The Opportunity for Psychiatry in Palliative Care
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.
Available from: Eva K Masel
- "Psychopharmacological agents are frequently prescribed by nonpsychiatric physicians, which further underlines the necessity of disseminating knowledge about psychiatric diseases and their treatment (Wancata et al., 1998). Our data substantiate the need for psychiatrists as consultants and as members of interdisciplinary teams in the field of palliative care (Irwin & Ferris, 2008; Jaiswal et al., 2014). The treatment of depressive comorbidities requires comprehensive knowledge of psychopharmacological substances and should be administered by doctors with suitable expertise. "
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Our aim was to evaluate the frequency and treatment of psychiatric symptoms in patients at palliative care units (PCUs).
Patients admitted to one of five participating PCUs in Austria were included. The short version of the Patient Health Questionnaire (PHQ-D) was used to evaluate their mental health status. Pain intensity was rated on a numeric rating scale (NRS) from 0 to 10 by patients and physicians. Patients with a previously diagnosed psychiatric disorder were compared to those without or with newly diagnosed psychiatric symptoms, based on PHQ-D results. Pain and psychopharmacological medication were assessed. Opioid doses were converted into oral morphine equivalents (OMEs).
Some 68 patients were included. Previously undetected psychiatric symptoms were identified in 38% (26 of 68), preexisting psychiatric comorbidities were evident in 25% (17), and no psychiatric symptoms were observed in 37% (25). Patients with a preexisting psychiatric comorbidity received antidepressants and benzodiazepines significantly more often than patients without or with previously undetected psychiatric symptoms (p < 0.001). Patient and physician median NRS ratings of pain intensity correlated significantly (p = 0.001). Median NRS rating showed no significant difference between patients with preexisting, previously undetected, or without psychiatric symptoms. OMEs did not differ significantly between preexisting, without, or previously undetected psychiatric symptoms. Patients with undetected and preexisting psychiatric comorbidities had a greater impairment in their activities of daily living than patients without psychiatric symptoms (p = 0.003).
Significance of results:
Undetected psychiatric comorbidities are common in patients receiving palliative care. Screening for psychiatric symptoms should be integrated into standard palliative care to optimize treatment and reduce the psychosocial burden of the disease.
- "As compared to hospital death, home death with hospice care has been shown to offer significantly improved mental health outcomes for both patients and family. While roughly half or more of terminal patients are affected by depression and/or anxiety (Higginson & Costantini, 2008;Irwin & Ferris, 2008), end-of-life patients at home experience significantly less anxiety and depression than those who die in acute care (Grande et al., 2000;Gomes & Higginson, 2004;Temel et al., 2010;Shepperd et al., 2012). Family caregivers of patients who die at home have better outcomes in bereavement and suffer less complicated bereavement, posttraumatic stress (Wright et al., 2010), and depression (Bradley et al., 2004) than caregivers of those dying in hospitals . "
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To explore the unique lived experiences of one patient who died at home and her family members, and to interpret how dying at home influenced patterns of bereavement for this patient's family.
Benner's (1985) interpretive phenomenological approach was employed to get at the embedded nature of the social phenomenon of dying at home, uncovering what may be taken for granted by participants — in this case, during and after the patient's home hospice course. The participants were a 78-year-old female diagnosed with amyotrophic lateral sclerosis six months prior to death, her husband, and three of her four children. In line with the patient's wish to die at home, she voluntarily forewent food and drink when she no longer wished to watch her body deteriorate and felt that her life had run its course. She informed her family of this plan, and all were supportive. For data collection, separate single in-depth interviews were conducted with the deceased three months prior to death, and after death with three of her four children and her spouse of 60 years. For data analysis, the interview transcripts were coded for paradigm cases, exemplars, and themes.
The paradigm case, “The Meaning of Being at Home,” revealed that for study participants, remaining home with hospice provided a richly familiar, quiet, and safe environment for being together over time and focusing on relationships. Exemplars included “Driving Her Own Course” and “Not Being a Burden.” Salient themes encompassed patient and family characteristics, support, emotions, the value of time, and aspects of the healthcare team.
Significance of results:
End-of-life care providers need to hold a patient-centered, family-focused view to facilitate patient and family wishes to remain home to die. Investigation into family relationships, from the perspectives of both patient and family members, longitudinally, may enrich understanding and ability and help patients to die at home.
Available from: Scott A Irwin
- "First a more thorough assessment of the target audience is needed. Clinicians will vary in their knowledge and skills about the assessment, diagnosis , and management of psychiatric issues as they relate to patients with life-threatening illnesses (Irwin & Ferris, 2008). Nonpalliative-care physicians and other members of the general health care team will need to achieve and maintain basic core competencies in the psychiatric aspects of palliative medicine. "
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