Palliative Psychiatry May Ease Suffering, Protect Against Futile Treatments

Some people with serious and enduring mental illness—who have exhausted evidence-based treatment and are declining further care—may benefit from a palliative psychiatry approach.

Although the United States has been slower to adopt palliative medicine than many other countries, this outgrowth of the hospice movement became its own medical specialty in this country in 2006. Its scope has widened considerably in the last two decades and is increasingly being provided earlier in the disease course and even alongside curative treatment. A palliative approach is being used to care for people with a variety of serious chronic illnesses, including psychiatric disorders.

“While curative psychiatry primarily aims at remission of mental illness, by contrast palliative psychiatry works around the mental illness focusing on symptom relief, improvements in day-to-day functioning, increases in quality of life, and harm reduction with the fewest restrictions,” Manuel Trachsel, M.D., Ph.D., head of the Clinical Ethics Unit at the University Hospital of Basel and senior lecturer at the Medical Faculty of the University of Basel in Switzerland, told Psychiatric News.

“Palliative psychiatry places great emphasis on maintaining the respect of people with severe and persistent mental illness who may face stigma and discrimination and have often been forced to undergo burdensome or futile treatments for most of their lives,” Trachsel said. “Palliative psychiatry aims to give people the opportunity to maintain a sense of control and autonomy in their lives.” To that end, it can help protect against polypharmacy, overly aggressive treatment, or even neglect.

Even with optimal treatment, about one-fifth of people with serious mental illness (SMI) do not achieve remission or an acceptable quality of life. In addition, with each unsuccessful treatment, the evidence base for further treatment becomes thinner, and the probability of symptom reduction declines, according to Anna L. Westermair, M.D., and colleagues in the December 2022 issue of the Australian & New Zealand Journal of Psychiatry. At the same time, intolerable side effects become more likely.

Rick Brian

“The idea of palliation is that we focus less on what is called in oncology ‘the war against the disease,’ which sometimes takes the person out of the equation, and more on reduction of suffering … and what the patient wants,” Thomas B. Strouse, M.D., a psychiatrist and palliative care specialist at the Stewart and Lynda Resnick Neuropsychiatric Hospital at the University of California at Los Angeles, told Psychiatric News. “Psychiatry has been slower than the rest of medicine to recognize that a palliative focus of improving quality of life, rather than solely extending quantity of life, is an important and valid treatment goal.”

Although psychiatric illnesses tend to be thought of as having no organic basis, many people with these disorders develop life-endangering comorbidities as they age, Strouse said. In fact, people with SMI have a much higher prevalence of chronic diseases that tend to be diagnosed later in life and are more severe than those of the general population. According to a viewpoint by Kwok Ying Chan and colleagues in JAMA Psychiatry in September 2023, patients with SMI are only one-third as likely to receive palliative care as the general population (only 0.5% versus 1.7%).

People who have received repeated rounds of involuntary, unsuccessful treatments; who are miserable and suffering; who refuse curative treatments; and/or who are near end-of-life due to medical comorbidities may be candidates for a palliative approach, Joel Yager, M.D., professor emeritus of psychiatry at the University of Colorado School of Medicine at the Anschutz Medical Campus, told Psychiatric News. They may include people with severe and enduring forms of anorexia, major depression, schizophrenia, or personality disorders.

“Palliative psychiatry does not impose treatments on patients; rather, it allows them to pick and choose from a menu of treatment options. At its core, it is advanced supportive care; it’s life-affirming care. It offers understanding, acceptance, and encouragement,” Yager said.

What’s more, palliative care may help protect patients from futile forced interventions, which can inflict trauma and shame, Yager said. “There’s some evidence that if families are really insistent, … treatment clinics and physicians are more inclined to impose coercion and involuntary treatment on patients.” By contrast, palliative care puts adult patients—rather than clinicians, the treatment facility, or even the family—in charge of their own care. However, he cautioned that this type of care alone should not be used for children, adolescents, or individuals who haven’t received high-quality, active treatment.

Important Considerations

Sarah Levitt, M.D., M.Sc., a psychiatrist at the University Health Network, associate director of the Azrieli Brain Medicine Fellowship Program, and an assistant professor of psychiatry at the University of Toronto, told Psychiatric News that palliative care for psychiatric disorders is in its infancy and needs to be better defined, with input from patients and their advocacy groups. “We want to address patient suffering in a different way, in a way that provides comfort. Only patients can decide what that is,” said Levitt, who has extensively researched ethics and the development of palliative medicine in psychiatry.

Levitt added that more work is also needed to refine the ethical decision-making process governing when psychiatrists should introduce a palliative care approach. “These need to be highly collaborative discussions with patients, their caregivers, their team, and whomever they rely on for support. These aren’t decisions that clinicians should make single-handedly,” she added.

One of the biggest challenges remains aligning a palliative approach with psychiatrists’ existing medical-legal responsibilities, including the need to detain individuals deemed a danger to themselves or others, added Levitt. “How do you align that with a palliative approach, which aims at being less coercive?”

Levitt and Trachsel said they are both proponents of the so-called bowtie model, which overlaps palliative care with curative treatments. Yager agreed: “The use of palliative care in no way rules out the possibility of trying a new approach, of more active treatment,” he said, adding that he is quick to inform his patients of new treatments as soon as they become available. “I tell my patients, ‘Let’s see if there’s anything else we can do.’ ”

Ultimately, Levitt said the option of palliative care for people with serious psychiatric disorders is particularly important in Canada, where she practices. That’s because a new law expected to take effect there soon will allow adults with SMI as their sole underlying condition to apply for Medical Aid in Dying (MAID).

“It’s not ethical for the sole option to be treatment as usual, in other words, pursuing remission or symptom reduction, versus MAID. There needs to be some palliative middle ground, one that is focused more on alleviating patient suffering and attaining what is meaningful in the patient’s life.”

As of press time, however, the Canadian government was still weighing its options on whether to allow MAID for people with SMI to begin this month as planned. Canada’s Centre for Addiction and Mental Health, its largest mental health teaching hospital, asked the government late last year for a delay, citing lack of readiness of its health system.

Palliation: Controversy, Benefits

Palliative care for people with SMI remains controversial for myriad reasons. Strouse said that palliative care options raise important ethical concerns, especially the need for a careful assessment of a patient’s previous treatment and capacity to choose this type of care. “Some psychiatrists say we should be very skeptical and have a very high standard for determining whether a patient with SMI has capacity to provide an informed consent.”

Deciding at what point in a patient’s illness to offer a palliative approach is also problematic. “In contrast to many physical illnesses, it is often difficult to make a precise diagnosis or predict the course and consequences of a mental illness,” Trachsel said. “Especially, it is challenging to determine from which point each additional curative attempt is futile or even harmful.”

Ultimately, Trachsel believes that the benefit of palliative care for SMI outweighs the risks. “Palliative psychiatry is often mistaken for giving up on a patient. However, the opposite is the case: It involves an unconditional maintenance of the therapeutic relationship.”

Yager said that palliative care keeps patients in treatment who have been turned away from traditional clinics for failure to comply with strict requirements, such as meeting weight targets, attending group therapy, or taking specific medications as a condition of participation.

“When pressures to get better are removed, patients often feel less distressed, freer, and more empowered,” Yager said. “Consequently, they may be better able to achieve stability or even modestly improve, more than might otherwise be expected.” ■