Palliative Care Psychiatry

Palliative Care Psychiatry, or as I call it, Palliative Psychiatry, is not a formal field, per se, though Psychiatry in Palliative Medicine is a growing area of study and practice. ‘

The most commonly and officially cited definition of Palliative Care is that put forth by the World Health Organization (WHO): “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” Of course, you will note psychosocial issues are subsumed therein.

Indeed, the modern Hospice Movement, from which Palliative Care emerged and in which, in its current realization within the U.S., Palliative Care is practiced, is largely seen as coming from the field of nursing as its founder, Dame Cicely Saunders, is largely recognized as a nurse, though she also became a social worker and, eventually, a physician. Indeed, much of the practice of interdisciplinary treatment conducted in the palliative care and hospice setting stems from the tradition of such practice that has existed within Psychiatry. Palliative Care practioners, in the same way that has historically been the case for Psychiatric consultants, have come to often be called upon to by overwhelmed medical providers to help deal with complex psychosocial issues which are difficult to face without such further support. As such, the field of Palliative Care has much to learn from the vast literature within Psychiatry and, specifically, its own subspecialty of Psychosomatic Medicne or Consultation-Liaison Psychiatry, in addressing these issues and the charged dynamics that may exist between patient, family, and provider in such circumstances of heightened and multifaceted distress.

Palliative Care as a formal medical subspecialty is called Hospice and Palliative Medicine, and probably subsumes the most potentially broad area, as such, in medicine (amongst the American Board of Medical Subspecialties), allowing physicians within 10 different specialty medical boards – Internal Medicine (not to mention all of its core subspecialties) Family Medicine, Anesthesiology, Emergency Medicine, Obstetrics and Gynecology, Pediatrics, Physical Medicine and Rehabilitation, Psychiatry, Neurology, Radiology, and Surgery – to pursue training in the field, not to mention the various other fields of medical care which have specialty-level Palliative Care education, including Nursing, Social Work, and Psychology.. A major factor in this, as I understand it, is that Palliative Care is as much a philosophy and approach to medical practice, as it is a distinct subspecialty, as evidenced by a major mission in the field being education. I mention this further to point out that Psychiatry is subsumed within this. One might think twice about some of these areas, though on quick consideration a clear rationale for involvement is evident. Palliative Care in Emergency Medicine is an area of huge import, even from a public health perspective, and is an active and flourishing area of study at present. Radiology includes interventional techniques which may address burdensome symptoms such as pain with minimal invasiveness. Surgery, likewise, can be conducted for palliative indications, again an area of important consideration. Anesthesiology, PM&R, and Neurology are all involved in pain management, for one. Internal Medicine may be most obvious, including, in particular, the subspecialty fields of Geriatrics and Oncology. Psychiatry takes on substantial focus, apart from the others, and does potentially subsume an entirely independent area of work if only for its relative lack of recognition, particularly with respect to the magnitude of its importance.

In the defining text on the topic now approaching its 3rd Edition, – the Handbook of Palliative Care in Psychiatry, the authors, William Breitbart and Harry Max Chochinov, refer to the evolving field as Psychiatric (or Psychosocial) Palliative Care and note that the last decade has seen an “all-encompassing multidisciplinary approach to care for the dying beginning to take hold” in palliative care which had heretofore been predominantly focused on somatic issues, overshadowing focus on psychological, existential, and spiritual issues at the end of life. How could it not? The universal issues facing people approaching death – “encountering illness, facing vulnerability, and confronting mortality”– have psychological import. In the Foreword to the 2nd Edition, Kathy Foley writes that, while psychological distress, while common, diagnosable, and treatable, in patients with serious life-limiting illnesses is often under-assessed, undertreated, and sometime stigmatized. She gives examples of potential issues including managing a family’s grief, caring for a dying child, providing pain management for a patient with a substance use disorder, or addressing death and dying in patients with serious or chronic mental illness.

To the extent that palliative care, most broadly defined, is expanding a focus of care to managing the burdensome symptoms related to an illness and its treatment, and their associated distress and burden/ impingement on quality of life, alongside the prospect of pursuing treatment only targeting the disease itself, issues addressed in palliative care by psychiatry generally include the management of psychiatric symptoms – such as the manifestations of delirium (agitation and confusion), depression, or demoralization, or existential despair/ crisis, anxiety/ fear/ nervousness, as well as insomnia, or even fatigue, concentration problems, or lack of appetite– in addition to physical ones like pain (which is only artificially extracted from a psychological underlay) or nausea. Psychiatric palliative care involves a range of interventions beyond psychopharmacologic maneuvers, including individual, group, or even family psychotherapies with supportive and existential approaches as well as bereavement focus, and separate spiritual or pastoral care. Some additional important topics in Palliative Care that fall in the psychiatric realm include Physician Assisted Suicide (only recognized in certain states, specifically Oregon and Washington)/ Euthanasia (prohibited in the U.S.) and desire for hastened death, and providing staff support.

Some well-known psychosocially oriented Palliative Care programs throughout the country include the San Diego Hospice which has an integrated Psychiatry and Palliative Care program, the Psychosocial Oncology program at Dana Farber Cancer Institute in Boston, as well as institutions with which I have been affiliated: the pre-eminent Division at Mount Sinai Hospital in New York where I attended medical school, and Department of Pain Medicine and Palliative Care at Beth Israel Medical Center, where I currently have a dual appointment along with the Psychiatry Department as part of my role serving as Director of Cancer Supportive Services at Continuum Cancer Centers of New York, as well as programs where I trained, including Memorial Sloan-Kettering Cancer Center where the field of Psycho-Oncology was founded in emergence with an early Palliative Care program, and the more recently developed service at Bellevue Hospital Center in New York, an institution well-known for its psychiatric service, where I completed my fellowship in Pain and Palliative Care and my residency in Psychiatry, respectively.

As an addendum, the first program which I mention, the San Diego Hospice, is that which is indicated as being the first of its kind in the country and founded by Dr. Scott Irwin, who is cited in the additional response to this question that I noticed been has helpfully posted. Palliative Care Psychiatry, or as I call it, Palliative Psychiatry, is not a formal field, per se, though Psychiatry in Palliative Medicine is a growing area of study and practice. ‘

The most commonly and officially cited definition of Palliative Care is that put forth by the World Health Organization (WHO): “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” Of course, you will note psychosocial issues are subsumed therein.

Indeed, the modern Hospice Movement, from which Palliative Care emerged and in which, in its current realization within the U.S., Palliative Care is practiced, is largely seen as coming from the field of nursing as its founder, Dame Cicely Saunders, is largely recognized as a nurse, though she also became a social worker and, eventually, a physician. Indeed, much of the practice of interdisciplinary treatment conducted in the palliative care and hospice setting stems from the tradition of such practice that has existed within Psychiatry. Palliative Care practioners, in the same way that has historically been the case for Psychiatric consultants, have come to often be called upon to by overwhelmed medical providers to help deal with complex psychosocial issues which are difficult to face without such further support. As such, the field of Palliative Care has much to learn from the vast literature within Psychiatry and, specifically, its own subspecialty of Psychosomatic Medicne or Consultation-Liaison Psychiatry, in addressing these issues and the charged dynamics that may exist between patient, family, and provider in such circumstances of heightened and multifaceted distress.

Palliative Care as a formal medical subspecialty is called Hospice and Palliative Medicine, and probably subsumes the most potentially broad area, as such, in medicine (amongst the American Board of Medical Subspecialties), allowing physicians within 10 different specialty medical boards – Internal Medicine (not to mention all of its core subspecialties) Family Medicine, Anesthesiology, Emergency Medicine, Obstetrics and Gynecology, Pediatrics, Physical Medicine and Rehabilitation, Psychiatry, Neurology, Radiology, and Surgery – to pursue training in the field, not to mention the various other fields of medical care which have specialty-level Palliative Care education, including Nursing, Social Work, and Psychology.. A major factor in this, as I understand it, is that Palliative Care is as much a philosophy and approach to medical practice, as it is a distinct subspecialty, as evidenced by a major mission in the field being education. I mention this further to point out that Psychiatry is subsumed within this. One might think twice about some of these areas, though on quick consideration a clear rationale for involvement is evident. Palliative Care in Emergency Medicine is an area of huge import, even from a public health perspective, and is an active and flourishing area of study at present. Radiology includes interventional techniques which may address burdensome symptoms such as pain with minimal invasiveness. Surgery, likewise, can be conducted for palliative indications, again an area of important consideration. Anesthesiology, PM&R, and Neurology are all involved in pain management, for one. Internal Medicine may be most obvious, including, in particular, the subspecialty fields of Geriatrics and Oncology. Psychiatry takes on substantial focus, apart from the others, and does potentially subsume an entirely independent area of work if only for its relative lack of recognition, particularly with respect to the magnitude of its importance.

In the defining text on the topic now approaching its 3rd Edition, – the Handbook of Palliative Care in Psychiatry, the authors, William Breitbart and Harry Max Chochinov, refer to the evolving field as Psychiatric (or Psychosocial) Palliative Care and note that the last decade has seen an “all-encompassing multidisciplinary approach to care for the dying beginning to take hold” in palliative care which had heretofore been predominantly focused on somatic issues, overshadowing focus on psychological, existential, and spiritual issues at the end of life. How could it not? The universal issues facing people approaching death – “encountering illness, facing vulnerability, and confronting mortality”– have psychological import. In the Foreword to the 2nd Edition, Kathy Foley writes that, while psychological distress, while common, diagnosable, and treatable, in patients with serious life-limiting illnesses is often under-assessed, undertreated, and sometime stigmatized. She gives examples of potential issues including managing a family’s grief, caring for a dying child, providing pain management for a patient with a substance use disorder, or addressing death and dying in patients with serious or chronic mental illness.

To the extent that palliative care, most broadly defined, is expanding a focus of care to managing the burdensome symptoms related to an illness and its treatment, and their associated distress and burden/ impingement on quality of life, alongside the prospect of pursuing treatment only targeting the disease itself, issues addressed in palliative care by psychiatry generally include the management of psychiatric symptoms – such as the manifestations of delirium (agitation and confusion), depression, or demoralization, or existential despair/ crisis, anxiety/ fear/ nervousness, as well as insomnia, or even fatigue, concentration problems, or lack of appetite– in addition to physical ones like pain (which is only artificially extracted from a psychological underlay) or nausea. Psychiatric palliative care involves a range of interventions beyond psychopharmacologic maneuvers, including individual, group, or even family psychotherapies with supportive and existential approaches as well as bereavement focus, and separate spiritual or pastoral care. Some additional important topics in Palliative Care that fall in the psychiatric realm include Physician Assisted Suicide (only recognized in certain states, specifically Oregon and Washington)/ Euthanasia (prohibited in the U.S.) and desire for hastened death, and providing staff support.

Some well-known psychosocially oriented Palliative Care programs throughout the country include the San Diego Hospice which has an integrated Psychiatry and Palliative Care program, the Psychosocial Oncology program at Dana Farber Cancer Institute in Boston, as well as institutions with which I have been affiliated: the pre-eminent Division at Mount Sinai Hospital in New York where I attended medical school, and Department of Pain Medicine and Palliative Care at Beth Israel Medical Center, where I currently have a dual appointment along with the Psychiatry Department as part of my role serving as Director of Cancer Supportive Services at Continuum Cancer Centers of New York, as well as programs where I trained, including Memorial Sloan-Kettering Cancer Center where the field of Psycho-Oncology was founded in emergence with an early Palliative Care program, and the more recently developed service at Bellevue Hospital Center in New York, an institution well-known for its psychiatric service, where I completed my fellowship in Pain and Palliative Care and my residency in Psychiatry, respectively.

As an addendum, the first program which I mention, the San Diego Hospice, is that which is indicated as being the first of its kind in the country and founded by Dr. Scott Irwin, who is cited in the additional response to this question that I noticed been has helpfully posted.