C-L Psychiatrists Bring Expertise to End-of-Life Care

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Consultation-liaison (C-L) psychiatrists have much to contribute to end-of-life care for patients with psychiatric illness, especially those with severe and persistent mental illness (SPMI), such as schizophrenia. Consider the role of the C-L psychiatrist in the following case:

Mr. F was a 68-year-old man with a history of treatment-refractory schizophrenia and metastatic colorectal cancer who was admitted to an academic hospital for management of intractable abdominal pain and psychiatric decompensation.

Mr. F had previously spent 10 years at a state psychiatric facility, where his symptoms included paranoia, bizarre delusions, and auditory hallucinations that limited his ability to live independently. He had a legal guardian and often required forced medications due to medication refusal and poor insight. Despite times of improvement, he often suffered recurrence of symptoms in the context of treatment self-discontinuation. He did not have a written advanced directive.

Mr. F received his diagnosis of cancer three years prior to this admission. After confirmation of the cancer diagnosis, he had a primary bowel resection followed by chemotherapy. Recent imaging demonstrated significant metastatic burden to liver, lungs, and brain.

On hospital presentation, Mr. F was experiencing pain, abdominal distention, and severe itching, which was due to a worsening obstructive liver lesion and hyperbilirubinemia. He was disorganized in his thought process and paranoid, reporting concerns that staff members were poisoning him.

Over the course of treatment, psychiatric, oncologic, and palliative care consultations were pursued. The C-L psychiatrists performed capacity assessments and adjusted medication recommendations based on the presence of hepatic dysfunction. With psychiatric treatment, the patient’s insight and paranoia improved slightly, though symptoms persisted. The C-L psychiatrist and collaborating clinical teams worked closely with both the patient and his state-appointed guardian to assist in difficult medical decisions. The patient had limited dispositional options available to him due to the behavioral component of his illness. Eventually, his cancer care shifted to focus on quality of life. The psychiatry and palliative care teams worked together to alleviate his symptoms including pain and existential distress. He passed away peacefully during the hospitalization.

Discussion

There is a need for specialized end-of-life care for patients with SPMI. People with SPMI have reduced life expectancy partially related to increased rates of suicide and injury, though primarily due to natural causes such as cardiovascular disease. Patient-related factors such as smoking, substance use, and diet as well as clinical factors such as stigma, poorer recognition of treatable medical issues, and the metabolic side effects of antipsychotic medications are contributory.

Despite the increased risks of premature death, more than half of people with schizophrenia live into their late 70s. People with SPMI are less likely to have formulated advance directives or designated a substitute decision-maker. It is important to note that lack of advance directives is generally not because individuals with SPMI are incapable of voicing their preferences or values; historically, those with SPMI have often been excluded from participating in their own health care decision-making due to a lack of understanding by other health professionals about the assessment of capacity, limited exposure to individuals with SPMI, and lack of education about these situations. Evidence that people with SPMI receive less hospital care, home care, or formal palliative care and spend more time in nursing homes at the end of life suggests there is much to be improved.

C-L psychiatrists may contribute to the care of patients with SPMI in many ways. A C-L psychiatrist may monitor psychiatric medication regimens in the setting of failing organ systems. They may also advocate for patients with SPMI, educate other team members (for example, regarding trauma-informed care), or assist with capacity assessments. Capacity assessments may be medically, legally, and/or ethically complicated and lend themselves well to a C-L psychiatrist’s input. Diminished capacity is not the same as complete absence of capacity, which is a common misconception. A collaborative and supportive decision-making approach is more patient centered than strictly substituted decision-making. This is further underscored when considering treatment over objection, which may not align with the patient’s long-standing values and choices.

Furthermore, as goals of care move from treating a reversible condition to reducing suffering and improving quality of life, C-L psychiatrists can call attention to physical, social, psychological, and spiritual contributors to symptoms. C-L psychiatrists may engage patients in end-of-life psychotherapy with analysis of psychological symptoms and existential distress. Palliative care specialists and C-L psychiatrists can collaborate in the assessment and management of psychological symptoms in both patients and caregivers.

In summary, the treatment of individuals with SPMI at the end of life requires special attention and is optimized through a collaborative interdisciplinary approach among C-L psychiatrists, palliative care medical specialists, spiritual care providers, and other indicated specialists. Future directions include eliciting input from patients so that their perspectives are represented in this discussion and advocating for instruction in palliative psychiatry to improve the care of individuals with SPMI at the end of life. ■

Gregg Robbins-Welty, M.D., M.S., is a fourth-year resident in the combined internal medicine and psychiatry residency program at Duke University Hospital, where he serves as the chief resident for consultation-liaison psychiatry. He is also an APA/APAF Leadership Fellow.

Diana V. Punko, M.D., M.S., is an attending physician at Massachusetts General Hospital.

Alan Bates, M.D., Ph.D., is the provincial practice leader for psychiatry and acting program medical director for supportive cancer care at BC Cancer and past president of the British Columbia Psychiatric Association.