In Review

The Opportunity for Psychiatry in Palliative Care

Scott A Irwin, MD, PhD1; Frank D Ferris, MD2

The need for psychiatrists to work with patients and families living with chronic
life-threatening illnesses has never been greater. Further, psychiatrists may find exciting
work within the relatively new field of palliative care, which is devoted to the prevention
and relief of all suffering. Increasingly, individuals are living longer with multiple issues
that cause suffering, interfere with their lives, and often lead to psychosocial sequelae. To
ensure state-of-the-art care for patients and families throughout an illness and any ensuing
bereavement period, many experienced psychiatrists are needed as consultants to, and as
members of, interdisciplinary palliative care teams. This need presents limitless
opportunities for psychiatrists to care for patients, provide education, and engage in
research. The potential to make a difference is great.
Can J Psychiatry 2008;53(11):713–724

Clinical Implications
· A gap in care for patients with serious illnesses exists.
· Psychiatrists are well poised to fill this gap.
· The potential impact and rewards from this work are great.

Limitations
· There are relatively few psychiatrists working with the seriously ill.
· There is little empirical evidence of the impact of psychiatry on care of the seriously ill.

Key Words: psychiatry, psychiatrist, hospice, palliative care, depression, delirium, anxiety,
psychotherapy, bereavement, caregiving

psychiatrist is, by definition, a healer of “the soul, mind,
A spirit, breath, life; the invisible animating principle or
entity that occupies and directs the physical body.”1 Given the
complex issues patients and families experience during
life-threatening illnesses and what it means to be a psychia-
trist, it is surprising that psychiatrists are not more involved in
caring for these patients and their families, particularly when
the end of the patient’s life is approaching.
The Experience of Life-Threatening Illness
Until the mid-20th century, people who survived infancy typi-
cally lived into their 60s. Infections and accidents caused most
deaths. After making the diagnosis, there was little a doctor
could do but comfort and support the patient and family.2–4
People frequently died within hours to days.
Beginning with the introduction of penicillin in the early
1940s, medicine has largely succeeded in controlling most
disease processes. The average life expectancy in North
America and much of western Europe has increased by
20 years during just the last 7 decades. Today, while a few
people die acutely, more than 90% live for months to years
with one or more chronic, potentially life-threatening,
diseases.
Along with the success of controlling disease and increasing
longevity has come the new reality of chronic illness, particu-
larly as people approach the end of their lives. Patients and
families must now cope with one or more potentially devas-
tating diagnosis. Then, they must adapt to live with the multi-
ple issues that derive from a chronic disease course
(Figure 1). These issues can cause suffering that lasts for
months to years. Families often have the daunting task of

The Canadian Journal of Psychiatry, Vol 53, No 11, November 2008 W 713
In Review
Figure 1 Common patient and family issues throughout illness and bereavementa
1. Disease
management
Primary diagnosis, prognosis,
evidence
Secondary diagnoses, for
example, dementia, psychiatric
diagnoses, substance use,
trauma
Comorbidities, for example,
delirium, seizures, organ failure
Adverse events, for example,
side effects, toxicity
Allergies
8. Loss, grief
Loss
Grief, for example, acute,
chronic, anticipatory
Bereavement planning
Mourning
7. End-of-life care and
(or) death management
Life closure, for example,
completing business, closing
relationships, saying goodbye
Gift giving, for example, things,
money, organs, thoughts
Legacy creation
Preparation for expected death
Anticipation and management of
physiological changes in the last
hours of life
Rites, rituals
Pronouncement, certification
Peri-death care of family,
handling of the body
Funerals, memorial services,
celebrations
a
Other common symptoms include, but are not limited to:
Cardio-respiratory: breathlessness, cough, edema, hiccups, apnea, agonal breathing patterns
Gastrointestinal: nausea, vomiting, constipation, obstipation, bowel obstruction, diarrhea, bloating, dysphagia, dyspepsia
Oral conditions: dry mouth, mucositis
Skin conditions: dry skin, nodules, pruritus, rashes
General: agitation, anorexia, cachexia, fatigue, weakness, bleeding, drowsiness, effusions (pleural, peritoneal), fever and (or) chills, incontinence,
insomnia, lymphoedema, myoclonus, odor, prolapse, sweats, syncope, vertigo
a
Adapted with permission from Ferris et al.3
714
2. Physical 3. Psychological
Pain and other symptoms a Personality, strengths, behaviour,
motivation
Level of consciousness, cognition
Depression, anxiety
Function, safety, aids:
- Motor, for example, mobility, Emotions, for example, anger, distress,
swallowing, excretion; hopelessness, loneliness
- Senses, for example, hearing,
Fears, for example, abandonment,
sight, smell, taste, touch;
burden, death
- Physiologic, for example,
breathing, circulation; Control, dignity, independence
- Sexual
Conflict, guilt, stress, coping responses
Fluids, nutrition
Wounds Self-image, self-esteem
Habits, for example, alcohol,
smoking
4. Social
Cultural values, beliefs, practices
Patient and family Relationships, roles with family, friends,
characteristics community
Isolation, abandonment, reconciliation
Demographics, for example,
Safe, comforting environment
age, gender, race, contact
information Privacy, intimacy
Routines, rituals, recreation, vocation
Culture, for example,
ethnicity, language, cuisine Financial resources, expenses
Legal, for example, powers of attorney
Personal values, beliefs, for business and (or) health care,
practices, strengths advance directives, last will and
testament, beneficiaries
Developmental state, Family caregiver protection
education, literacy
Guardianship, custody issues
Disabilities
5. Spiritual
6. Practical
Meaning, value
Activities of daily living, that is, for personal care =
ambulation, bathing, toileting, feeding, dressing, Existential, transcendental
and transfers; for household activities = cooking,
cleaning, laundry, banking, and shopping Values, beliefs, practices, affiliations
Spiritual advisors, rites, rituals
Caregiving
Dependents, pets Symbols, icons
Telephone access, transportation
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 The Opportunity for Psychiatry in Palliative Care

Figure 2 Patient and family transition from wellness through illness and bereavementa

a
Adapted with permission from Ferris et al.3

Figure 3 Common patient and family needs based on Maslow’s Hierarchy of Human Needsa

a
Adapted from Herbst5 and Zalenski and Raspa.6

caregiving for years, which ultimately ends with the death of a
loved one. Everyone struggles to cope with multiple changes,
including the burden of increasing dependence, while trying
to have as many meaningful and valuable experiences as pos-
sible (Figure 2).
the resulting needs are not fully addressed and supported,
they can negatively impact on patients’, families’, and care-
givers’ capacity to live meaningful and valuable lives and
realize their full potential. The effects can last for the duration
of a patient’s life and last long after his or her death.

These issues, and the tensions that arise from them, inevitably Palliative Care as a Response
impact each person’s physical well-being and their sense of To achieve our full potential as a society, we must strive to
safety, love, and esteem (Figure 3; a modification of keep people as healthy as possible (that is, “a state of com-
Maslow’s Hierarchy of Human Need).5,6 If these issues and plete physical, mental, and social well-being and not merely

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In Review

Table 1 Causes of suffering that may benefit by the multiple issues patients, families, and caregivers face,
from psychiatric expertise and the needs these create, at any stage during an acute or
chronic life-threatening illness (Table 1 and Figure 1).
· Abandonment
· Anger Typically, therapies to cure or control an underlying disease
· Anxiety are the initial focus of care for patients and their health care
· Bereavement providers. Palliative care augments these disease-modifying
therapies and helps individuals achieve their full potential
· Boundary setting
throughout their illness experience by helping to address the
· Burden
multiple issues that can lead to suffering and any related
· Caregiving needs whenever they arise, starting from diagnosis and
· Coping extending through the bereavement period (Figure 4).11 Over
· Delirium time, as an illness advances and goals of care change, pallia-
· Dementia tive care may become the total focus of care.
· Denial The concept of palliative care was first introduced in Canada
· Dependence in the mid-1970s. It derives from the Latin verb palliare,
· Depression which means to cloak, to comfort,1 and grew out of, and
· Desire for hastened death includes, hospice care—specialized care for patients and
· Dignity
families approaching the end of a patient’s life. Hospice care
includes interventions to help patients and families close
· Distress
their lives together, manage the last hours of life, and provide
· Fear bereavement care for family who survive the patient’s death
· Grief (Figure 5).12,13
· Habits, for example, alcohol and smoking
While some family practitioners, general internists, and spe-
· Hope
cialists provide primary (basic) and secondary (advanced)
· Hopelessness palliative care, most are not yet competent with this new
· Insomnia knowledge and skill set. Similar to other medical specialties,
· Loneliness interdisciplinary services specializing in palliative care pro-
· Loss vide tertiary (expert) consultative services to manage chal-
· Nausea lenging and complex situations, particularly when goals of
care shift to focus more on comfort and quality than cure.
· Pain (acute and chronic)
Today, palliative care consultation is increasingly available
· Personality issues
in acute and long-term care facilities, in ambulatory outpa-
· Professional burnout tient settings, and in patients’ homes. Specialized palliative
· Professional self-care care and hospice inpatient units and free-standing facilities
· Shortness of breath have also developed to care for patients with complex situa-
· Substance use, abuse, or dependence tions, and when goals of care shift to focus on palliative care
· Suicidal ideation when the patient can no longer be cared for at home.

The Need for Psychiatry

the absence of disease or infirmity,”7, p 1 as defined by the
World Health Organization). To achieve this goal, health care
must address the multiple issues individuals face during a
chronic illness, not just focus on curing or controlling physi-
cal manifestations of the underlying disease.
Palliative care is the newest body of knowledge and skill in
health care. Recently, it has been recognized as a medical spe-
cialty in Australia, Canada, Ireland, the United Kingdom, and
the United States.8–10 It includes a wide range of therapeutic
interventions that aim to prevent and relieve suffering caused
Growing evidence indicates that psychosocial and psychiat-
ric issues in patients with advanced life-threatening illnesses
are prevalent, often unacknowledged (for example, thought
of as normal responses to anticipated death), unassessed,
underdiagnosed, and undertreated across all health care set-
tings and disciplines.14–16 With the increasing prevalence of
both acute and chronic life-threatening illnesses, there are
rapidly increasing opportunities and need for psychiatrists,
along with other mental health professionals, to care for these
patients and their families. Along with providing necessary
care, these professionals will participate in education,

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 The Opportunity for Psychiatry in Palliative Care

Figure 4 The role of palliative care during illness and bereavementa

a
Reprinted with permission from Ferris et al.3

Figure 5 The role of hospice care during the last phase of illness and bereavementa

a
Reprinted with permission from Blum et al.13

research, and advocacy that will significantly benefit their
patients, families, and health care systems worldwide.
While many palliative care experts have learned to manage
numerous common psychiatric issues, most are not experts at
assessing, diagnosing, or managing complex situations. A
wide range of issues could benefit from psychiatric expertise
(Table 1 and Figure 1). As patients with complex psychiatric
issues in the context of advanced, life-threatening illnesses are
often referred to palliative care teams, many palliative care
psychiatrists are needed as consultants to, or as liaison
members of, interdisciplinary palliative care teams to address
this burden of suffering. These teams have many resources
that increase the likelihood of psychiatrists having a signifi-
cant impact, including skilled nurses, social workers, spiri-
tual and bereavement counsellors, and volunteers.
Specific Therapeutic Expertise
As with other psychiatric illness, a combination of supportive
psychotherapy and psychopharmacology is usually the best
therapeutic intervention.

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In Review
Psychotherapy
Ongoing supportive psychotherapy by a skilled psychiatrist
can provide a safe setting that encourages patients and fami-
lies to share issues that may be causing them suffering, espe-
cially issues they may be reluctant to share with their palliative
care team. Several studies have shown that group therapy
reduces distress and mood symptoms in patients with
advanced and (or) metastatic breast cancer.17–19 Existential
group therapy, which focuses on issues of meaning and is
based on Frankl’s logotherapy,20 was also proposed as a use-
ful intervention for dying individuals.21–23 Chochinov et al24
designed an individual psychotherapeutic intervention,
coined Dignity Therapy, targeted at psychosocial and existen-
tial distress among patients near the end of life. They reported
that most patients receiving Dignity Therapy experienced a
heightened sense of dignity, purpose, and meaning, and an
increased will to live. Patients receiving Dignity Therapy also
reported a significantly diminished sense of suffering and
reduced depressive symptoms.
Pharmacotherapy
When indicated, patients with life-threatening illnesses
typically respond to the usual armamentarium of
psychopharmaceuticals. Particularly important to these
patients is the time required to achieve a therapeutic response.
Patients with limited life expectancy need therapies that act
quickly. Many will not live even the few weeks needed to real-
ize the effects of standard antidepressants.
Given the complexity of most psychiatric issues, along with
their interplay with medical illness and therapies, most
nonpsychiatrists will be at a loss, or reluctant, to use psychiat-
ric medications properly. Almost universally, only psychia-
trists have the knowledge and experience to use medications
in atypical, off-label ways that may benefit these patients,
such as stimulants for the rapid relief of depression,25,26
first-generation antipsychotics for delirium, 27–29 and
benzodiazepines for irreversible delirium.30
Specific Areas of Expertise
Depression
Depression is one of the most common symptoms experi-
enced by patients with life-threatening illnesses. Prevalence
of up to 42% has been reported in patients enrolled in pallia-
tive care programs.31–33
Untreated depression can increase the perceived severity of
pain and other symptoms35–38; affect physical health and qual-
ity of life31,35; impair a patient’s capacity to make decisions,
interact with caregivers, and (or) attain final goals of life; and
significantly increase the probability of morbidity,
mortality,39 and suicide.40–44 While there is evidence that early
recognition and treatment of depression reduces disability and
718
health care costs, further work is needed to determine
whether this is true in palliative care settings.45
Depressive symptoms are commonly underrecognized in
patients with advanced life-threatening illnesses.15 Patients,
families, and clinicians sometimes assume that emotional
distress is inevitable and untreatable in the context of
advanced, life-threatening illnesses.46 Patients and families
often do not recognize or give adequate credence to depres-
sive symptoms accompanied by considerable physical ail-
ments.47 Even when the symptoms are recognized, patients
and families are often reluctant to voice emotional com-
plaints to clinicians. The situation is further complicated by
the fact that many clinicians are unable to appropriately esti-
mate their patients’ levels of psychological distress.48–51
A psychiatrist can help a palliative care team make the diag-
nosis. This is inherently difficult, as many of the typical
symptoms of depression evolve over time and are con-
founded by the underlying illness and its treatment (for
example, changes in weight, fatigue, sleep disturbances,
decreased concentration, and altered appetite).52 A psychia-
trist can also help distinguish grieving and normal adjustment
processes 53,54 from clinically significant depressive
disorders.31
Even when the symptoms are recognized, depression is fre-
quently undertreated in patients with advanced, life-
threatening illnesses.55–57 Older studies demonstrated that, in
spite of the high prevalence rates, antidepressant medications
were administered to only 3% of terminal cancer patients46,58;
although, this may be improving.33 Withholding treatment is
sometimes rationalized as not interfering with normal griev-
ing; however, this may be at the cost of ignoring a critically
serious psychiatric disorder.
Both psychotherapy and standard antidepressant therapy
appear effective in treating depression in patients with cancer
and other significant medical problems. In a metaanalysis of
patients with chronic medical illness and depression, anti-
depressants were shown to significantly reduce depressive
symptoms.59
Palliative care teams will benefit significantly from experi-
enced psychiatrists who can help them decide which anti-
depressants to choose from amongst the armamentarium of
more than 24 antidepressants with at least 7 different mecha-
nisms of action, and when to change to an alternate anti-
depressant if a 4- to 6-week trial does not produce the desired
results.60–62
For depressed patients with a limited life expectancy of only
weeks, who may die before the usual antidepressants are
effective, psychiatrists experienced with the management of
depression using off-label medications will be invaluable
(for example, methylphenidate and modafinil).63–65
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Delirium
Among patients with cancer admitted to a hospital or hospice,
44% may experience delirium. It is estimated that 50% of this
delirium may be reversible.66 As patients with cancer or other
diagnoses approach the end of their lives, more than 80% may
experience delirium.27,29,66–70 One-third of palliative care
patients experience terminal delirium while they are actively
dying.71
Delirium can be a frightening and distressing experience for
patients, families, and caregivers.72 It is associated with sig-
nificant morbidity and mortality,27,66,73–82 and can impair the
recognition and control of other physical and psychological
symptoms, such as pain.83 These symptoms can lead to unnec-
essary medical intervention or inpatient admissions that are
frequently prolonged and costly.79–82
In patients with advanced life-threatening illnesses, delirium
is often underrecognized and misdiagnosed.81,84–86 An experi-
enced psychiatrist can help clinicians understand the termi-
nology used to describe and differentiate between cognitive
impairments, choose good bedside screening and diagnostic
tools, and improve their understanding of delirium.14,81 They
can also help to: make an accurate diagnosis; differentiate
delirium from other psychiatric disorders67,84; establish the
reversibility of a delirium; and, establish the most appropriate
goals of care given the patient’s situation, particularly when
patients are approaching the end of their lives. 30,87
Delirium is often inappropriately treated by clinicians who are
not experienced with its management. However, appropriate
interventions usually improve outcomes.27–29,88–90 An accu-
rate diagnosis is very important, as the treatment of agitation
may vary depending on the etiology, context, and goals of care
(that is, reversible, compared with irreversible, delirium,
dementia, or schizophrenia).30,91
Psychiatrists can recommend strategies to: ensure patient,
family, and caregiver safety; modify the environment and
teach family and staff helpful behaviours; recommend appro-
priate medications, depending on whether the delirium is
reversible (that is, if reversible, use antipsychotics and avoid
benzodiazepines, or if irreversible terminal delirium, use
benzodiazepines for their sedative, amnestic, muscle-
relaxant, and antiepileptic properties); and, provide ongoing
support to the patient, family, caregivers, and the health care
team.27,30,92,93
Anxiety
Although it has received little attention, anxiety is thought to
occur in more than 70% of medically ill patients, especially
those approaching the end of their lives.14,33,94,95 Most of these
patients have worries, fears, and apprehensions that result in
symptoms of anxiety but do not rise to the level of an anxiety
disorder. They express fears about what their death will look
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The Opportunity for Psychiatry in Palliative Care
like and what events will lead up to it. They frequently voice
concerns about religious beliefs, spiritual issues, existential
matters, or how to achieve a good death. Fear of uncontrolled
symptoms or dependency are sometimes accompanied by a
heightened interest in hastened death.96
Recognizing anxiety can be particularly difficult, as dying
patients often have a complex mix of physical, psychologi-
cal, and psychiatric issues.96 It frequently presents with
somatic symptoms that overshadow psychological and cog-
nitive manifestations.97 A psychiatrist can be instrumental in
helping the palliative care team use these symptoms as cues
to inquire about the patient’s psychological state. They can
also help diagnose an underlying anxiety disorder. 98
An experienced psychiatrist will help the team with the diffi-
cult task of deciding when to intervene, and what therapies to
use.96 Nonpharmacological interventions are typically the
first line of therapy in patients with advanced life-threatening
illnesses. Supportive and (or) group psychotherapy, Dignity
Therapy, and alternative medical approaches, such as pro-
gressive muscle relaxation, massage therapy, guided imag-
ery, hypnosis, meditation, or aromatherapy, can be
particularly useful tools to decrease anxiety.17–19,20–24,96
If psychopharmacology is needed, a psychiatrist can suggest
and monitor the effect of medications not typically used for
anxiety, such as beta-blockers, mood stabilizers, and
trazodone.99 In general, benzodiazepines should not be used
as first-line agents and only play a very limited role for anxi-
ety management in this patient population. Psychiatric exper-
tise can help minimize any inappropriate use of
benzodiazepines to manage anxiety in these patients.
Care of the Family
During the Illness. Care for the family during an advanced
life-threatening illness is as important as caring for the
patient, particularly when the patient is a child. It involves
many of the same issues that patients deal with, including the
need for supportive psychotherapy, and the management of
depression, anxiety, and grief. Attention to these issues can
reduce burden on other family obligations (for example,
work, children, social, and financial obligations), and may
reduce the risk of increased morbidity and mortality among
caregivers,100–108 including the risk of major depression and
complicated bereavement.109–111 If attention is paid to the
needs of the family during the patient’s illness, and they are
prepared for the patient’s death, caregiving outcomes will
improve, caregiver satisfaction will be greater, and their
bereavement experience may be very different.
After a Death (Bereavement). Psychiatrists and other mental
health professionals are ideal members of bereavement teams
to help identify and treat psychiatric sequelae of grief,
whether the grief is normal or takes a more serious and
719
In Review
disabling course. Following a death, the immediate family,
relatives, very close friends, coworkers, and classmates can
find themselves bereft.112 Although many bereft reactions do
not require professional attention, some can become over-
whelming, chronic, and set the stage for a complicated
bereavement (that is, major depression). Psychiatrists can
help palliative care team members differentiate between nor-
mal and more serious bereavement outcomes. They can help
identify risk factors for complicated bereavement so that more
intense interventions can be initiated promptly when
indicated.113
Many psychiatric issues can arise during bereavement,
including depressive symptoms, 114–121 subsyndromal
symptoms, 1 2 2 , 1 2 3 minor depression, 1 2 4 and major
depression.113,125 Major depressive episodes have been
reported in about 50% of widows and widowers at 1 month
after the death,115 25% at 2 months, 16% at 1 year, and 14% to
16% at 2 years.115,117,125 Zisook and Shuchter125 found that by
the second month, bereavement-related depressions tended to
be chronic, led to protracted biopsychosocial dysfunction,
and were associated with impaired immunological function.
The presence of a major depressive episode 2 months after a
death is a major risk factor for depression at 1 year.125 As such,
many psychiatrists believe that all severe major depressive
episodes, at any time, including all cases meeting criteria for
major depression in the context of bereavement, should be
diagnosed and treated similar to nonbereavement-related
depressions.
Anxiety disorders also occur and can be long-lasting during
bereavement.126,127 Jacobs et al128 found higher than expected
rates of both panic and generalized anxiety disorders through-
out the first year of spousal bereavement, agoraphobia in the
first 6 months, and social phobia in the next 6 months.
Posttraumatic stress disorder was also reported during
bereavement.129,130
Depression and anxiety interfere with grief work. Aggressive
treatment by skilled psychiatrists and other mental health pro-
fessionals will facilitate the grieving process.118,131 Consider-
able evidence now exists that an episode of major depression
should be treated, even in the context of bereavement.132
Major depression is woefully underdiagnosed and rarely
treated when it occurs during bereavement.125 Five open stud-
ies118,130–135 and one placebo-controlled study13 support the
safety and efficacy of antidepressants in the bereft. There was
no indication that treating depression interfered with the nor-
mal grieving process; however, depression in the setting of
bereavement did respond to antidepressant therapy similarly
to nonbereavement-related depression. Group and individual
psychotherapy, as well as psychopharmacology, were all
shown to be effective for treating psychiatric syndromes in the
bereaved.136–147
720
Need for Education
Inevitably, the absence of psychiatric training related to
advanced life-threatening illnesses contributes to the
underrecognition and undertreatment of these issues, cer-
tainly to the detriment of patients and their families.148 With-
out experience, clinicians, including psychiatrists, are not
adequately prepared to manage these complex patients effec-
tively. Some may even avoid caring for these patients, as they
find it very stressful.149
To increase clinicians’ knowledge and skills, formal educa-
tion in the assessment, diagnosis, and management of psychi-
atric issues as they relate to patients and families living with
life-threatening illnesses is needed, including education tar-
geted at:
· Nonpalliative care physicians and other members of the
general health care team who need to achieve and
maintain basic core competencies in the psychiatric
aspects of palliative medicine.
· Palliative medicine experts, and other members of
hospice and palliative care team, who need advanced
training and expertise in the psychiatric aspects of
palliative medicine.
· Psychiatrists and other mental health professionals, who
can provide consultative services to hospice and
palliative care teams and other health care professionals,
and who need basic core competencies in the psychiatric
aspects of palliative medicine; this should become a
routine part of professional training programs. 149
· Palliative care psychiatry specialists will require
advanced training and expertise in the psychiatric aspects
of palliative medicine, as well as in palliative medicine
itself.
A recent survey of more than 90 psychiatry residents from 17
psychiatry residency programs in the United States demon-
strated that an overwhelming majority of those surveyed
believed that psychiatrists should be trained in the psychiatric
aspects of end-of-life care (97%) and that there should be for-
mal education about these issues as part of psychiatry resi-
dency training (94%).150 With the American Board of
Psychiatry and Neurology as one of the sponsors of the new
subspecialty of Palliative Medicine in the United States,
opportunities for psychiatrists to transition to palliative medi-
cine fellowships need to be created and encouraged within
residency training. There may even be a need for a special-
ized palliative medicine fellowship track targeted at
psychiatrists.
The integration of psychiatrists into interdisciplinary pallia-
tive care teams will lead to the best results for patients and
families. In the consultative role, psychiatrists will be in the
position to educate physicians and other members of the pal-
liative care team about the complexities of psychiatric care in
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this patient population and how to best use the psychiatrist’s
expertise.
Opportunities for Research
Given the realities that our aging population is increasing and
that there is a high prevalence of psychiatric issues among
patients with advanced life-threatening illnesses, there is a
wonderful opportunity and a real need for psychiatric
researchers to expand our knowledge and skills about defin-
ing, recognizing, assessing, and managing psychiatric issues
in this patient population. To date, therapeutic interventions
for psychiatric conditions have primarily been studied in the
medically well. There is a paucity of solid evidence that
derives from patients and families who are living with
advanced illnesses, going through the dying process, and cop-
ing with bereavement.
Now that palliative medicine is a recognized medical
subspecialty of the American Board of Psychiatry and Neu-
rology, it is time for psychiatry to become more focused on
expanding its role within palliative care. The opportunity to
improve the quality of life for many people is greater than ever
before. Innovative research will play a prominent role in
improving care for these patients facing psychiatric complica-
tions, which all too often punctuate life-threatening and
-limiting conditions.
Conclusion
Patients and families living with life-threatening illness often
have multiple, complex, and interrelated problems that
emerge as part of their underlying disease processes (Table 1
and Figure 1). These issues impact their sense of personhood,
diminish their sense of well-being, and impair their ability to
realize their full potential. Psychiatric complications in these
patients are frequently challenging to assess and require
expert knowledge, skills, and experience to diagnose and
manage (Table 1).
When a patient’s life expectancy is believed to be short, there
is frequently an urgency for the patient and family to complete
numerous tasks, such as saying goodbye and realizing their
full potential together before the loss occurs. After the death,
bereaved families often need help to face their loss, cope with
their emotions, transition their roles and responsibilities, and
rebuild their lives.
While family practitioners, general internists, and palliative
care clinicians can all develop core competencies regarding
psychiatric complications in the context of providing pallia-
tive care, when the situation and potential treatments are com-
plex, and the risk of medication interactions and (or) adverse
events high, the health care team will benefit greatly from con-
sultation and support from experienced psychiatrists and
mental health professionals.
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The Opportunity for Psychiatry in Palliative Care
What better role for psychiatrists and mental health profes-
sionals to perform than to help people address their needs for
physical comfort, safety, love, and esteem, and to realize their
full potential? Within the context of palliative care, this
means helping patients and families maintain their dignity,
while achieving as much comfort and peace of mind as possi-
ble. Such an approach will enable families to cope as opti-
mally as possible during this stressful period, and avoid the
likelihood of a protracted or complicated bereavement. It will
also help families to move into the next phase of their lives, it
is hoped with memories of the deceased least tainted by the
experience of illness and how the life of their loved one
ended. In other words, it will help them “follow the path of
least regret” and mitigate the possibility of a complicated and
protracted bereavement (Harvey Max Chochinov, 23 May
2008, personal communication).
Not only are the personal rewards and opportunities for clini-
cal work, education, and research in palliative care psychia-
try outstanding, work in this field will help establish a
standard of care that embraces the essence of quality and
compassionate care. It is also worth pondering that “the stan-
dards of practice we create and the people we train will look
after us when it is our turn to receive care.”12 Will your health
care system be competent to maintain your comfort and meet
your needs, ensuring that you and your family face death with
as much comfort, peace of mind, and dignity as possible?
Psychiatrists are well poised to ensure that the answer to this
provocative question is yes.
Funding and Support
This work was supported, in part, by the John A Hartford Center
of Excellence in Geriatric Psychiatry at the University of
California, San Diego, and by donations from the generous
benefactors of the education and research programs of the Center
for Palliative Studies at The Institute for Palliative Medicine at
San Diego Hospice and Palliative.
The Canadian Psychiatric Association proudly supports the In
Review series by providing an honorarium to the authors.
Acknowledgements
The authors acknowledge the support from the staff of the
Institute for Palliative Medicine at San Diego Hospice. We thank
Dr Harvey Max Chochinov for the invitation to write this
manuscript, for permission to reference his personal
communication, and for his helpful comments throughout.
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Manuscript received May 2008, revised, and accepted June 2008.
1
Director, Psychiatry Programs, The Institute for Palliative Medicine at
San Diego Hospice, San Diego, California.
2
Director, International Programs, The Institute for Palliative Medicine at
San Diego Hospice, San Diego, California.
Address for correspondence: Dr SA Irwin, Director, Psychiatry Programs,
The Institute for Palliative Medicine at San Diego Hospice, 4311 Third
Avenue, San Diego, CA 92103; sirwin@sdhospice.org

Résumé : L’opportunité de la psychiatrie dans les soins palliatifs

Le besoin de psychiatres pour travailler auprès de patients et de familles vivant avec des maladies
chroniques possiblement mortelles n’a jamais été aussi criant. En outre, les psychiatres peuvent
découvrir un travail passionnant dans le domaine relativement nouveau des soins palliatifs, qui se
consacrent à la prévention et au soulagement de toute souffrance. De plus en plus, les gens vivent
plus longtemps avec des problèmes multiples qui causent des souffrances, entravent leur vie, et
entraînent souvent des séquelles psychosociales. Afin d’assurer des soins de pointe aux patients et à
leurs familles, durant toute la maladie et durant la période de deuil qui s’ensuit, il faut de nombreux
psychiatres d’expérience comme conseillers et membres d’équipes de soins palliatifs
interdisciplinaires. Ce besoin présente aux psychiatres d’infinies possibilités de soigner les patients,
de leur offrir une éducation, et de s’adonner à la recherche. La possibilité de faire une différence est
immense.

724 W La Revue canadienne de psychiatrie, vol 53, no 11, novembre 2008