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Psychiatric Aspects of Excellent End-of-Life Care

The Academy of Psychosomatic Medicine (APM) is the organization of Consultation-Liaison (C-L) Psychiatry. Its international membership includes many of the leading clinicians and researchers in the field of C-L Psychiatry, a discipline which focuses on the psychiatric care of the medically ill. This clinical focus includes the psychiatric problems of catastrophically ill and dying patients. Prepared by the APM's Ad Hoc Committee on End-of-Life Care, this Position Statement has been approved by the APM Executive Council in the method described in the constitution and bylaws of the APM. This document is the APM's Position Statement regarding psychiatric aspects of care provided to patients nearing the end of life.

1. Psychiatric morbidity at the end of life is significant and causes substantial, potentially remediable suffering to dying patients and their families. Further, we believe that quality care for the psychiatric complications of terminal illness is and should be an integral component of excellent, comprehensive end-of-life care.

2. The most basic challenge at the end of life which stresses patients and families is loss, which is related to both the disabilities of the illness with their threats to self-esteem, and the patient's death, which ruptures the direct relationship with the family. Psychiatric problems and issues commonly seen at the end of life include anxiety symptoms and anxiety disorders, depressive symptoms and depressive disorders, delirium and other cognitive disorders, suicidal ideation, consequences of low perceived family and other social support, personality disorders or personality traits that cause problems in the setting of extreme stress, questions of capacity to make informed decisions, grief and bereavement, and general and health-related quality of life. Spiritual and religious issues, including both personal faith and relationship to a community of believers, are important for most people. Good end-of-life care requires explicit attention to these matters.

3. Studies show that psychiatric morbidity in the setting of terminal illness is exceptionally high. The prevalence of delirium in terminal cancer and AIDS patients ranges from 30-85%, and the prevalence of clinically significant depression ranges from 20-50%. The prevalence of depression among terminally ill patients with a desire for death is eight times higher than in those without a significant de sire for death. Depression is the strongest determinant of suicidal ideation and desire for death in those with serious or terminal illness.

4. Psychiatric complications at the end of life are treatable, but often go unrecognized and untreated. Several factors or barriers contribute to the underrecognition and undertreatment of psychiatric problems at the end of life. These include:

  • Difficulty in diagnosing psychiatric disorders (e.g., anxiety, delirium, depression) in the setting of significant physical illness, owing to the overlap in the symptoms caused by the psychiatric disorder and the comorbid physical problems.
  • Beliefs held by many patients, family members, physicians, and hospice and palliative care providers whereby psychiatric symptoms, especially depression, are viewed as normal parts of the dying process.
  • The fact that many patients and physicians do not understand that patients who suffer from mental disorders at the end of life can respond to treatment. This therapeutic nihilism prevents the search for treatable mental disorders at the end of life.
  • The presence of structural barriers to coordinated care of dying patients. Psychiatrists may not be readily available to care for terminally ill patients and consult with physicians providing end-of-life care for a variety of reasons. Among these are limited geographic access (most C-L psychiatrists are affiliated with academic medical centers in urban areas), psychiatrists who feel inadequately prepared to assess and treat dying patients, healthcare insurance carve-outs (which may limit or exclude access to and coverage for psychiatric care), and logistical obstacles to formal addition of a psychiatrist to a hospice care team.
  • The stigma experienced by patients and families due to psychiatric evaluations or the assignment of a psychiatric diagnosis. Physicians and other caregivers may share this feeling.
  • The occurrence of countertransference of hopelessness on the part of families and healthcare providers that may discourage seeking assessment of suffering from psychiatric causes in dying patients and weaken the commitment to helping maintain morale at the end of life.
  • The fact that treatment based on formal diagnosis (as opposed to symptomatic treatment) is not sufficiently emphasized in palliative care.

5. We believe that the current enthusiasm for legalized assisted suicide and euthanasia at least partly reflects public concern that suffering (including suffering due to psychiatric causes) and distress at the end of life may elude or exceed our best current treatment efforts, making death seem preferable. Appropriately, aggressive treatment for psychiatric complications of terminal illness is the best way to address this fear and should reduce requests for assisted suicide and euthanasia.

6. We maintain that laws and regulations must allow physicians to provide appropriately aggressive care for psychiatric complications of terminal illness and must provide protection for qualified physicians who provide this care. For example, excellent treatment of depression at the end of life often requires the use of psychostimulants, most of which are Schedule II controlled substances. Appropriate use of these agents to control depression at the end of life should be viewed as analogous to the use of opiate analgesics to treat pain in this setting. Similarly, appropriate treatment of agitated and delirious patients who are dying may require sufficient sedation to relieve the suffering of the patient and family. When clinically indicated and acceptable to the patient or surrogate, such sedation is the standard of care and should be employed even if it hastens death. Such treatment is ethically sound and is not an act of assisted suicide or euthanasia.

7. In response to the above, the APM believes that remedial efforts must be encouraged. These include:

  • Education about the prevalence and morbidity of psychiatric complications of terminal illness. Target audiences should include the general public, students and trainees in all healthcare professions, and healthcare providers in hospice and palliative care, primary care, and medical specialties (including psychiatry).
  • Education and other efforts to reduce or remove barriers to excellent psychiatric end-of-life care, as outlined in Section 4 above.
  • Education and advocacy efforts to insure that legal or regulatory barriers do not hinder or prevent excellent psychiatric care at the end of life.
  • Clinical (and, where appropriate, basic science) research into psychiatric complications of terminal illness, their effects on suffering and quality of life in dying patients and their families; interactions with other comobid conditions such as pain, fatigue, shortness of breath, anorexia and nausea; and reliably effective treatment strategies used at the end of life. Collaboration with governmental funding agencies and private foundations should be encouraged to develop research in these areas. Particular attention should be paid to training young investigators in research related to the psychiatric complications of terminal illness.

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