Far less attention is paid by mental health clinicians to aspects of death and dying. This Psychiatric Times Death and Dying Special Report helps fill some of that gap.
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SPECIAL REPORT: DEATH & DYING
“Death is no enemy of life; it restores our sense of the value of living. Illness restores the sense of proportion that is lost when we take life for granted. To learn about value and proportion we need to honor illness, and ultimately to honor death.” —Arthur W. Frank1
As mental health clinicians, we often confine our conversations about death and dying to recognizing suicide risk and preventing suicide. And for good reason. Suicide is the 11th leading cause of death in the United States, the 3rd leading cause for individuals aged 15 to 24 years, and the 2nd leading cause for individuals aged 25 to 34 years.2 Every suicide is a tragedy that affects not only the deceased’s immediate and extended family, but also friends and acquaintances, health and mental health professionals, clergy, police, firefighters, funeral directors, coroner’s office staff, and others who may be involved in discovery or processing activities related to the death. The estimated suicide rates may be only the tip of the iceberg. The Centers for Disease Control and Prevention (CDC) estimates that 4.8% of adults in the US have thought about suicide, 1.6 million have attempted suicide, and more than 50% have been affected by suicide in some way.2
Treating Prolonged Grief Disorder: Innovations and Future Directions
Daniella Spencer-Laitt, MA; Henry A. Willis, PhD; Natalia Skritskaya, PhD; M. Katherine Shear, MD
Suffering Revisited: Tenets of Intensive Caring
Harvey Max Chochinov, MD, PhD, FRCPC
Guidelines for Supporting the Dying and Their Families
Ken Druck, PhD
CME: End-of-Life Care for Patients With Psychiatric Disorders
Joel Yager, MD; Jonathan Treem, MD; and Thomas B. Strouse, MD
Far less attention is paid by mental health clinicians to other aspects of death and dying. But we are human, first and foremost, and coping with a host of issues related to the end of life is inextricably bound to both our professional and personal lives. Like it or not, death is part of life. We, as mental health clinicians, are not always as prepared as we would like to be to help ourselves, our loved ones, our patients, and their loved ones deal with loss, dying, death, and bereavement. For many physicians, 1 or 2 hours in medical school and perhaps another few hours during residency are all the training we receive in these complex and challenging clinical issues.3,4 This Psychiatric Times Death and Dying Special Report helps fill some of that gap. The special report features 4 timely articles highlighting novel approaches to help support patients and their families in these most challenging periods.
Chochinov provides a clinician’s guide for “being with” dying patients. He offers ways of providing intensive caring to enhance empathy, respect, connectivity, and hope, and to make the experience of a dying patient more tolerable than it otherwise might be. Since reading the first draft of this manuscript, I have utilized his Patient Dignity Question, which asks, “What do I need to know about you as a person to take the best care of you possible?” on several occasions with gratifying results for both the patient and me.
Druck provides a road map for clinician self-care that also can be offered to patients and families to help them navigate the process of death and dying. He shares the tragedy of losing his daughter to sudden and unanticipated death and illuminates his guidelines with personal vignettes and examples. He also provides pragmatic guidelines for honoring one’s loved one after they have died, and he discusses what clinicians should—and should not—do, as well as what to share with family members, friends, neighbors, coworkers, and other mental health professionals.
In the coordinating CME, Yager et al focus on caring for individuals with psychiatric disorders at the end of life. They make a point that is rarely discussed in psychiatric circles: Some psychiatric disorders can themselves result in terminal conditions, such as sometimes seen in patients with anorexia nervosa. Absent effective treatments, clinicians are still morally obligated to care for these patients. Yager et al describe some of the roadblocks to transitioning to palliative care and guidelines for providing it when appropriate. They also introduce the controversial and divisive topic of medical aid in dying (MAiD) for patients with intractable symptoms attributed to their mental disorders. Although there is no consensus on if or when MAiD is indicated, it is a topic that cannot be ignored.
Finally, in an article available online, Spencer-Laitte et al describe an evidence-based treatment for a common, serious, and distressing clinical condition: prolonged grief disorder (PGD). PGD has only recently been formalized by the ICD and DSM and is relatively underappreciated in most clinical settings.5 PGD is particularly prevalent in certain populations, such as those bereaved by suicide. Prolonged grief therapy (PGT) is robustly effective for PGD,6 including for those who have lost someone to suicide.7 There is reason to believe that treating someone with PGD with PGT following suicide-loss may be an effective prevention technique.8 Now that we have compelling evidence that PGT is highly effective for PGD, this article focuses on the all-important next step, which is how to implement PGT and/or other evidence-based treatments in clinical settings.
It is time to put education and training on death and dying on the front burner for health students, trainees, and mental health clinicians. The topic has been taboo for too long, perhaps especially in the medical culture in the US. We hope this special report provokes further conversation, debate, and dialogue.
Dr Zisook is a distinguished professor of psychiatry at UC San Diego in California.
References
1. Frank AW. At the will of the body: Reflections on illness. Houghton Mifflin Harcourt; 2002.
2. Centers for Disease Control and Prevention. Data & Statistics Fatal Injury Report for 2022. May 11, 2024. Accessed August 12, 2024. https://wisqars.cdc.gov/reports/
3. Patterson L, Decker A, Weaver R, et al. Death and dying education in US medical schools: a scoping review. Innov Aging. 2023;7(suppl 1):311.
4. Wynter K, Brignall R. End-of-life medical education: is it dead and buried? Med Teach. 2020;42(9):1065-1066.
5. Prigerson HG, Shear MK, Reynolds CF 3rd. Prolonged grief disorder diagnostic criteria—helping those with maladaptive grief responses. JAMA Psychiatry. 2022;79(4):277-278.
6. Shear MK, Reynolds CF 3rd, Simon NM, et al. Optimizing treatment of complicated grief: a randomized clinical trial. JAMA Psychiatry. 2016;73(7):685-694.
7. Zisook S, Shear MK, Reynolds CF, et al. Treatment of complicated grief in survivors of suicide loss: a HEAL report. J Clin Psychiatry. 2018;79(2):17m11592.
8. Jordan JR. Postvention is prevention—the case for suicide postvention. Death Stud. 2017;41(10):614-621.
