Psychiatry’s Place in Caring for the Terminally Ill

Despite what Benjamin Franklin said, the only really certain thing in life is death (he was a bit off on that taxes thing, since people have found ways to evade them either by lawful or illegal means). Very few of us know when it will occur but, at some point, occur it will. Even the greatest escape artist of all, Harry Houdini, couldn’t find a way to escape death, even though he sought a way to do so.

It is understandable that it is not a topic most of us like to spend very much time thinking about. At one time, how or when you died was essentially unalterable. However, we now have a number of different options that affect these variables and, as health care professionals, we have the responsibility to understand them so we can best guide our patients.

[[{"type":"media","view_mode":"media_crop","fid":"29792","attributes":{"alt":"psychiatry and end-of-life care","class":"media-image","id":"media_crop_1085869097002","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3110","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","title":"","typeof":"foaf:Image"}}]]The Institute of Medicine (IOM) recently released its report Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life, and its general thrust is that we have a long way to go in providing appropriate care for those nearing the end of their lives.¹ It’s a long document (several hundred pages) so it’s impossible for me to discuss all of it. But there are several portions of special importance to psychiatrists, especially the discussion of the role psychiatrists could and, in my view, should be playing regarding end-of-life decisions as well as, not coincidentally, pain management.

Palliative care includes many different interventions; the IOM defines it as “care that provides relief from pain and other symptoms, that supports quality of life, and that is focused on patients with serious advanced illness and their families.” The specific mention of pain management highlights its importance.

The IOM report also notes the importance of areas that are widely considered to fall under the purview of psychiatry, stating that the care should, in addition to offering relief of physical symptoms, provide “management of emotional distress” and “counseling of patient and family.” One hopes that physicians who specialize in palliative care are trained to provide this. However, based on my own experience, this is not always the case. The majority of physicians who are board-certified in hospice and palliative care are internists, and it is doubtful that many have spent much of their residencies focusing on managing emotional stress or counseling patients.

Another aspect of the IOM report of special interest is its conclusions as to why many patients don’t receive proper palliative care and its recommendations on how to improve the situation. The report notes that there is insufficient attention paid to palliative care in medical school and physicians aren’t being taught the communication skills needed to provide this type of care. Moreover, there isn’t much interest in developing interprofessional teams that could provide palliative care. The report recommends that “educational institutions, credentialing bodies, accrediting boards, state regulatory agencies, and health care delivery organizations should establish the appropriate training, certification, and/or licensure requirements to strengthen palliative care knowledge and skills of all clinicians who care for individuals with advanced serious illness who are near the end of life.”

Reading these conclusions and recommendations, I have a tremendous sense of déjà vu-these are the same problems encountered in pain management and the same solutions that need to be implemented. Why the authors of the report expect more improvement to result from their call to action regarding palliative care than similar ones that have been issued for years regarding pain management is beyond me.

I hope I am wrong and that the IOM report will have a significant impact on the care of terminally ill patients. However, everything in my experience having to do with improving pain management indicates that the current report will have little, if any, effect and that the same problems cited in it will continue-the recommendations will be only minimally implemented, if at all. Pain management and palliative care will not receive proper attention in medical education until they are fitted into one of the already accepted major subject areas in which students are required to rotate. In a more ideal world, medical education would be truly interdisciplinary, but as it is set up now, it rarely is.

So, if one specialty needs to take the lead, why not psychiatry? In addition to those contained in the IOM report, there are other reasons why psychiatrists should be taking a greater role both in the care of the terminally ill patients and in pain management. Some of these reasons are highlighted by recent studies.

Two studies, which were performed in the UK, examined depression and its treatment in patients with cancer. The first found that 73% of the patients with cancer and depression were not receiving treatment for depression.²In the second study, among cancer patients with depression, the depression was treated with the involvement of a team of cancer nurses and psychiatrists or with usual treatment by primary care physicians alone.³ Not too surprisingly, the involvement of the team significantly improved the management of depression, and it was found to reduce pain in these patients.

We have known for years that chronic pain and depression have a high degree of comorbidity and that each feeds on the other. Thus, addressing both is of vital importance. In a literature review of whether pain interfered with response to antidepressants in patients with both pain and depression, results from 9 of the 10 studies showed that it did.⁴

As the current IOM report and a previous one on chronic pain⁵ along with virtually every other study on the management of chronic pain and pain in cancer patients and the terminally ill have demonstrated, psychiatrists cannot depend on their non-psychiatrist colleagues to properly manage pain. Untreated pain can interfere with the treatment of depression and the successful treatment of depression can have an impact on pain; treating both consecutively is of great importance. Add to this the obvious importance of both the psychological and physical aspects of chronic pain and pain in the terminally ill, and it appears that psychiatry should have a much greater role than it currently plays in the management of both.

References:

1. Institute of Medicine of the National Academies. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: National Academies Press; 2014.

2. Walker J, Hansen CH, Martin P, et al. Prevalence, associations, and adequacy of treatment of major depression in patients with cancer: a cross-sectional analysis of routinely collected clinical data. Lancet Psychiatry. 2014 Aug 28; [Epub ahead of print].

3. Sharpe M, Walker J, Holm Hansen C, et al; SMaRT (Symptom Management Research Trials) Oncology-2 Team. Integrated collaborative care for comorbid major depression in patients with cancer (SMaRT Oncology-2): a multicentre randomised controlled effectiveness trial. Lancet. 2014;384:1099-1108.

4. Fishbain DA, Cole B, Lewis JE, Gao J. Does pain interfere with antidepressant depression treatment response and remission in patients with depression and pain? An evidence-based structured review. Pain Med. 2014;15:1522-1539.

5. Institute of Medicine Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academies Press; 2011.