POSITION STATEMENT:
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:
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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.
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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.
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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.
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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.
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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.
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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.
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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:
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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).
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Education and other efforts to reduce or remove barriers to
excellent psychiatric end-of-life care, as outlined in Section 4 above.
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Education and advocacy efforts to insure that legal or regulatory
barriers do not hinder or prevent excellent psychiatric care at the end of
life.
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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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