
towardterminallyillpatientsbutmayhamperthecareprovidedtosuchpatients.There-
fore, other tools for dealing with the emotional reaction associated with caring for termi-
Ayalon / PROVIDING CARE IN THE END OF LIFE
123
nally ill patients are recommended. Mahoney (1991) has acknowledged the emotional
strain associated with providing care for others and has offered several options aimed
toward increasing clinicians’ ability to take care of themselves. Individual therapy, adop-
tionofhobbies,takingcareofpsychospiritualneeds,peersupervision,anddevelopment
of a support system are all excellent resources that should be utilized by clinicians to
improve their ability in providing care for the dying.
REFERENCES
Acosta, F. (1987). Weaning the anxious ventilator patient using hypnotic relaxation: Case report. American
Journal of Clinical Hypnosis, 29, 272-280.
American Association for Respiratory Care. (1991). A study of chronic ventilator patients in the hospital: A
patient profile and analysis conducted by the Gallup organization for the American Association for Respi-
ratory Care. Dallas, TX: Author.
American Psychological Association. (2001). Formation of APA Working Group on assisted suicide and end-
of-life decisions. Retrieved from www.apa.org/pi/aseol/introduction.html
Barusch, A. S., & Abu-Bader, S. H. (1999). Depressive symptoms in the frail elderly physical and psycho-
social correlates. International Journal of Aging and Human Development, 49, 107-125.
Benazzi, F. (2000). Late-life chronic depression a 399-case study in private practice. International Journal of
Geriatric Psychiatry, 15, 1-6.
Block, S. D., & Billings, J. A. (1995). Patient requests for euthanasia and assisted suicide in terminal illness:
The role of the psychiatrist. Psychosomatics, 36, 445-457.
Blumenfield,M.,Levy,N.,&Kaufman,D.(1979).Thewishestobeinformedofafatalillness.OMEGA,9,
323-326.
Bowen, D. E. (1989). Ventilator weaning through hypnosis. Psychosomatics, 30, 449-450.
Bruce,M.L.(2000).Depressionanddisability.InG.M.Williamson,D.R.Shaffer,&P.A.Parmelee(Eds.),
Physical illness and depression in older adults (pp. 11-31). New York: Kluwer Academic/Plenum.
Cadoret,R.,&Widmer,R.B.(1988).Thedevelopmentofdepressivesymptomsinelderlyfollowingonsetof
severe physical illness. Journal of Family Practice, 27, 71-76.
Carson, S. S., Bach, P. B., Brzozowski, L., & Leff, A. (1999). Outcomes after long term acute care. An analy-
sis of 133 mechanically ventilated patients. American Journal of Respiratory and Critical Care Medicine,
159, 1568-1573.
Cohen-Cole, S., & Stoudemire, A. (1987). Major depression and physical illness: Special considerations in
diagnosis and biological treatment. Psychiatric Clinics of North America, 10, 1-17.
Coward, D., & Reed, P. (1996). Self-transcending: A resource for healing at the end of life. Issues in Mental
Health Nursing, 17, 275-288.
Frankel, V. (1946). Old age in our society. In Man’s search for meaning (pp. 293-337). Boston: Beacon.
Frazer, D. W., Leicht, M. L., & Backer, M. D. (1996). Psychological manifestations of physical diseases. In
L. L. Carsensen, B. A. Edelstein, & L. Dornbrand (Eds.), The practical handbook of clinical gerontology
(pp. 217-239). Thousand Oaks, CA: Sage.
Goldblum, P., & Martin, D. (2000). Principles for the discussion of life and death options with terminally ill
clients with HIV. Professional Psychology: Research and Practice, 30, 187-197.
Gottfries, C. (1997). Recognition and management of the elderly in the elderly. International Journal of
Psychopharmacology, 12, S31-S36.
Grau, L., & Padgett, D. (1988). Somatic depression among the elderly: A sociocultural perspective. Interna-
tional Journal of Geriatric Psychiatry, 3, 201-207.
Homer,L.E.(1984).Organizationaldefacesagainsttheanxietyofterminalillness:Acasestudy.DeathEdu-
cation, 8, 137-154.
124
CLINICAL CASE STUDIES / April 2003
Karel,M.J.,&Gatz,M.(1996).Factorsinfluencinglifesustainingtreatmentdecisionsinacommunitysam-
ple of families. Psychology and Aging, 11, 226-234.
Kevin,K.,&Velkoff,A.V.(2001).Anagingworld:2001(U.S.CensusBureauseries,p.5/01-1).Washington,
DC: U.S. Government Printing Office.
Kirchberg,T.M.,&Neimeyer,B.A.(1991).Reactionsofbeginningcounselorstosituationsinvolvingdeath
and dying. Death Studies, 15, 603-610.
Koenig, H. G., & Kuchibhatla, M. (1998). Use of health services by hospitalized medically ill depressed
elderly patients. American Journal of Psychiatry, 155, 871-877.
Koenig, H. G., George, L. K., & Peterson, B. L. (1998). Religiosity and remission of depression in medically
ill older patients. American Journal of Psychiatry, 155, 536-542.
Koenig,H.G.,Larson,D.B.,&Matthews,D.A.(1996).Religionandpsychotherapywitholderadults.Jour-
nal of Geriatric Psychiatry, 29, 155-184.
Kubler-Ross, E. (1969). On death and dying. New York: McMillan.
Labbot, S. M. (1998). COPD and other respiratory disease. In P. M. Camic & S. J. Knight (Eds.), Clinical
handbook of health psychology: A practical guide to effective interventions (pp. 99-123). Seattle, WA:
Hogrefe and Huber.
Lewinsohn,P.M.(1974).Abehavioralapproachtodepression.InR.M.Friedmanand&M.M.Katz(Eds.),
The psychology of depression: Contemporary theory and research. New York: John Wiley.
Lieff, J. (1982). Eight reasons why doctors fear the elderly, chronic illness, and death. Journals of
Transpersonal Psychology, 14, 47-60.
Mahoney, M. J. (1991). The person and experience of the psychotherapist. In Human change processes: The
scientific foundations of psychotherapy (pp. 346-369). New York: Basic Books.
Mishkin, B. (1989). Determining the capacity for making health care decisions. Issues in Geriatric Psychia-
try, Advanced Psychosomatic Medicine, 19, 151-166.
Moss,D.M.,McGaghie,W.C.,&Rubinstein,L.I.(1978).Medicalresistance,crisisministry,andterminal
illness. Journal of Religion and Health, 17, 99-116.
Princeton Religion Research Center. (1985). Religion in America. Princeton, NJ: Gallup Poll.
Quill, T. E. (2000). Initiating end-of-life discussion with seriously ill patients: Addressing the “elephant in
the room.” Journal of the American Medical Association, 284, 2502-2507.
Rea, M. P., Greenspoon, S., & Spilka, B. (1975). Physicians and the terminal patient: Some selected atti-
tudes and behavior. OMEGA, 6, 291-303.
Reilly, R. B., Teasdale, T. A., & McCullough, L. B. (1994). Projecting patients’ preference from living wills:
Aninvalidstrategyformanagementofdementiawithlifethreateningillness.JournalofAmericanGeriat-
ric Society, 42, 997-1003.
Retsinas, J. (1988). A theoretical reassessment of the applicability of Kubler-Ross’s stages of dying. Death
Studies, 12, 207-216.
Riggio, R. E., Singer, R. D., Hartman, K., & Sneider, R. (1982). Psychological issues in the case of critically
ill respiratory patients: Differential perceptions of patients, relatives, and staff. Psychological Reports, 51,
363-369.
Rothchild, E. (1998). Family dynamics in decisions to withhold or withdraw treatment. In M. D. Steinberg
&S.J.Younger(Eds.),Endoflifeperspective:Apsychologicalperspective (pp.77-109).Washington,DC:
Library of Congress Cataloging.
Scharlach, A., & Fuller-Thomson, E. (1994). Coping strategies following the death of an elderly parent.
Journal of Gerontological Social Work, 21, 85-100.
Searight,R.,&Hubbard,S.(1998).Evaluatingpatientcapacityformedicaldecisionmaking:Individualand
interpersonal dimensions. Families, Systems and Health, 16, 41-54.
Segal, E. S. (1996). Common medical problems in geriatric patients. In L. L. Carsensen, B. A. Edelstein, &
L. Dornbrand (Eds.), The practical handbook of clinical gerontology (pp. 451-468). Thousand Oaks, CA:
Sage.
Shaffer,D.R.(2000).Physicalillnessanddepressioninolderadults:Anintroduction.InG.M.Williamson,
D. R. Shaffer, & P. A. Parmelee, (Eds.), Physical illness and depression in older adults (pp. 1-11). New
York: Kluwer Academic/Plenum.
Ayalon / PROVIDING CARE IN THE END OF LIFE
125
Shulz, R., & Beach, S. R. (1999). Caregiving as a risk factor for mortality. Journal of the American Medical
Association, 282, 2215-2219.
Silveria, M., DiPiero, A., Gerrity, M., & Feudtner, C. (2000). Patients’ knowledge of options at end of life:
Ignorance in the face of death. Journal of the American Medical Association, 284, 2483-2488.
Stedeford, A. (1979). Psychotherapy for the dying patient. British Journal of Psychiatry, 135, 7-14.
Vandecreek, L., & Frankowski, D. (1996). Barriers that predict assistance to completing a living will. Death
Studies, 20, 73-82.
Weinstock,R.,Leong,G.B.,&Silva,J.A.(1994).Competencetoterminatelife-sustainingcare:Ethicaland
legal considerations. American Journal of Geriatric Psychiatry, 2, 95-106.
Williamson, G. M., & Shaffer, D. R. (2000). The activity restriction model of depressed affect: Antecedents
and consequences of restricted normal activities. In G. M. Williamson, D. R. Shaffer, & P. A. Parmelee
(Eds.), Physical illness and depression in older adults: A handbook of theory, research, and practice (pp.
173-200). Dordrecht, the Netherlands: Kluwer Academic Publishers.
Wolfe, R., Morrow, J., & Fredrickson, B. L. (1996). Mood disorders in older adults. In L. L. Carsensen, B. A.
Edelstein, & L. Dornbrand (Eds.), The practical handbook of clinical gerontology (pp. 274-303). Thou-
sand Oaks, CA: Sage.
Yalom, I. (1980). Existential psychotherapy. New York: Basic Books.
126
CLINICAL CASE STUDIES / April 2003