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Susan D. Block, M.D.
Abstract: Over the past 15 years, in response to widely-recognized gaps in the care of patients at the end of life, palliative care has emerged as a recognized subspecialty, focused on the care of patients with advanced, progressive, lifethreatening illness. The aim of palliative care is to optimize the quality of life for the patient and family through the provision of expert interdisciplinary care, including symptom assessment and treatment, psychosocial and spiritual support to the patient and family, help with complex decisions about treatment options, coordination of care in the community, and bereavement care for families. A growing evidence base demonstrates the effectiveness of palliative care clinical programs in improving symptoms, quality of life, communication, concordance between patient wishes and care received, family satisfaction, and bereavement outcomes and in reducing costs. There are many opportunities for psychiatrists to contribute to care for patients at the end of life through enhanced involvement in palliative care teams. Over the past 15 years, in response to public and professional recognition of problems in the care of patients at the end of life, palliative care has emerged as a clinical discipline focused on the provision of comprehensive, interdisciplinary care focused on maintaining and enhancing quality of life for patients living with advanced, progressive, lifethreatening illness and for their families. In 1994, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) of more than 9000 patients in ﬁve academic medicine centers across the country, demonstrated pervasive problems in care of patients at the end of life, including deﬁcits in pain management, knowledge of and adherence to patient preferences for life-prolonging care, frequent use of aggressive care without beneﬁt, and depletion of family resources (1, 2). Additional research has demonstrated high levels of family dissatisfaction with symptom management, communication, emotional support, and respect provided to the patient; the highest levels of satisfaction were reported for patients cared for by hospice (3, 4). Undertreatment of symptoms, especially in nursing homes, remains a signiﬁcant issue (5). Discussions about physician-assisted suicide (PAS) built on patients’ fears that they would suffer and that their wishes would not be honored at the end of life and resulted in the legalization of PAS, under speciﬁed circumstances, in the state of Oregon in 1997. In addition, this often-contentious dialogue contributed to the strengthening of the ethical foundation for withholding and withdrawing life-sustaining treatment, aggressive use of medications for pain and other physical suffering, even if such treatment might hasten death (the so-called “double effect”) (6), and greater appreciation of the role of psychiatric disorders (e.g., depression and anxiety), as well as patients’ psychological characteristics (e.g., desire for control), as factors in patients’ desires to hasten death (7). A growing evidence base in palliative care has identiﬁed patient perspectives on high-quality end-of-life care, focusing on the elements of optimizing physical comfort, maintaining a sense of continuity of one’s self, maintaining and enhancing relationships, making meaning, achieving a sense of control, and confronting and preparing for death (8, 9). The ﬁeld of palliative care has grown rapidly in the United States, mirroring earlier growth in the United Kingdom. Hospice use has grown from 158,000 patients per year in 1985 to 1.2 million patients per year in 2005 (10) (approximately one third of all deaths) and has become a $9 billion care system; more than 2200 physicians have been certiﬁed in Hospice and Palliative Medicine, and more than 1300 hospitals have developed clinical palliative care services. In 2007, Hospice and Palliative
CME Disclosure Susan D. Block, M.D., Dana-Farber Cancer Institute, Brigham and Women’s Hospital, and Harvard Medical School Center for Palliative Care, Harvard Medical School Boston. No relevant ﬁnancial relationships to disclose. Address Correspondence to: Dr. Susan Block, Division of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, 44 Binney Street, Boston, MA 02115; e-mail, firstname.lastname@example.org.
Fall 2007, Vol. V, No. 4
The focus of care is on alleviation of suffering and restoring the patient to a sense of “wholeness” (30). Research in palliative care has lagged behind clinical and educational development. insomnia. and delirium) as well as to help patients explore feelings of grief. of life. spiritual. palliative care complements these goals with the focus on optimizing quality of life for the patient and family. appear to enhance family support.BLOCK Medicine became an Accreditation Council for Graduate Medical Education (ACGME). a greater likelihood of death at home. Anger at or isolation from God. nurses. better communication. and bereavement outcomes among patients hospitalized in an intensive care unit and their families (23). ideally. and constipation. and uncertainty and fear about the afterlife are among the common issues that arise in this domain. psychotherapies to enhance quality of life at the end of life (27. a chaplain. Proactive communication strategies. psychological. including nausea. but receive it less often (24). V. inpatient palliative care programs may provide consultative services or have specialized units for care of 394 Fall 2007. and home settings. similar intensive strategies are used to treat other common symptoms at the end of life. Whereas the traditional focus of medicine is cure and life prolongation.. and value of one’s life arise frequently and are the subject of attention.and American Board of Medical Specialties (ABMS)recognized subspecialty of Internal Medicine. social workers.g. nursing home. with 10 cosponsoring boards. the ACGME and the Liaison Committee on Medical Education (LCME) have promulgated standards for education in end-of-life care for medical students and residents (11. New strategies for treatment of depression in advanced illness (25. Vol. research demonstrates positive attitudes and interest in learning these clinical competencies. 14 –20). reduced caregiver distress. outpatient. greater concordance between patient wishes and care received. pharmacist. the toll of caregiving. and exploring concerns about key relationships are commonly a focus of palliative care. and interventional approaches. fatigue.. Although medical students and residents continue to have major deﬁcits in their preparation to care for patients with palliative care needs. this state of “peaceful awareness” is associated with better mental health and quality of death. guilt about past behavior. enabling clinicians to better understand the wishes of an increasingly diverse population. in addition. The impact of the patient’ s illness on family members. Outstanding communication competencies are integral to the practice of palliative medicine (32). physician communication about prognosis appears to be associated with peacefulness at the end of life (22). Psychosocial care and communication emerge repeatedly as areas of particular weakness in physicians’ educational preparation for caring for patients at the end of life (13). Spiritual/religious and existential issues are also a focus of assessment and treatment. Palliative care clinicians also seek to evaluate and treat psychiatric disorders (e.(3. an interdisciplinary team involving physicians. Cultural differences in values about end-oflife care are now appreciated. Care is provided across the entire age spectrum (31). existential concerns about the meaning. Over a similar time frame. and complicated bereavement are also emerging (29). loneliness. No. appropriate end-of-life decision making. and social components of the patient’s and family’s distress. Palliative care clinicians provide expert symptom assessment and meticulous treatment of pain. Because of the breadth and intensity of issues. purpose. For example. 26). Care can be provided in the inpatient. We are learning that spirituality and religion represent valuable resources that help patients cope and that spiritual support is associated with better quality of life in patients with advanced cancer (21). as well as greater opportunities for families to express their feelings and concerns. and concerns about loved ones. THE PALLIATIVE CARE CLINICAL APPROACH TREATMENT STRATEGIES AND EVIDENCE A growing body of evidence suggests that the provision of palliative care services is associated with improved symptom control. and. 28). including providing a brochure. depression. improved family satisfaction. bereavement.g. a psychiatrist works together to provide personalized treatment. 4 FOCUS THE JOURNAL OF LIFELONG LEARNING IN PSYCHIATRY . within a model that views the patient and family as a single unit. as well as the shortened time frame for addressing them. fear and uncertainty about the future. nonpharmacologic treatments (e. and reduced hospital costs. improved quality of life. Although only about one ﬁfth of patients with advanced cancer are both aware of their terminal prognosis and at peace about it. whereas Hispanics prefer aggressive care. often using medications. meditation or hypnosis). including the American Board of Psychiatry and Neurology. African Americans are more likely to prefer and receive less information disclosure and more aggressive care at the end Palliative care clinicians seek to understand and treat the physical. preparation for death. however. anxiety. enhanced bereavement outcomes for survivors. 12). the evidence base for the ﬁeld is rapidly improving.
psychiatrists can play a role in helping palliative care teams understand and develop treatment plans for patients with personality and substance abuse disorders.org FOCUS Fall 2007. psychiatrists play an invaluable role in helping palliative care teams tease out these interactions and in developing a rational approach to management. Hospice is an invaluable resource for the provision of care in the community. requests for physician aid in dying. The National Consensus Standards for Quality Palliative Care (33) and the National Comprehensive Cancer Network (34) have promulgated recommendations for patients with advanced disease. whereas a small proportion are provided in nursing homes and inpatient hospice facilities. Figure 1.BLOCK patients with palliative care needs. Whereas past practice has incorporated hospice or palliative care only when curative or disease-modifying treatments have failed. many of the most challenging clinical problems in the ﬁeld are those about which psychiatrists could have much to offer: how do patients move from denial and fear to a state of peace and acceptance of approaching death? How is depression best recognized and treated in the setting of terminal illness? How do patients and their families process and “metabolize” loss? Do drugs help? Is the desire for PAS a manifestation of psychopathology or a healthy adaptive response? How does repeated exposure to death and loss affect health care professionals? Psychosomatic medicine/medical psychiatry services. and our comfort in working with patients dealing with other losses can be a valuable resource in helping a palliative care team learn how to deal with intense suffering from the losses of advanced illness. skills in deep- ening the encounter and moving toward intense affect. many psychotherapies deal centrally with loss. 4 395 . Issues that arise infrequently. as well as those with major mental illness and psychiatric disorders that may compromise decision making. in most settings. Many of the elements of psychotherapy—intense. V. the psychiatrist can often play an important role in facilitating team reﬂection about their experiences in caring for patients who are dying and in supporting effective self-care strategies for their palliative care colleagues. more than 90% of hospice services are provided in patients’ homes. contemporary palliative care practice integrates palliative care principles and approaches from the time of diagnosis with a life-threatening illness as demonstrated in Figure 1. in particular. BARRIERS TO PSYCHIATRISTS’ INVOLVEMENT WITH PALLIATIVE CARE Although psychosocial care and communication represent two of the most critical elements of excellent palliative care practice and education. and self-reﬂection focused on countertransference issues—are essential competencies for palliative care clinicians and are supported by the presence of a psychiatrist on the team. Vol. Traditional Model for Patients with Advanced Illness Care Disease-Directed Treatment Palliative Care Death Time of Diagnosis CLINICAL SYNTHESIS Integrated Care for Patients with Advanced Illness Bereavement Disease-Directed Treatment Palliative Care Time of Diagnosis Death Hospice THE ROLE OF THE PSYCHIATRIST The differential diagnostic issues for mental health disorders in the setting of advanced illness are challenging because of the contribution of medical symptoms and comorbidities. complex drug regimens. often arouse intense emotions within the team. As nonpsychiatrically trained physicians. In addition. psychiatrists can play a key role in helping the team work through these issues. and psychological issues.psychiatryonline. clinical guidelines for the provision of palliative care have been developed by a variety of organizations. attention to process. Traditional and Contemporary Palliative Care Approaches. Understanding loss and grief is a key competency for palliative care clinicians. Further. the ability to tolerate intense affect. as well as explicit teaching about these issues. Over the past 10 years. psychiatry has been sparsely represented in the palliative care movement. have little interaction with palliative medicine and tend to focus on diagnosis and treatment of disorders such as depression and delirium in the hospital setting. most palliative care physicians beneﬁt from collaboration with a psychiatrist who is able to teach them about management of these challenging patients. cognitive behavior techniques such as reframing and problem solving. empathic listening to the words and the emotional “music” beneath the words. rather than the focus. including. No. and can be stimuli for reﬂection and exploration of issues of suffering. present challenging clinical issues. Yet. engaged.
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