Hospice and Palliative Medicine Fellowship Training in Mental Health: A Survey of Program Directors

The Prevalence of Social Isolation and Loneliness Among Older Adults Residing in Rural Utah Communities

An estimated 24% of community-dwelling older adults experience social isolation defined as infrequent social contact or having few social relationships, and 35% of adults aged >45 report being lonely, a subjective feeling of isolation or lack of social contact. Social isolation and loneliness are associated with poor physical and mental health. The purpose of our study was to assess the prevalence of social isolation and loneliness among older adults receiving home health services in rural Utah communities. We conducted a cross-sectional study with 41 persons at the onset of enrollment in home care services in 2 rural counties in Utah. We assessed loneliness, social support and quality of life using validated surveys. We conducted descriptive statistics to describe the participants demographics and Pearson's Correlation Coefficients to assess a relationship between loneliness and quality of life and satisfaction with health. Participants were predominately older, with an average age of 75.6 years (range 59-93 years.) The majority of participants were female 27 (65.8%) and identified as White 36 (87.8%). Overall, the average loneliness score was 1.51 (0.67 SD) indicating the prevalence of loneliness was low among our study population. We found statistically significant correlation among participants who rated their loneliness higher with lower rates of satisfaction with their health and overall quality of life. Future research is needed with larger sample sizes to validate our findings which may inform policy changes including standardizing assessment of social isolation and loneliness and offering person-centered interventions to prevent the physical and psychological consequences of social isolation.

Clinician Perspectives on Palliative Care for Older Adults With Serious Mental Illnesses: A Multisite Qualitative Study

OBJECTIVES

Approximately 5.5% of the population live with serious mental illnesses (SMI). Older adults with SMI experience a high burden of serious medical illnesses and disparities in advance care planning, symptom management, and caregiver support. The objectives of this study are to explore interdisciplinary clinician perspectives on the palliative care needs of older adults with SMI and serious medical illnesses.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study utilized thematic analysis of semi-structured interviews of interdisciplinary clinicians practicing palliative care, geriatrics, or geriatric/consultation-liaison psychiatry at four hospitals within an urban health system.

MEASUREMENTS

Themes related to care of older adults with serious mental illness and serious medical illness with respect to clinician experiences, challenges in care, and opportunities to improve care.

RESULTS

The authors interviewed 45 clinicians. Major themes identified were: (1) Current paradigms of palliative care do not meet the needs of patients with SMI; (2) Clinicians are motivated to care for this population but require more training and interdisciplinary practice; (3) There is a need for structural integration of psychiatric and palliative care services.

CONCLUSIONS

The study underscores the inadequacy of current palliative care models in meeting the unique needs of older adults with SMI. Models of integrated psychiatric and serious illness care and enhanced training are needed to improve the delivery of palliative care. Integrated care models and workforce development at the interface of serious illness care and psychiatric have the potential to improve outcomes for this vulnerable population.

Increasing Awareness and Access to Integrated Behavioral Health and Palliative Care: An Introduction to the American Journal of Hospice and Palliative Medicine's

Mental health symptoms are common in the general population and are overrepresented in patients receiving palliative care and hospice services. This introduction to the special issue on Mental Health in Palliative Care and Hospice highlights the ongoing need for research and training to prepare our palliative care workforce to address the concerns of patients experiencing serious illness and mental health concerns. Multilevel approaches are needed to enhance understanding of mental health needs among people with serious illness. Public health outreach is needed within our communities, targeted support is needed for family caregivers, and structured training for palliative care and hospice clinicians is needed to enhance competent mental health in these settings.

Our Unrealized Imperative: Integrating Mental Health Care into Hospice and Palliative Care

The field of Hospice and Palliative Medicine (HPM) has its roots in the principles, promulgated by Dame Cicely Saunders, that patient and family are the unit of care and that comprehensive integration of physical, psychological, social, and spiritual care is necessary to address suffering in all its dimensions. Although we aspire to provide comprehensive care for our patients, most hospice and palliative care (HPM) physicians lack basic competencies for identifying and managing patients with psychological distress and mental health distress and disorders, a growing segment of our clinical population. In this article, I argue that we are not living up to the founding values of our field in how we practice, how we educate our trainees, our research, and in how we pursue our own professional development as faculty. The history of our field, the nature of our clinical workforce, the culture of PC, and our educational programs all contribute to our current practice model, which is not adequate to meet the mental health needs of our patients. I propose strategies to address these challenges focused on enhancing integration between psychiatry/psychology and HPM, changes in fellowship education and faculty development, addressing the stigma against people with mental health diagnoses, and addressing system and cultural challenges that limit our ability to provide the kind of comprehensive, integrative care that our field aspires to.

Top Ten Tips Palliative Care Clinicians Should Know About the Psychiatric Manifestations of Nonpsychiatric Serious Illness and Treatments

Mental health issues are widespread and significant among individuals with serious illness. Among patients receiving palliative care (PC), psychiatric comorbidities are common and impact patient quality of life. Despite their prevalence, PC clinicians face challenges in effectively addressing the intricate relationship between medical and psychiatric disorders due to their complex, intertwined and bidirectionally influential nature. This article, created collaboratively with a team of psychiatric-palliative care experts, is the second in a two-part series examining the bidirectional relationship between medical and psychiatric illness in PC. This article explores 10 prevalent psychiatric manifestations associated with severe illness and its treatment. Building upon the first article, which focused on 10 common physical manifestations of psychiatric illness among patients receiving PC, these two articles advocate for an integrated approach to PC that prioritizes mental and emotional wellbeing across the continuum of serious illness.

Trainee Perceptions of a Competency-Based Mid-Career Fellowship in Hospice And Palliative Medicine

Context: The time-variable, competency-based mid-career fellowship in Hospice and Palliative Medicine (HPM) is a multicenter pilot program for physicians who want to train in HPM part-time. Objectives: This study describes the experience of the early cohort of mid-career fellows. Methods: Fellows at the seven sites were surveyed about their perceptions of the program and their confidence in subspecialty skills. Results: Surveys were sent to 13 fellows and completed by 8. All reported positive experiences with curricula, direct observation, feedback, and cross-site case reviews. Most responses were positive regarding individualized learning plans and case-stimulated reviews. Respondents reported high confidence in 9 of the 13 specialty-specific skills, including communication, caring for dying patients, and pain management. They reported less confidence with psychological and non-pain symptoms, spirituality, and prognostication. Fewer than half indicated that the process for graduation was clear. Conclusion: Physicians in the competency-based HPM fellowship report a positive experience and high confidence in subspecialty skills.

Mind the Gap: Understanding Palliative Care Clinician Attitudes Toward Mental Health Training

Background: Palliative care (PC) clinicians provide mental healthcare to individuals with serious illnesses. Despite this, there is limited knowledge regarding their mental health training opportunities. Methods: To identify predictors of satisfaction with mental health training opportunities and assess the relationship between training opportunities and clinician comfort in managing mental health comorbidities, we conducted a secondary analysis of a nationwide survey involving 708 PC clinicians. Results: Satisfaction with mental health training was moderate (M = 2.75/5, SD = .915). Access to lectures/webinars was the most common training opportunity (54%). Significant predictors of satisfaction with training included access to lectures/webinars (β = .328, P <.001) and case discussions (β = .231, P = .007). Academic practice settings and satisfactory mental health referrals were associated with a greater number of different training opportunities. Clinicians in academic settings had higher odds of accessing various training opportunities, such as lectures/webinars (OR = 2.58, P <.001) and longitudinal training pathways (OR = 4.51, P <.001). A moderate, positive correlation was found between training satisfaction and comfort in managing mental health comorbidities (r = .30, P <.001). Discussion: This study is among the first to elucidate factors influencing PC clinicians' satisfaction with mental health training. Low-resource training opportunities, such as webinars and lectures, significantly predict satisfaction, suggesting the potential of these scalable solutions to enhance training. The findings underscore the importance of expanding evidence-based mental health training for PC clinicians to improve patient care.

Palliative Care Psychiatry: Building Synergy Across the Spectrum

PURPOSE OF REVIEW

Palliative care (PC) psychiatry is a growing subspecialty focusing on improving the mental health of those with serious medical conditions and their caregivers. This review elucidates the current practice and ongoing evolution of PC psychiatry.

RECENT FINDINGS

PC psychiatry leverages training and clinical practices from both PC and psychiatry, addressing a wide range of needs, including enhanced psychiatric care for patients with serious medical illness, PC access for patients with medical needs in psychiatric settings, and PC-informed psychiatric approaches for individuals with treatment-refractory serious mental illness. PC psychiatry is practiced by a diverse workforce comprising hospice and palliative medicine-trained psychiatrists, psycho-oncologists, geriatric psychiatrists, other mental health professionals, and non-psychiatrist PC clinicians. As a result, PC psychiatry faces challenges in defining its operational scope. The manuscript outlines the growth, current state, and prospects of PC psychiatry. It examines its roles across various healthcare settings, including medical, integrated care, and psychiatric environments, highlighting the unique challenges and opportunities in each. PC psychiatry is a vibrant and growing subspecialty of psychiatry that must be operationalized to continue its developmental trajectory. There is a need for a distinct professional identity for PC psychiatry, strategies to navigate administrative and regulatory hurdles, and greater support for novel clinical, educational, and research initiatives.