Advanced stages of diseases such as cancer, COPD, end-stage renal disease and heart failure can lead to a constellation of physical and psychosocial distress. Symptoms such as fatigue, poor sleep and appetite, dyspnea, nausea and pain impact quality of life and can cause significant suffering.

Often, these symptoms are intertwined with intense feelings of sadness, anxiety or depression. For those involved in the care of these individuals, the goal is to alleviate physical and emotional suffering as much as possible with the purpose of improving quality of life and optimizing well-being.

In recent years, a great deal of attention has been given to the value of cognitive behavioral therapy (CBT) in the palliative setting. Traditional CBT is a very effective form of psychotherapy centered around changing maladaptive thought patterns or perceptions that lead to mood disorders such as anxiety and depression.

Simply stated, changing maladaptive thoughts to more realistic, positive or adaptive ones leads to improvements in mood. But this approach does not always fit perfectly into the palliative or hospice setting wherein patients with serious disease have very real fears about suffering, uncontrolled pain, dyspnea and other noxious symptoms; these thoughts are not maladaptive nor are they unreasonable.

Fortunately, mental health and palliative clinicians have focused on modifying cognitive behavioral therapy to better address the unique needs of those living with life-limiting illness.

With CBT’s emphasis on the present rather than on what lies ahead, clinicians can address a patient’s symptom burden and its resulting psychosocial impact.

For an individual with metastatic pancreatic cancer and concomitant shortness of breath, for instance, incorporating CBT techniques can be very effective in terms of promoting relaxation, shifting the focus away from troubling symptoms and addressing intrusive thoughts that lead to anxiety.

The keys to easing suffering through cognitive behavioral interventions are to:

1. Acknowledge the very real fears, worries and concerns that patients have.

2. Educate them about the cyclical and bidirectional nature of physical symptoms and anxiety (e.g., dyspnea can make one feel anxious and the anxiety, in turn, may manifest itself physiologically as shortness of breath).

3. Create awareness of the automatic thoughts that get triggered when symptoms or side effects arise. Oftentimes patients mistake medication or treatment side effects for progression of disease (i.e., “My nausea must mean that the tumor is growing.”).

4. Utilize a variety of techniques to address intrusive thoughts, calm the acute stress response and manage depression or anxiety.

These techniques include, but are not limited to, cognitive restructuring (questioning and modifying potentially maladaptive thoughts); relaxation techniques, such as autogenic relaxation training and deep breathing exercises; promoting engagement in self-soothing and pleasurable activities; problem-solving around troublesome symptoms; and acceptance of disease progression through mindfulness and meditation.

It can be very beneficial to incorporate existential therapies and spiritual practices, particularly when the illness is deemed terminal and the clinician is called upon to support the individual and his/her family around acceptance.

For patients facing life-limiting disease, suffering can be physiological, emotional and existential. Burdensome symptoms not only impact quality of life, but they have a bidirectional relationship with anxiety and depression. Treating this set of symptoms through cognitive behavioral therapy may ease unnecessary suffering and lead to improved mood, more meaningful interactions with loved ones and overall improved quality of life.