Psychological Trauma Can Worsen Symptom Burden at End-of-Life

Recent research has found that traumatic experiences can lead to increased pain and symptom burden at the end of life, along with a greater likelihood of emotional suffering and isolation.

Collective trauma experiences have been associated with higher instances of pain and dyspnea among more than half of seniors nationwide, a recent study found, published in the Journal of Pain and Symptom Management. Traumatized seniors are also more likely to experience loneliness, dissatisfaction with their life and depression.

The findings suggest that traumatized terminally ill patients may have a multitude of greater physical, psychosocial and emotional needs compared to others, according to researcher Dr. Ashwin Kotwal, assistant professor of medicine at the University of California San Francisco’s (UCSF) Division of Geriatrics.


Hospices need a greater understanding of both the depth of these patients’ suffering and the scope of their unique needs to improve trauma-informed care delivery, Kotwal said at the American Academy of Hospice and Palliative Medicine (AAHPM) and the Hospice & Palliative Nurses Association (HPNA) Annual Assembly.

“Little is known about the epidemiology of trauma among persons approaching the end of life,” Kotwal said during the assembly. “There are notable differences in the types of traumatic events, and these events were strongly associated with an increased burden of end-of-life physical and psychosocial needs. For physical symptoms, this can reflect the accumulation of lifelong impacts of trauma on physical functioning, chronic disease and aging.”

Kotwal and fellow UCSF researchers recently examined the traumatic experiences shared by roughly 6,500 adults 51 and older nearing the end of life between 2006 and 2020 in a national Health and Retirement Study. Individuals were surveyed with questionnaires that addressed their experience and the lifetime impacts related to their physical symptoms, mental health conditions and social needs.


A large portion (83%) of respondents reported experiencing at least one lifetime traumatic event. About one-third had three or more traumatic experiences. Trauma events included physical abuse, violence and weapon-related combat, natural disasters and early childhood experiences, among others.

These individuals reported relatively poorer health with multiple comorbid conditions, and often had sensory, functional or cognitive impairment compared to others, Kotwal stated.

Pain, fatigue and dyspnea increased from 46% to 60% among people with five or more traumatic lifetime events in the last year of life, the study found. Rates of depression rose up to 40% of these individuals within four years prior to death, with frequent or severe social isolation and loneliness reported among up to nearly a quarter (22%).

Data on the pain and symptom impacts are a “useful starting point” for hospice and palliative care providers to shape their trauma-informed care approaches, Kotwal. More research is needed to help providers better understand the scope of physical, emotional and psychosocial impacts of trauma to improve quality outcomes for dying patients and their families, he stated.

“We need a lot more research in the future to understand how to tailor existing trauma-formed care interventions to patients with serious illness and outcomes relevant to the end of life,” Kotwal said. “Our study results suggest that we should consider actively screening and exploring prior traumatic experiences in a structured format with the support of an interdisciplinary team. While trauma-informed care can make a difference, applying existing interventions may be limited by someone’s life expectancy or symptom burden and competing health and social priorities.”

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