Background Anxiety and fear occur commonly in the dying patient. However, disabling anxiety and/or panic is not a normal aspect of the dying process. Separating “normal” death-related anxiety from pathological panic is an important palliative care skill. See Fast Fact #186 for more information about anxiety in palliative care and Fast Fact #398 for post-traumatic stress disorder (PTSD) at the end of life.

Definitions

• A panic attack is defined by the DSM-V as “an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes.” Four or more of the following symptoms must occur: palpitations, pounding/accelerated heart rate, sweating, trembling/shaking, sensations of shortness of breath/smothering, feeling of choking, chest pain/discomfort, nausea/abdominal distress, feeling dizzy, unsteady, lightheaded/faint, derealization or depersonalization, fear of losing control or “going crazy”, fear of dying, paresthesia (numbness or tingling sensation), chills.
• Derealization describes a sensation of feeling estranged or detached from one’s environment.
• Depersonalization is an altered and unreal perception of self, one’s feelings and/or situation. Described by one patient as “feeling like you are on the outside looking in”.

Diagnosis

• A combination of physical symptoms (feeling dizzy, weak, nauseous, unsteady, lightheaded, breathless) and affective symptoms (fear of loss of control) are used to diagnose a panic disorder.
• Terminally ill patients may often have many of the physical symptoms listed above as a part of their illness process. Thus the presence of derealization, depersonalization and fear of loss of control are more useful in making the diagnosis of panic disorder in the terminally ill.
• A contributing feature to the diagnosis of panic disorder is if a patient develops recurrent symptoms, worries about future ‘attacks’ and alters her/his behavior in anticipation of such attacks.
• Terminally ill patients with chronic dyspnea may often worry about “suffocating to death.”

Management

• Educate patients about the diagnosis and reassure them that their symptoms can be greatly palliated with appropriate treatment.
• Optimize medical management of symptoms like pain, non-pain symptoms (especially dyspnea) and depression.
• Ideal therapy is a combination of medical therapy with counseling from a trained psychologist.
• Consider complementary treatments such as music therapy, massage therapy, guided imagery, biofeedback, end-of-life doulas, aromatherapy, pet therapy, etc.
• Medical management is influenced by the anticipated lifespan and severity of panic symptoms.
• Selective serotonin reuptake inhibitors (SSRI) either as monotherapy or augmented with low dose benzodiazepines for a period of 3 to 4 weeks (taper off benzodiazepines after 3 weeks) is indicated in patients with an anticipated lifespan of several weeks or more.
• SSRIs can exacerbate anxiety in some patients during the first few days of therapy. Consider adding benzodiazepines as needed for the first few weeks in such cases.
• Benzodiazepine monotherapy should be considered in patients with an anticipated lifespan of days to weeks. Consider low-dose long-acting benzodiazepine therapy on schedule (e.g. diazepam 1 mg every 12 hours) with short-acting benzodiazepines (e.g. lorazepam 0.5 mg every 4 to 6 hours as needed) for acute breakthrough symptoms.
• Many terminally ill patients need maintenance therapy for the rest of their life span, as relapse rates are high on treatment discontinuation. In cases where treatment termination is attempted, it is recommended that the medications be tapered gradually over a several week period to allow early detection of a relapse.
• Abrupt termination of benzodiazepine therapy often may result in intense rebound anxiety. This may happen when the patient is actively dying and unable to take oral medications. In such cases, use alternate routes of drug administration (diazepam gel, diazepam rectal suppository or diazepam or midazolam infusions).
• Ketamine and psilocybin are being more thoroughly evaluated for depression and emotional/spiritual/existential distress.

References

1. Periyakoil VS, Skultety K, Sheikh J. Panic, anxiety, and chronic dyspnea J Pallit Med. 2005; 8:453-459.
2. DSM-V: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.
3. Anderson A, ed. The ASAP Dictionary of Anxiety and Panic Disorders. Available at: http://anxiety-panic.com/dictionary/en-main.htm.
4. Substance Abuse and Mental Health Services Administration. Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2016 Jun. Table 3.10, Panic Disorder and Agoraphobia Criteria Changes from DSM-IV to DSM-5. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t10/.
5. DeDiego, Amanda C., et al. “Professional Roles, Services, and Quality of Life for End-of-Life Doulas in the United States.” Journal of Pain and Symptom Management 66.4 (2023): e469-e473.
6. Goldman N, Frankenthaler M, Klepacz L. The Efficacy of Ketamine in the Palliative Care Setting: A Comprehensive Review of the Literature. J Palliat Med. 2019 Sep;22(9):1154-1161. doi: 10.1089/jpm.2018.0627. Epub 2019 May 15. PMID: 31090477.
7. Whinkin, E., Opalka, M., Watters, C., Jaffe, A., & Aggarwal, S. (2023). Psilocybin in Palliative Care: An Update. Current geriatrics reports, 12(2), 50–59. https://doi.org/10.1007/s13670-023-00383-7.

Version History: This Fast Fact was originally edited by David E Weissman MD and published in November 2005; 2nd Edition in April 2009; 3rd Edition in July 2015; 4th Edition in September 2024 by Ryan Jozwiak MD.
Conflicts of Interest: None to report.