While palliative care grows as an interdisciplinary specialty, more clinicians are asking how it can benefit certain patients with severe mental illness.
Palliative care, which developed with the founding of hospices in the 1960s, initially focused on patients who were dying from cancer. The specialty – which emphasizes improving patients’ quality of life rather than finding a cure, and which is different from hospice – can now be used for patients with noncancer diagnoses such as dementia and HIV/AIDS (Psychiatry. 2009 Jun;8[6]:212-15).
Some psychiatrists think that certain patients with another diagnosis would benefit from palliative care: those with severe persistent mental illness.
In fact, this approach might apply to psychiatric patients who are in long-term residential care with “severe/chronic schizophrenia and insufficient quality of life, those with therapy-refractory depressions and repeated suicide attempts, and those with severe long-standing therapy-refractory anorexia nervosa,” wrote Manuel Trachsel, MD, PhD, and his colleagues (BMC Psychiatry (2016 Jul 14:1-9).
Scott A. Irwin, MD, PhD, who coauthored that article and a letter examining these issues, said Dr. Trachsel’s theories lie on the frontiers of current thinking about incorporating palliative care and psychiatric medicine.
Meanwhile, both Dr. Irwin and Maria I. Lapid, MD, another psychiatrist with expertise in palliative care, said that in many ways, the field of psychiatry is inherently palliative in nature.
Palliative ‘approach’ in SPMI
Dr. Trachsel presented unpublished results from a survey of U.S. psychiatrists at the annual meeting of the American Psychiatric Association in May that sought to discern whether they favored supporting short-term quality of life rather than long-term disease modification in certain patients with severe and persistent mental illness (SPMI) – defined as mental illness that is chronic or recurring, requires ongoing intensive psychiatric treatment, and seriously impairs functioning.
Courtesy Dr. Trachsel
Dr. Manuel Trachsel
Specifically, a palliative care approach to SPMI could include a more relaxed use of agents considered potentially addictive or problematic long term, such as benzodiazepines, Dr. Trachsel said. For patients with medical decision-making capacity, it could 1) include withdrawal of care at a patient’s insistence or periods of intermittent sedation – which is used in palliative medicine for patients with intractable pain; or 2) mean switching a patient with end-stage anorexia and multiple failed treatment attempts to hospice care rather than force feeding, Dr. Trachsel said.
Neither Dr. Trachsel’s survey respondents nor those who attended his presentation seemed comfortable with the idea of extending the term “palliative care” – which is often and incorrectly associated with well-defined end-of-life scenarios – to serious, treatment-refractory mental illness. In those illnesses, disease trajectories may be less certain and futility is harder to define. They and other clinicians, however, did voice general support for the underlying concepts of promoting quality of life and decision-making autonomy for patients with SPMI, as well as palliative care targeted at the medical illnesses often acquired by those with SPMI.
According to Dr. Irwin and Dr. Lapid, reducing symptoms, acknowledging that there is no cure for SPMI, and focusing on optimizing patients’ quality of life would be core components of palliative care.
Futility difficult to define
Dr. Irwin said in an interview that the ideas in the letter (Lancet Psychiatry. 2016 Mar;3[3]:200) in which he and a few other colleagues collaborated with Dr. Trachsel were essentially “a thought experiment and very philosophical.” In addition, the letter, which proposed palliative psychiatry “as a means to improve quality of care, person-centeredness, and autonomy” for patients with SPMI, was supported by a handful of case studies, most of them in patients with end-stage anorexia, he said. Furthermore, end-of-life interventions are only a subset of what palliative care brings to the table, said Dr. Irwin, palliative care psychiatrist at Cedars-Sinai Health System’s Samuel Oschin Comprehensive Cancer Center in Los Angeles.
Dr. Scott A. Irwin