Article

The opportunity for psychiatry in palliative care.

Psychiatry Programs, The Institute for Palliative Medicine at San Diego Hospice, San Diego, California 92103, USA.
Canadian journal of psychiatry. Revue canadienne de psychiatrie (Impact Factor: 2.41). 12/2008; 53(11):713-24.
Source: PubMed

ABSTRACT 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.

0 Bookmarks
 · 
68 Views
  • [Show abstract] [Hide abstract]
    ABSTRACT: Palliative care consult services have emerged as an excellent resource for physicians seeking help with patients' symptoms. Symptoms include those of a psychiatric nature (e.g., depression, anxiety, delirium); however, little information is known about whether palliative care services include psychiatric input as part of multidisciplinary teams. To explore 1) the current level of collaboration between psychiatrists and palliative care consult services across the U.S. and 2) the factors that support or restrict such involvement. A national survey was developed and distributed electronically to program directors identified in the National Palliative Care Registry maintained by the Center to Advance Palliative Care. Analyses examined trends in psychiatry involvement with hospital-based palliative care teams. The survey had a 59% response rate, with final analyses including surveys completed by 260 palliative care program directors (67% inclusion rate from total respondents). Seventy-two percent of respondents reported some form of involvement with a psychiatrist on their palliative care service, with only 10% of those identifying a psychiatrist as a full- or part-time member of the team. Most respondents reported that they would like psychiatrists to be more involved with the palliative care services (71%). Secondary analyses of qualitative responses identified common impediments to increased psychiatry involvement, which included financial constraints, provider interest, and perceived disciplinary disconnect. There are shared objectives between psychiatry and palliative care; however, currently, co-involvement on treatment teams is quite limited. Future research is needed to identify ways to facilitate the interface of palliative care and psychiatry.
    Journal of pain and symptom management 10/2013; 47(6). DOI:10.1016/j.jpainsymman.2013.06.015 · 2.42 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: This investigation sought to systematically identify and characterize a cohort of patients treated in hospice for life-limiting injuries sustained in a suicide attempt that was not immediately lethal. Method: We developed a case series of all completed suicides in a large, community-based hospice, from 2004 through 2010. Clinical documentation and county medical examiner reports were used to identify those deaths that resulted from a suicide attempt made prior to hospice admission. Cases were characterized in terms of basic demographic variables, the temporal sequence of events in the transition from hospital care to hospice, the mechanism of injury and medical complications, the presence of mental illness, and family involvement in decision making. Results: Out of a total of 20,887 hospice deaths during the study period, 8 deaths resulted from an incomplete suicide attempt made prior to hospice admission. Subjects were nearly all male (6/8), and 46 years old on average; substantially younger than the general hospice population. Drug overdose was the most common method of suicide (5/8), and irreversible anoxic brain injury was the main medical complication. The majority of subjects (6/8) had evidence of serious mental illness. Most cases were complicated by estranged family relationships; however, family members were involved in end-of-life decision making for nearly all patients. Significance of results: Whereas a failed suicide attempt leading to hospice appears to be a relatively rare event, patients in this population appear unique in several regards. Further study may serve to better characterize this group and prepare hospice agencies and clinicians for caring for this unique population.
    Palliative and Supportive Care 06/2013; 11(3):273-6. DOI:10.1017/S1478951513000096 · 0.98 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Abstract Background: Depression and anxiety are prevalent and undertreated in patients receiving hospice care. Standard antidepressants do not work rapidly or often enough to benefit most of these patients. Ketamine has many properties that make it an interesting candidate for rapidly treating depression and anxiety in patients receiving hospice care. To test this hypothesis, a 28-day, open-label, proof-of-concept trial of daily oral ketamine administration was conducted in order to evaluate the tolerability, potential efficacy, and time to potential efficacy in treating depression and anxiety in patients receiving hospice care. Methods: In this open-label study, 14 subjects with symptoms of depression or depression mixed with anxiety warranting psychopharmacological intervention received daily oral doses of ketamine hydrochloride (0.5 mg/kg) over a 28-day period. The primary outcome measure was the Hospital Anxiety and Depression Scale (HADS), which was used to rate overall depression and anxiety symptoms at baseline, and on days 3, 7, 14, 21, and 28. Results: Over the 28-day trial there was significant improvement in both depressive symptoms (F5,35=8.03, p=0.002, η(2)=0.534) and symptoms of anxiety (F5,35=14.275, p<0.001, η(2)=0.67) for the eight subjects that completed the trial. One hundred percent of subjects completing the trial responded to ketamine for both anxiety and depression. A significant response in depressive symptoms occurred by day 14 for depression (mean Δ=3.5, d=1.14, 95% CI=1.09-5.9, p=0.01) and day 3 for anxiety (mean Δ=2.4, d=0.67, 95% CI=1.0-3.7, p=0.004). These improvements remained significant through day 28 for both depression (mean Δ=4.0, d=1.34, 95% CI=2.3-5.9, p=0.001) and anxiety (mean Δ=6.09, d=1.34, 95% CI=3.6-8.6, p<0.001). Side effects were rare, the most common being diarrhea, trouble sleeping, and trouble sitting still. Conclusions: Patients who received daily oral ketamine experienced a robust antidepressant and anxiolytic response with few adverse events. The response rate for depression is similar to those found with IV ketamine; however, the time to response is more protracted. The findings of the potential efficacy of oral ketamine for depression and the response of anxiety symptoms are novel. Further investigation with randomized, controlled clinical trials is necessary to firmly establish the efficacy and safety of oral ketamine for the treatment of depression and anxiety in patients receiving hospice care or other subject populations.
    Journal of palliative medicine 06/2013; DOI:10.1089/jpm.2012.0617 · 1.84 Impact Factor