Anxiety

Key messages

Assessment

The identification of anxiety in palliative care involves both screening and comprehensive assessment to ensure that patients receive appropriate management and support. Screening tools like the State-Trait Anxiety Inventory (STAI) and the Distress Thermometer are commonly employed as initial measures to identify patients who may be at risk of anxiety. [3,4] These tools are valuable for quickly detecting levels of distress that require further evaluation. For a more focused exploration of existential distress, Templer's Death Anxiety Scale is often used, as it specifically measures fear of death and related concerns. [2,3]

Following screening, a comprehensive assessment should be conducted to explore the severity, nature, and impact of anxiety symptoms on the patient’s quality of life. This involves combining self-reported measures with clinician observations to better capture the complexity of anxiety in palliative care settings. [1,9] Regular monitoring is advised, as anxiety symptoms may vary throughout the illness journey, influenced by factors such as changes in physical condition, treatment responses, and psychosocial dynamics. [2,6] Integrating open-ended questions into the assessment process allows for a deeper understanding of specific triggers, such as fears about symptom burden or concerns about family responsibilities, which might not be fully captured by standardised scales. [9,10]

Referral pathways play an essential role in the management of anxiety in palliative care. Given the complexity of anxiety symptoms and their potential impact on well-being, it is often necessary to involve healthcare professionals with specialist knowledge in palliative care psychology or psychiatry. Referring patients to these specialists can support accurate diagnosis, the development of tailored treatment plans, and the implementation of interventions that address the individual needs of patients. [6,11] Engaging interdisciplinary teams, including psychologists, social workers, and spiritual care providers, can enhance the support provided to patients, ensuring a holistic approach to care. [6,11]

Death anxiety, in particular, requires a sensitive and holistic approach, as it often intersects with spiritual distress and a search for meaning at the end of life. [4,8] Addressing these concerns may involve not only psychological support but also spiritual care and conversations about the patient’s values and beliefs. Referral to specialists who can provide targeted interventions is recommended to help patients navigate these complex issues.

Cultural considerations are also essential in both the screening and assessment of anxiety in palliative care. Recognising that cultural differences influence how patients express and understand anxiety is critical. Tools like the Hospital Anxiety and Depression Scale (HADS), which have been validated in diverse populations, may be preferable for use in culturally sensitive contexts. [3,8] Clinicians are encouraged to adopt a culturally attuned approach, acknowledging that expressions of distress may vary according to cultural norms and beliefs about illness and death.

Non-pharmacological treatment

Non-pharmacological interventions play a valuable role in managing anxiety in palliative care, often used alongside pharmacological treatments to address the psychological and existential dimensions of distress. Evidence supports the use of mindfulness-based stress reduction (MBSR), cognitive-behavioural therapy (CBT), metacognitive therapy (MCT), and other therapeutic approaches, although the effectiveness of these interventions varies depending on individual patient needs and contexts. [10,12,13]

Metacognitive therapy (MCT) is a structured form of therapy that aims to modify the thought processes that sustain anxiety by helping patients gain control over their rumination and worry patterns. Research suggests that MCT can be effective in reducing anxiety symptoms by shifting the focus away from negative thoughts and beliefs about worry itself, encouraging a more adaptive cognitive approach. [13] This approach may be particularly beneficial for patients experiencing anxiety related to their illness, as it offers strategies to manage distressing thoughts and improve emotional resilience.

Mindfulness-based interventions, including MBSR, have shown promise in reducing anxiety symptoms by helping patients develop greater awareness and acceptance of their thoughts and emotions. However, studies have highlighted that the strength of the evidence for MBSR is still evolving, with some findings indicating moderate effects on anxiety reduction. [9,11] The variability in outcomes suggests that mindfulness approaches may be more beneficial for some patients than others, depending on factors such as their level of engagement and previous experience with meditation techniques.

Hypnosis and music therapy are additional non-pharmacological approaches that have been explored for anxiety relief in palliative care settings. Evidence suggests that hypnosis can be useful in reducing anxiety and enhancing emotional well-being by altering the patient's perception of distress. [14,15] Music therapy, which involves using music to promote relaxation and emotional expression, has also demonstrated positive effects on reducing anxiety levels and improving the overall quality of life in some patients. [14] However, the quality of evidence for these interventions remains variable, and further research is needed to establish their effectiveness in different palliative care contexts.

Psychedelic-assisted therapies, such as those using psilocybin and MDMA, are emerging as potential interventions for managing end-of-life anxiety and existential distress. Preliminary studies indicate that these therapies may lead to reductions in anxiety and improved emotional well-being, particularly for patients with terminal illnesses. [10,16] Although early findings are promising, the application of psychedelic therapies is currently limited to clinical trials, and more robust research is required to fully understand their safety, efficacy, and ethical implications in palliative care settings.

Non-pharmacological interventions should be tailored to the individual patient's preferences, cultural background, and specific needs to optimise their effectiveness. In culturally diverse populations, it is important to consider culturally specific practices that may provide comfort and align with the patient's beliefs. [3,8] Involving family members in these therapeutic approaches can also enhance the patient's sense of support and connectedness, which may contribute to reduced anxiety and distress during end-of-life care. [11] Referral to specialists with expertise in psychological and spiritual care is recommended when implementing non-pharmacological treatments. These professionals can provide targeted interventions that are informed by the latest evidence and tailored to meet the unique needs of each patient, ensuring a comprehensive and compassionate approach to anxiety management in palliative care. [6,11]

Pharmacological treatment

Pharmacological interventions are frequently used in palliative care to manage anxiety, particularly when non-pharmacological approaches alone are insufficient or when patients experience severe distress. The choice of medication should be tailored to the individual's needs, taking into account the patient's overall condition, comorbidities, and potential drug interactions. [6,17]

Benzodiazepines are among the most commonly prescribed medications for anxiety in palliative care due to their rapid onset of action and ability to provide short-term relief from acute anxiety symptoms. Medications such as lorazepam and midazolam are frequently used for their anxiolytic and sedative effects, particularly in situations where anxiety is accompanied by agitation or insomnia. [11,17] However, caution is advised when using benzodiazepines, as they may cause side effects such as drowsiness, cognitive impairment, and dependency, especially in older adults or those with reduced renal or hepatic function.

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are often recommended for patients with more persistent or generalised anxiety disorders. These medications, including drugs like sertraline and venlafaxine, are generally well-tolerated and can be effective in reducing anxiety levels over time. [1,13] SSRIs and SNRIs are typically considered when patients require longer-term management of anxiety, although they may take several weeks to achieve their full therapeutic effect.

Antipsychotic medications may be used as adjunctive treatments in cases where anxiety is severe or accompanied by symptoms such as delirium or hallucinations. Low-dose antipsychotics, like quetiapine and olanzapine, can help stabilise mood and reduce anxiety in patients who do not respond adequately to first-line treatments. [10,12] It is essential to balance the potential benefits with the risk of side effects, including extrapyramidal symptoms and metabolic changes, especially when used in vulnerable populations.

For patients experiencing death anxiety or existential distress that does not respond to conventional treatments, low-dose ketamine is being explored as a potential option. Preliminary evidence suggests that ketamine may provide rapid relief from anxiety symptoms by modulating the brain's glutamatergic system, although its use remains experimental and should be approached with caution. [10,16] Further research is required to establish the safety, efficacy, and appropriate dosing of ketamine in the context of palliative care.

Pharmacological treatment should be considered as part of a broader, holistic approach to anxiety management in palliative care, often in conjunction with non-pharmacological interventions. Close monitoring of patients is necessary to assess the effectiveness of treatment and manage any adverse effects promptly. Referral to a specialist, such as a psychiatrist or palliative care physician, may be warranted for complex cases requiring expert input on medication management. [6,11]

Equity and access

Access to anxiety management in palliative care is shaped by social and structural determinants of health, leading to disparities in care quality. Factors like socioeconomic status, cultural background, geographical location, and health literacy significantly influence a patient’s ability to receive timely and appropriate anxiety treatments. [7,17,18] Patients from underserved communities often face barriers such as limited mental health services, financial constraints, and language or cultural differences that may hinder effective engagement with care providers.

Culturally competent care can help address these inequities by aligning anxiety management with patients' diverse needs. Understanding cultural variations in distress expression and integrating culturally specific practices into care plans can enhance comfort and trust. [19,20] For instance, some patients from culturally and linguistically diverse (CALD) backgrounds may prefer traditional or spiritual approaches, which should be respected and included where appropriate. [21] Training healthcare professionals in cultural sensitivity is vital to foster open communication and build rapport with patients from diverse backgrounds. [22]

Referral pathways are essential for addressing trauma-related anxiety, as specialised support may be needed beyond standard palliative care. Employing trauma-informed care to identify trauma signs and ensuring timely referrals to psychological or trauma specialists can be critical in managing anxiety effectively. [23,24] Early involvement of mental health professionals aids in developing tailored treatment plans that address individual needs. [25]

Geographical barriers further complicate access to anxiety management, particularly in rural or remote areas where specialised services are scarce. [26,27] Telehealth and digital solutions can bridge these gaps by providing remote support, though challenges like digital literacy and internet access must be addressed to ensure equitable access. [25,28]

Care context

The care context in which palliative care is delivered can strongly influence anxiety management strategies, with approaches often varying depending on the setting—such as hospitals, specialist palliative care in-patient units, residential aged care homes, and community-based services.

Hospital and specialist palliative care in-patient settings tend to offer a multidisciplinary approach, where structured support for anxiety management can be facilitated by specialised palliative care teams. However, communication between providers can sometimes pose challenges, potentially impacting the continuity of care in addressing anxiety effectively. [29]

For patients with chronic non-cancer illnesses like chronic obstructive pulmonary disease (COPD), managing anxiety is often challenging due to the need for continuous symptom control and the psychological burden associated with a progressive illness. Integrated care models that combine respiratory and psychological support, particularly within pulmonary rehabilitation programs, appear promising in addressing these multifaceted needs. [9]

In cancer care settings, patients frequently experience heightened anxiety due to the existential distress of their diagnosis and the impact of treatments. Psycho-oncology services, which offer interventions such as CBT and MBSR, have been found to help patients manage their anxiety by addressing both psychological and emotional needs. [19] Peer support groups also provide valuable emotional support, although their effectiveness can depend on the individual's engagement and the group's dynamics. [23]

Within residential aged care homes, anxiety among older adults is often linked to cognitive decline, frailty, and social isolation. Evidence suggests that activities promoting social engagement and mental stimulation can be beneficial, but it's important to respect individual autonomy, as not all residents may desire to participate in these interventions. [30] In community-based palliative care, the ability to deliver care at home allows for a more personalised approach to anxiety management. Telehealth services are increasingly being used to deliver mental health support remotely, making anxiety management more accessible for patients who prefer or require care outside traditional clinical environments. [26] However, the effectiveness of these services is often contingent upon their adaptability to individual patient needs and the availability of supportive resources.

Implications for families and carers

Families and carers in palliative care settings often experience significant emotional distress as they support loved ones with anxiety, which can lead to heightened levels of anxiety and depression in carers themselves. [18] This emotional burden is compounded by feelings of helplessness and anticipatory grief, particularly as carers witness the progression of the patient's illness and confront their own fears about the impending loss. [2] Such distress not only affects their well-being but also influences their ability to offer effective support to the patient, highlighting the need for targeted emotional support for carers during this period.

The social isolation that carers frequently experience further intensifies their psychological challenges, as the demands of caregiving often limit their opportunities for social interaction and self-care. [14] This isolation can exacerbate feelings of loneliness and reduce the informal support available to them from friends and family, increasing their vulnerability to burnout. Providing carers with opportunities for peer support and social connection can play an important role in alleviating their sense of isolation, enhancing their resilience, and helping them cope more effectively with the stresses of caregiving. [9]

Decision-making regarding the care of their loved ones also poses significant challenges for carers, as they navigate complex medical and emotional choices amidst uncertainty. [4] The weight of these decisions can heighten their anxiety, particularly when they feel unprepared or unsupported in making such critical choices. Guidance and reassurance from healthcare professionals are essential to empower carers in these moments, ensuring they feel informed and supported while balancing the patient's needs with their own emotional well-being. [8]