Does psychiatry have a role in palliative care?
CrossCurrents
Avril Roberts
When you hear the term palliative care, what springs to mind? Pain and symptom control? For many health care providers, that
has been the traditional focus. But the field is recognizing that end-of-life care also encompasses psychological, social
and spiritual concerns – areas where psychiatrists and other mental health professionals can play a key role.
Dr. John Shuster, a research physician at the Tuscaloosa Veterans Administration Medical Center in Alabama and founder of
the University of Alabama’s Palliative Medicine Program, highlights key goals for psychiatry in palliative care: helping people
feel they are not abandoned; facilitating their achievement of spiritual and emotional peace; providing comfort through the
relief of physical symptoms; helping restore and maintain harmony in important relationships; and assisting people in achieving
life completion, including understanding what their life has meant, particularly to others.
These elements of care are more in the domain of mental health, but pain and symptom control are still top priorities. “You
have to clear the decks in terms of intolerable pain, nausea, anxiety and shortness of breath,” says Shuster. “Otherwise you
can’t focus on things relating to meaningful relationships and wholeness.”
Palliative care in Canada tends to be a multidisciplinary field, with doctors, nurses, social workers, psychologists, pastoral
care workers, psychiatrists and other professionals participating in palliative care programs and psychosocial oncology services.
In their traditional role, psychiatrists are not new to palliative care: They assess and treat major mental disorders, such
as clinical depression; determine whether illness or treatment is causing psychiatric disturbance; assist with managing organic
mental disorders, such as end-stage delirium; and intervene when there is threat of suicide or self-harm. Undiagnosed, untreated
depression has been identified as a critical factor in terminally ill clients’ desire for a hastened death.
But perhaps less familiar to psychiatrists and other mental health care professionals are the existential and spiritual issues
people often grapple with as their lives near an end. Dr. Harvey Chochinov, Canada Research Chair in Palliative Care, has
researched this area for more than 15 years. “We all have aspects of our lives that we see as being self-defining,” says Chochinov.
“If those things become threatened by illness, it raises the existential issue – am I still me? Despite my various losses,
am I able to maintain some essence of who I am? Near the end of life, such challenges are extremely common, so one task of
the mental health provider is to help patients navigate that difficult, existential landscape.”
Feeling that one is a burden to others is another recurring concern. “It is the epitome of feeling that life has no value
or purpose and is often associated with the wish for life to end sooner rather than later,” says Chochinov.
The literature on euthanasia, assisted-suicide and palliative care points to these psychological, existential and spiritual
concerns as being even more important than physical well-being in influencing clients’ will to live. Chochinov says this challenges
mental health professionals to ask, “What can we do to engender a sense of meaning or purpose?”
In recent years, there has been renewed interest in psychotherapies for end-of-life care. Sparked by a desire to have something
to offer his cancer and aids clients with a short prognosis, Dr. William Breitbart, chief of Psychiatry Service at the Memorial
Sloan-Kettering Cancer Center in New York, has developed meaning-centred psychotherapy, a novel intervention based on psychiatrist
Viktor Frankl’s logotherapy. “It focuses on helping patients understand concepts of meaning in life and provides information
and experiential exercises on common sources of meaning,” says Breitbart. “It also teaches people how to be flexible to move
from one source of meaning to another to sustain or even enhance their sense of meaning, purpose and hope in the face of death.”
The therapy has been offered in group format and individual sessions. Breitbart received funding recently to conduct a large
multi-centre trial examining its efficacy as group psychotherapy for palliative care. Breitbart’s colleague, Dr. David Kissane,
chairman of the Department of Psychiatry and Behavioral Sciences at the Centre, has developed a family-focused grief therapy,
doing anticipatory bereavement work with clients and families and continuing to work with families after the client’s death.
In the Manitoba Palliative Care Research Unit at CancerCare Manitoba, Chochinov is testing a dignity psychotherapy based on
his research into ways to preserve clients’ dignity at the end of life. At the heart of that research is Chochinov’s discovery
that “how patients perceive themselves to be seen by others, particularly by care providers, is one of the most vigorous predictors
of intact or maintained sense of dignity near the end of life.” This highlights the palliative care provider’s responsibility
to acknowledge a person’s humanity. “When a person is near death, all of their vulnerabilities are closer to the surface,
so the subtleties, messages and ways health care providers communicate are very important.”
Psychiatric training programs in Canada and the United States rarely have a formal rotation in palliative care. Breitbart
says general psychiatry residents tend to not view their role as being involved in palliative care. “The curriculum for most
residency training focuses on general psychiatry and major psychotic and psychiatric illnesses, with limited exposure to psychosomatic
medicine or consultation liaison psychiatry.”
Instead, palliative care is usually offered as post-graduate training in fellowship programs, such as the Fellowship in Psychiatric
Oncology that Chochinov completed at Memorial Sloan-Kettering under Breitbart’s tutelage. Chochinov sees a need to add palliative
care to the current curricula for psychiatric trainees to heighten awareness of end-of-life care issues and raise the level
of available expertise.
Shuster adds that palliative care can be profoundly rewarding. “You often get to see important broken relationships heal and
see patients consolidate the meaning of their lives through telling you their life stories. You help folks write the last
chapter of their lives in a way that is healing to them and their families.”
Centre for Addiction
