Acceptability of palliative care approaches for patients with severe and persistent mental illness: a survey of psychiatrists in Switzerland

Abstract

Background Some patients develop severe and persistent mental illness (SPMI) which is therapy-refractory. The needs of these patients sometimes remain unmet by therapeutic interventions and they are at high risk of receiving care that is inconsistent with their life goals. Scholarly discourse has recently begun to address the suitability of palliative care approaches targeting at enhancing quality of life for these patients, but remains to be developed. Method A cross-sectional survey asked 1311 German-speaking psychiatrists in Switzerland (the total number of German-speaking members of the Swiss Society for Psychiatry and Psychotherapy) about the care of SPMI patients in general, and about palliative care approaches in particular. 457 (34.9%) returned the completed survey. In addition, participants were asked to evaluate three case vignettes of patients with SPMI. Results The reduction of suffering and maintaining daily life functioning of the patient were rated as considerably more important in the treatment of SPMI than impeding suicide and curing the underlying illness. There was broad agreement that SPMI can be terminal (93.7%), and that curative approaches may sometimes be futile (e.g. 72.4% for the anorexia nervosa case vignette). Furthermore, more than 75% of the participating psychiatrists were in favour of palliative care approaches for SPMI. Conclusions The results of the present study suggest that the participating psychiatrists in Switzerland regard certain forms of SPMI as posing high risk of death. Additionally, a majority of respondents consider palliative care approaches appropriate for this vulnerable group of patients. However, the generalizability of the results to all psychiatrists in Switzerland or other mental health professionals involved in the care of SPMI is limited. This limitation is important considering the reservations towards palliative care in the context of psychiatric illness, mainly because of the association with death and futility. Palliative care approaches, however, are applicable in conjunction with other therapies intended to prolong life. A next step could be to involve service users and develop a consensus of what palliative care might encompass in SPMI. A framework for identifying which patients might benefit from palliative care, should be explored for the future development of care for SPMI patients.

A palliative care approach in psychiatry: clinical implications

“…Thus, engaging patients in goals of care conversations or other interventions described in palliative terms may not necessarily be seen as an intrinsic part of a psychiatrist's work duties. The use of any specific terminology involving explicit references to palliation is certainly not the vital part of the argument; indeed, we realize that the mere act of labeling an approach as palliative could initially worry patients and families as well as health care professionals-although a recent survey among Swiss psychiatrists suggests that the concept may in fact not be all that controversial [10]. Even so, acknowledging the importance of even daring to apply a palliative perspective in the treatment of patients with severe mental illness could in many cases lead to more favorable outcomes [3,11].…”

“…We realize that the mere use of the term 'palliative' may be considered controversial [2,10]. In fact, in one of the programs described above, this terminology is to be explicitly avoided ("[case management] is not to be seen as a 'last resort' or as palliative care" ( [21] , p. 4), presumably because many patients will instinctively think of palliative treatment as an intervention that connotes an impending death.…”

“…In this context, it is also worth distinguishing palliative care in psychiatry from the concept of harm reduction [10], i.e., interventions aimed at reducing negative consequences of problematic behaviors such as substance use without necessarily fully extinguishing the underlying behaviors themselves [68]. Harm reduction techniques can certainly be applied as part of a palliative approach to mental health, as seen in the clinical scenarios described above.…”

“…In recent years, there has been a growing academic interest in palliative approaches in severe and persistent mental illness. More specifically, the discussion has focused on whether psychiatric care could benefit from explicitly acknowledging that a curative treatment is not always possible in major psychiatric disorders, and whether a focus on symptom reduction and quality of life may sometimes be a better option, even in potentially life-threatening conditions [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16]. According to these ideas, clinical psychiatry could learn from palliative care in somatic medicine by adopting a similar approach to patients suffering from psychiatric conditions beyond cure.…”

“…Furthermore, in order for it to be a meaningful concept, it needs to entail an active approach with specific and attainable treatment goals [3]. However, palliative care in psychiatry is a comparatively novel concept and thus, except for case studies and a survey of clinicians' attitudes, empirical research on its clinical applicability is still lacking [3,4,10,12]. Moreover, it is yet to be spelled out what specifically distinguishes palliative care from other care options in psychiatry [3,13].…”