On the Margins of Death: A Scoping Review on Palliative Care and Schizophrenia

Place of Death for People with Schizophrenia and Bipolar Disorder in New Zealand: A National Retrospective Cohort Study

OBJECTIVES

Inequities in access to physical health care for those with mental health conditions and substance use disorders are well recognised, and evidence of unequal access to palliative care is emerging. This study uses complete national data to examine the place of death for those with specific mental health conditions in Aotearoa New Zealand. Methods: Mortality data between 2013 and 2018 was linked to secondary mental health service usage. Place and cause of death were compared between those with diagnoses of bipolar affective disorder or schizophrenia and those without, stratified by ethnicity. Results: A cohort of 498,293 individuals was identified. People diagnosed with bipolar disorder and schizophrenia had different patterns of cause and place of death from other New Zealanders. This group was less likely to die in hospices, even after adjustment for differences in cause of death and age (adjusted OR 0.59, CI 0.52-0.68). Patterns of place of death differed by ethnicity. Conclusions: Inequities in healthcare provision for those diagnosed with psychotic disorders continue at the end of life, with reduced access to hospice facilities. Further research is needed to understand the quality of healthcare provision and wishes of those with mental health conditions in end-of-life care.

The perspectives on advance care planning of older people with psychotic illnesses and their carers

PURPOSE

To examine the attitudes, experiences, and perceived facilitators and barriers to Advance Care Planning (ACP), of older people with schizophrenia and other psychotic illness and their carers.

METHODS

Older people with a psychotic illness and carers were recruited from public mental health services in Sydney, Australia. Semi-structured interviews to explore attitudes, experiences, and perceived barriers and facilitators to ACP were conducted by an external clinician. Consumers' medical, psychiatric and drug health diagnoses were recorded and they completed cognitive and symptom rating scales. Reflexive thematic analysis was used to analyse the transcripts of interviews, within an interpretive description framework.

RESULTS

Thematic saturation was achieved with 12 consumers and 5 carers. Emergent themes from consumer interviews were (i) 'What is ACP?'; (ii) 'I have not done ACP because…..'; (iii) 'I want to do ACP'; (iv) 'If I was to do ACP I would need..'; and (v) 'Mental health clinicians have the skills to help me with ACP'. Carer themes included (i) 'We do not participate in ACP', (ii) 'I want to participate in ACP', and (iii) 'Key clinician skills are needed'. There was convergence of themes from both groups.

CONCLUSION

This study demonstrates that older people with a psychotic illness can express views regarding ACP, despite ongoing symptoms of psychosis, cognitive impairment and mild-moderate severity of illness. The emergent themes highlight opportunities to intervene to overcome barriers to ACP, including education for both participant groups and clinicians, practical considerations and the need for all to collaborate, including with primary care.

Home Health Nurses' Perceptions of Caring for Persons With Severe and Persistent Mental Illnesses

BACKGROUND

Severe and persistent mental illnesses (SPMIs) affect a significant portion of the adult population in the United States. Despite their increased medical disease burden, individuals with SPMIs often lack access to appropriate medical care. Home health services offer cost-effective options for caring for this population in the comfort of their homes. However, little is known about the perceptions of home health nurses providing care to persons with SPMIs, and how they are adjusting care to persons with SPMIs.

AIMS

This study aimed to explore home health nurses' perspectives on caring for persons with SPMIs.

METHODS

Using a grounded theory approach, individual semi-structured interviews were conducted with home health and home hospice nurses. The research questions focused on the nurses' experiences, barriers and facilitators to care, and the impact of the home environment on caring for persons with SPMIs. Data analysis followed coding procedures outlined in grounded theory, resulting in the development of an axial coding model.

RESULTS/CONCLUSIONS

The findings provide valuable insights into the challenges and opportunities faced by home health nurses when providing care for individuals with SPMIs. The outcomes of this study are intended to contribute to the understanding of current care practices and can guide the allocation of resources to improve care for this vulnerable population, such as incorporating training specific to persons with severe psychiatric illnesses.

The perspectives of hospital doctors about end-of-life care in people with mental illness: an observational pilot study

BACKGROUND

Negative attitudes towards people living with mental illness (PLWMI), defined here as mentalism, are a major contribution to health care inequity, which may extend into end-of-life care. There is a clear need for investigation of the attitudes of doctors towards PLWMI at the end of life as doctors may lead processes of care that contribute to this inequity.

AIMS

The aim of this pilot study is to examine the perspectives of hospital-based doctors regarding end-of-life care and medical decision-making in PLWMI.

METHODS

A survey was created to explore whether mentalism is present in the perspectives of hospital doctors regarding end-of-life care for PLWMI. The survey included demographic characteristics of participants and questions comprising statements and vignettes that required agree/disagree responses. Descriptive statistics were used to summarise responses, and chi-square tests examined associations with demographic variables.

RESULTS

The survey was commenced by 48 hospital-based doctors and completed by 45. Descriptive statistics indicated that mentalism is present in the attitudes of hospital doctors regarding end-of-life care of PWLMI, with 47 of 48 participants (98%) endorsing at least one mentalist response. One significant association found that psychiatrists and psychiatry trainees were less likely to endorse a stereotype response in one vignette.

CONCLUSIONS

This preliminary study addresses a gap within the literature on the potential contribution of mentalist attitudes in doctors to the poorer end-of-life care outcomes for PLWMI. The findings highlight the need for further study of this topic and suggest a role for targeted medical education in the pursuit of health care equality for PLWMI.

Diagnostic significance and potential function of miR-320d in schizophrenia

OBJECTIVES

Schizophrenia is a chronic brain disorder and needs objective diagnostic biomarkers. MicroRNAs are highly expressed in the nervous system. The study investigated the expression and clinical values of serum miR-320d in schizophrenia patients. In addition, the underlying mechanism was preliminarily examined via bioinformatic analysis.

MATERIALS AND METHODS

Serum samples were collected from 57 patients with first-episode schizophrenia and 62 healthy controls. The cognitive function of patients was assessed via Measurement and Treatment Research to Improve Cognition in Schizophrenia Consensus Cognitive Battery (MCCB) consisting of seven domains. Serum miR-320d levels were tested via qRT-PCR. The miRNA target predictions were obtained from Target Scan, and annotated through Gene Ontology and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis.

RESULTS

Based on the GSE167630 dataset, downregulated serum miR-320d in schizophrenia was identified, which was determined in the serum of schizophrenia patients. Serum miR-320d presented a conspicuous relationship with MCCB score in both the control group and the schizophrenia group. After adjusting for age, sex, BMI, and education, serum miR-320d was still independently related to the occurrence of schizophrenia. It can identify schizophrenia cases from healthy ones with an AUC of 0.931. The Go enrichment analysis indicated that the target genes were mainly enriched in homophilic cell adhesion and cell-cell adhesion via plasma-membrane adhesion molecules, and GTPase activity and guanosine diphosphate (GDP) binding. Rap1 signaling pathway was enriched via KEGG analysis.

CONCLUSION

Serum miR-320d can be taken as a candidate marker for the diagnosis of schizophrenia. Its regulatory role in neuronal cell adhesion and Rap1 signaling pathway might be the potential underlying mechanism of miR-320d in schizophrenia.

Nonphysical Suffering: An Under-Resourced and Key Role for Hospice and Palliative Care Social Workers

This article highlights recent research findings that have significance for hospice and palliative care social work in Canada, and for the field of hospice and palliative care more broadly. A 2020 discourse analysis study examined the experiences of 24 interdisciplinary palliative care clinicians across Canada in their work with patients' nonphysical suffering. Nonphysical suffering is suffering that may be emotional, psychological, social, spiritual and/or existential in nature. The study found an absence of specialist social workers on hospice and palliative care teams or limited time for specialist social workers to address patients' nonphysical suffering due to high caseloads and complex practical needs. While the study recognizes social workers have expertise in supporting patients' nonphysical suffering, a competency and skill that has not been sufficiently captured in the existing literature, the systemic barriers they face in providing care may leave patients' needs unmet. The study also highlights the unique pressure social workers may feel to relieve patients' nonphysical suffering due to the psychosocial focus of their role. The need for specialist social workers to be included and adequately resourced on hospice and palliative care teams across diverse settings in Canada is evident.

Health equity for persons with disabilities: a global scoping review on barriers and interventions in healthcare services

BACKGROUND

Persons with disabilities experience health inequities in terms of increased mortality, morbidity, and limitations in functioning when compared to the rest of the population. Many of the poor health outcomes experienced by persons with disabilities cannot be explained by the underlying health condition or impairment, but are health inequities driven by unfair societal and health system factors. A synthesis of the global evidence is needed to identify the factors that hinder equitable access to healthcare services for persons with disabilities, and the interventions to remove these barriers and promote disability inclusion.

METHODS

We conducted a scoping review following the methodological framework proposed by Arksey and O'Malley, Int J Soc Res Methodol 8:19-32. We searched two scholarly databases, namely MEDLINE (Ovid) and Web of Science, the websites of Organizations of Persons with Disabilities and governments, and reviewed evidence shared during WHO-led consultations on the topic of health equity for persons with disabilities. We included articles published after 2011 with no restriction to geographical location, the type of underlying impairments or healthcare services. A charting form was developed and used to extract the relevant information for each included article.

RESULTS

Of 11,884 articles identified in the search, we included 182 articles in this review. The majority of sources originated from high-income countries. Barriers were identified worldwide across different levels of the health system (such as healthcare costs, untrained healthcare workforces, issues of inclusive and coordinated services delivery), and through wider contributing factors of health inequities that expand beyond the health system (such as societal stigma or health literacy). However, the interventions to promote equitable access to healthcare services for persons with disabilities were not readily mapped onto those needs, their sources of funding and projected sustainability were often unclear, and few offered targeted approaches to address issues faced by marginalized groups of persons with disabilities with intersectional identities.

CONCLUSION

Persons with disabilities continue to face considerable barriers when accessing healthcare services, which negatively affects their chances of achieving their highest attainable standard of health. It is encouraging to note the increasing evidence on interventions targeting equitable access to healthcare services, but they remain too few and sparce to meet the populations' needs. Profound systemic changes and action-oriented strategies are warranted to promote health equity for persons with disabilities, and advance global health priorities.

Finding the Hidden Professional Culture of Mental Health Nursing-Spiritual Care for Individuals with a Co-morbid Life-Limiting Illness

People with severe mental illness are dying up to thirty years earlier than the general population. The limited literature on their experience of dying indicates that they often suffer from inequities in their access to healthcare services, and further, what care they do receive is frequently poor. Living with both a mental illness and facing death can engender spiritual concerns and dying at a younger age is a risk factor for spiritual despair. Hence, addressing spiritual concerns can be an important dimension of mental health nursing care. The aim of this ethnographic study of 11 senior and experienced mental health nurses was to determine if the culture of the mental health service impacted their spiritual care for those patients who were facing death. The data highlighted that the nurses felt comfortable in providing spiritual care when the person was suffering from psychosis. Yet, the results also revealed that nurses felt disempowered by the dominance of the biomedical culture, in which they felt unable to articulate their care. However, it was identified that their spiritual care was inherent within the professional values, knowledge, and skills of mental health nursing and framed through their therapeutic relationships. Therefore, strategies need to be used by the organization to assist nurses to reclaim their power and assist the mental health service to further develop and engage in spiritual care practices.

Challenges and opportunities for improvement when people with an intellectual disability or serious mental illness also need palliative care: A qualitative meta-ethnography

BACKGROUND

People with diagnoses of intellectual disability or serious mental illness have higher mortality rates due to physical comorbidities; better understanding is needed to guide best practice in provision of palliative care for these populations.

AIMS

To identify multivoiced perspectives, drawn from lived experience of: what works, and what does not, in palliative care for people with intellectual disability or serious mental illness; challenges in, and opportunities to improve, palliative care.

DESIGN

A systematically constructed qualitative meta-ethnography. Protocol published (PROSPERO: CRD42021236616).

DATA SOURCES

MEDLINE, PsychINFO, CINAHL PLUS and Embase used without date limitations. Papers published in English, containing qualitative data on palliative care provision for people with a diagnosis of intellectual disability or serious mental illness were included. Global five-point strength score applied for relevance/quality appraisal.

RESULTS

Familiarity (of location, people and/or things) is important for good palliative care. Assumptions and misunderstandings about the role of mental capacity assessment to appropriately involve the patient in decision-making are common. Adapting training for palliative care staff to address concerns and beliefs about mental illness is one of the methods that helps avoid diagnostic overshadowing. Proactive identification of service arrangements to meet needs of persons with personality, psychotic, delusional and bipolar affective disorders will help optimise care.

CONCLUSIONS

Evidence, including the voices of people with intellectual disability or serious mental illness is urgently needed to guide efforts to improve their access to and experience of palliative care. More evidence is especially needed to understand, develop and implement best practice for people with psychosis, bipolar affective disorder, mania and personality disorder.

Ageism, human rights and ethical aspects of end-of-life care for older people with serious mental illness

There are many complex concepts to consider during end-of-life discussions and advance care planning, especially when vulnerable populations such as older individuals with serious mental illness are involved. This article aims to summarize some of these important concepts, such as the effects of ageism, preservation of human rights and dignity, supported or shared decision making and palliative approaches. It emerged from a study that found two thirds of 100 participants 60 years of age and older with serious mental illness had end-of-life decision-making capacity. This finding highlighted the individual and contextual nature of decision-making capacity, the importance of consideration of individual values and protection of human dignity during end-of-life care. Healthcare providers have a duty to initiate end-of-life and advance care discussions, to optimize decision-making capacity, and to protect autonomous decision-making. Chronological age or diagnostic categories should never be used as reasons for discrimination and all patients should receive end-of-life care in keeping with their preferences and values.

Disparities and inequalities in cancer care and outcomes in patients with severe mental illness: Call to action

OBJECTIVES

People with severe mental illness (SMI) are at extreme risk of being stigmatized and to receive poor quality physical care. It has been demonstrated that they have higher morbidity and poorer prognosis of several medical diseases than the general population, with an at least 10-20-year reduction in life expectancy.

METHODS

A special issue of Psycho-Oncology focusing on cancer care among patients affected by SMI was called by the Editorial Board of the journal, with the aim to explore cancer health disparities and inequalities among people with SMI, mortality from cancer, problems of communication between multidisciplinary oncology and psychiatric teams and need for more structured intervention (i.e., screening, prevention, treatment).

RESULTS

Authors from eight countries contributed. The problem of stigma and barriers to cancer care provision for patients with SMI were studied (e.g., the complex nature of SMI and healthcare providers' misunderstanding of SMI). Key barriers were related to both patients, clinicians and institutional problems, such as fragmentation of care. A higher mortality from cancer and poor knowledge about cancer risk-factors was shown in patients with SMI. Models of intervention were also proposed.

CONCLUSIONS

Several conclusions have been recommended by the authors, such as the need for guidelines and clinical procedures specific for cancer care in mental health settings; large-scale studies to address the disparities of care in people with SMI; a larger vision of psychosocial oncology as the facilitator of the liaison between oncology and psychiatry.

End of life care for people with severe mental illness: Mixed methods systematic review and thematic synthesis (the MENLOC study)

BACKGROUND

Parity of esteem means that end-of-life care for people with severe mental illness should be of equal quality to that experienced by all.

AIM

To synthesise international, English language, research and UK policy and guidance relating to the organisation, provision, and receipt of end-of-life care for people with severe mental illness.

DESIGN

A mixed methods systematic review was conducted following the Evidence for Policy and Practice Information and Co-ordinating Centre approach and informed by a stakeholder group. We employed thematic synthesis to bring together data from both qualitative and quantitative studies, and from non-research material. We assessed the strength of synthesised findings using the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approaches.

DATA SOURCES

Ten electronic databases were searched from inception to December 2019, along with 62 organisational websites. Quality appraisal was conducted using Critical Appraisal Skills Programme checklists or other study design-specific alternatives as necessary.

RESULTS

Of the 11,904 citations retrieved, 34 research publications were included plus 28 non-research items. The majority of research was of high or acceptable quality. An overarching synthesis including 52 summary statements, with assessments of confidence in the underpinning evidence, was produced using four themes: Structure of the system; Professional issues; Contexts of care; and Living with severe mental illness.

CONCLUSIONS

Implications for services and practice reflect evidence in which there is a high degree of confidence. Partnership should be developed across the mental health and end-of-life systems, and ways found to support people to die where they choose. Staff caring for people with severe mental illness at the end-of-life need education, support and supervision. End-of-life care for people with severe mental illness requires a team approach, including advocacy. Proactive physical health care for people with severe mental illness is needed to tackle problems of delayed diagnosis.

Cancer care for people with mental disorders: A qualitative survey among cancer care and psychiatric care professionals in Japan

OBJECTIVE

It is widely assumed that there are multiple levels (from individual to policy level) of problems involving disparities in cancer care for people with mental disorders. However, few studies have comprehensively investigated issues as perceived by medical professionals. The purpose of the present study was to identify a wide range of issues in cancer care for people with mental disorders and offer corresponding solutions for both cancer care professionals and psychiatric care professionals.

METHODS

We distributed open-ended questionnaires to 754 healthcare professionals in various medical facilities, including designated cancer hospitals, psychiatric hospitals, and other local healthcare/welfare facilities. Participants were asked to describe issues in cancer care for people with mental disorders.

RESULTS

Of the 754 recruited professionals, 439 (58.2%) responded to the questionnaire. Sixty-one issues were extracted and categorized into 10 categories: patient factors; isolation and lack of support; obstacles to transport; socioeconomic factors; attitudes of psychiatric professionals; medical system of psychiatric hospitals; attitudes of cancer care professionals; medical system of designated cancer hospitals; regional cancer medical systems; and lack of coordination among multidisciplinary healthcare professionals. Forty-eight specific solutions were summarized into 12 goals.

CONCLUSIONS

The present study widely identified issues causing disparities in cancer care for patients with mental disorders. We found that the issues extended from the patient level to the public-policy level. Our findings suggest the need for a multidisciplinary approach that includes both cancer and psychiatric care professionals to address the gap in cancer care for people with mental disorders.

Help Me Understand: Providing Palliative Care to Individuals With Serious Mental Illness

Individuals with serious mental illness (SMI) have shortened life expectancy with increased risk of developing comorbid medical illnesses. They might have difficulty accessing care and can be lost to follow-up due to complex socioeconomic factors, placing them at greater risk of dying from chronic or undiagnosed conditions. This, in combination with stigma associated with SMI, can result in lower quality end-of-life care. Interdisciplinary palliative care teams are in a unique position to lend assistance to those with SMI given their expertise in serious illness communication, values-based care, and psychosocial support. However, palliative care teams might be unfamiliar with the hallmark features of the various SMI diagnoses. Consequently, recognizing and managing exacerbations of SMI while delivering concurrent palliative or end-of-life care can feel challenging. The goal of this narrative review is to describe the benefits of providing palliative care to individuals with SMI with concrete suggestions for communication and use of recovery-oriented language in the treatment of individuals with SMI. The salient features of 3 SMI diagnoses-Bipolar Disorders, Major Depressive Disorder, and Schizophrenia-are outlined through case examples. Recommendations for working with individuals who have SMI and other life-limiting illness are provided, including strategies to effectively manage SMI exacerbations.

End-of-Life Decision-Making Capacity in Older People With Serious Mental Illness

Background: The study's main aim was to assess the end-of-life decision-making capacity and health-related values of older people with serious mental illness. Methods: A cross-sectional, observational study, was done at Weskoppies Psychiatric Hospital, Gauteng Province, South Africa that included 100 adults older than 60 years of age and diagnosed with serious mental illness. The Mini-Cog and a semi-structured clinical assessment of end-of-life decision-making capacity was done before a standardized interview, Assessment of Capacity to Consent to Treatment, was administered. This standardized instrument uses a hypothetical vignette to assess decision-making capacity and explores healthcare-related values. Results: The Assessment of Capacity to Consent to Treatment scores correlated (p < 0.001) with the outcomes of the semi-structured decision-making capacity evaluation. Significant correlations with impaired decision-making capacity included: lower scores on the Mini-Cog (p < 0.001); a duration of serious mental illness of 30-39 years (p = 0025); having a diagnosis of schizophrenia spectrum disorders (p = 0.0007); and being admitted involuntarily (p < 0.0001). A main finding was that 65% of participants had decision-making capacity for end-of-life decisions, were able to express their values and engage in advance care discussions. Discussion and Conclusion: Healthcare providers have a duty to initiate advance care discussions, optimize decision-making capacity, and protect autonomous decision-making. Many older patients with serious mental illness can engage in end-of-life discussions and can make autonomous decisions about preferred end-of-life care. Chronological age or diagnostic categories should never be used as reasons for discrimination, and older people with serious mental illness should receive end-of-life care in keeping with their preferences and values.

Schizophrenia and cancer

PURPOSE OF REVIEW

The cancer mortality rate in persons with schizophrenia is higher than it is in the general population. The purpose of this review is to determine why, and to identify solutions.

RECENT FINDINGS

The recent literature points to three groups of reasons why mortality is high: patient reasons such as nonadherence to treatment, provider reasons such as diagnostic overshadowing, and health system reasons such as a relative lack of collaboration between medicine and psychiatry. Strategies for cancer prevention, early detection, and effective treatment are available but difficult to put into practice because of significant barriers to change, namely poverty, cognitive and volitional deficits, heightened stress, stigma, and side effects of antipsychotic medication. The literature makes recommendations about surmounting these barriers and also offers suggestions with respect to support and palliative care in advanced stages of cancer. Importantly, it offers examples of effective collaboration between mental health and cancer care specialists.

SUMMARY

The high mortality rate from cancer in the schizophrenia population is a matter of urgent concern. Although reasons are identifiable, solutions remain difficult to implement. As we work toward solutions, quality palliative care at the end of life is required for patients with severe mental illness. VIDEO ABSTRACT.

End-of-life decision-making capacity in an elderly patient with schizophrenia and terminal cancer

Medical practitioners are confronted daily with decisions about patients’ capacity to consent to interventions. To address some of the pertinent issues with these assessments, the end-of-life decision-making capacity of a 72-year-old female with treatment-resistant schizophrenia and terminal cancer is discussed, as are the role of the treating clinician and the importance of health-related values. There is a recommendation that the focus of these assessments can rather be on practical outcomes, especially when capacity issues arise. This implies that the decision-making capacity of the patient is only practically important when the treatment team is willing to proceed against the patient’s wishes. This shifts the focus from a potentially difficult assessment to the simpler question of whether the patient’s capacity will change the treatment approach. Clinicians should attend to any possible underlying issues, instead of focusing strictly on capacity. Compared to the general populations people with serious mental illness (SMI) have higher rates of physical illness and die at a younger age, but they do not commonly access palliative care services. Conversations about end-of-life care can occur without fear that a person’s psychiatric symptoms or related vulnerabilities will undermine the process. More research about palliative care and advance care planning for people with SMI is needed. This is even more urgent in light of the coronavirus disease-2019 (COVID-19) pandemic, and South African health services should consider recommendations that advanced care planning should be routinely implemented. These recommendations should not only focus on the general population and should include patients with SMI.

Supportive and palliative care for people with respiratory problems and preexisting serious mental illness

PURPOSE OF REVIEW

People living with serious mental illness are at a higher risk of developing respiratory problems that can lead to increased morbidity and early mortality. This review aimed to identify recent advances in care provision for people with respiratory problems and preexisting serious mental illness to ease symptom burden and reduce the risk of premature mortality.

RECENT FINDINGS

Intervention-based studies in this area are scarce. The evidence reviewed originated from observational studies. Concluding comments from the synthesis suggest there are specific needs for proactive screening of respiratory function as part of routine physical health checks across care settings for people living with serious mental illness, more stringent monitoring of comorbid chronic lung conditions and increased attention in reducing the frequency respiratory infections. Integrated services across care settings are needed to support people with serious mental illness to limit the impact of modifiable lifestyle factors known to be detrimental to respiratory health, such as smoking.

SUMMARY

Key priorities are identified to improve accessibility and inclusivity of respiratory care pathways for people living with serious mental illness to support early detection and proactive monitoring of respiratory problems to help reduce the risk of early mortality.

End-of-Life Care in Individuals With Serious Mental Illness

Background

Approximately 4.5% of the population live with serious mental illness (SMI), a term referring to mental health disorders that are chronic, impair function, and require ongoing treatment. People living with SMI are at risk of premature mortality relative to people without SMI. Chronic medical illnesses contribute significantly to mortality among individuals with SMI. The standard of care for individuals with serious medical illnesses includes palliative care. However, the provision of palliative care has not been operationalized for individuals with SMI.

Objectives

To review existing data on end-of-life and palliative care for individuals with serious medical illness and comorbid serious mental illness. To operationalize the role of the consultation-liaison (C-L) psychiatrist in such care, with a particular eye towards redressing disparities.

Methods

In this narrative review, we draw upon a review of the literature on end-of-life and palliative care provision for individuals with serious medical illness and comorbid serious medical illness. We also draw upon the experiences of the authors in formulating best practices for the care of such patients.

Results

Individuals with SMI are at risk of suboptimal end-of-life care. Patient, clinician, and system-level factors all contribute to disparities including decreased access to palliative care, uneven continued engagement with mental health services, and low rates of advance care planning. C-L psychiatrists can use their expertise at the intersection of medicine and psychiatry to address such disparities by (1) correcting misassumptions, (2) promoting advance care planning, (3) engaging long-term caregivers, (4) recognizing social needs, (5) ensuring ongoing access to psychiatric treatment, and (6) addressing suffering.

Conclusions

There are significant disparities in the end-of-life care of individuals with SMI. C-L psychiatrists have expertise to ally with medical providers and redress these disparities.

A palliative care approach in psychiatry: clinical implications

Background

Traditionally, palliative care has focused on patients suffering from life-threatening somatic diseases such as cancer or progressive neurological disorders. In contrast, despite the often chronic, severely disabling, and potentially life-threatening nature of psychiatric disorders, there are neither palliative care units nor clinical guidelines on palliative measures for patients in psychiatry.

Main text

This paper contributes to the growing literature on a palliative approach in psychiatry and is based on the assumption that a change of perspective from a curative to a palliative approach could help promote patient-centeredness and increase quality of life for severely ill patients in psychiatry as well as in somatic medicine. To exemplify this, we offer three different clinical scenarios: severe and enduring anorexia nervosa, treatment-refractory schizophrenia, and chronic suicidality and persistent self-injury in borderline personality disorder.

Conclusion

We emphasize that many typical interventions for treatment-refractory psychiatric disorders may indeed be of a palliative nature. Furthermore, introducing traditional features of palliative care, e.g. so-called goals of care conversations, could aid even further in ensuring that caregivers, patients, and families agree on which treatment goals are to be prioritized in order to optimize quality of life in spite of severe, persistent mental disorder.

End-of-life care and place of death in adults with serious mental illness: A systematic review and narrative synthesis

BACKGROUND

People with serious mental illness have greater mortality risk than the general population. They experience health care inequalities throughout life; it is not clear if this persists to end of life.

AIM

Assess the empirical evidence describing end-of-life care and place of death for people with serious mental illness.

DESIGN

A systematic review of original, peer-reviewed research, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data were analysed using a narrative synthesis approach.

DATA SOURCES

Five online databases (Embase, PsycArticles, PsycINFO, Medline, PubMed) and additional sources were searched (without time restriction) for primary research reporting health care utilisation in the last year of life or place of death in adults with serious mental illness.

RESULTS

After full-text screening, 23 studies were included. We found studies reporting hospital admissions, emergency department care, palliative care, and general practitioner (GP) visits at end of life. We found conflicting evidence for the association between serious mental illness and end-of-life care, although different patient groups, settings and measures were used across studies. People with serious mental illness were more likely to die in care homes than the general population. There were no patterns for other places of death.

CONCLUSIONS

The evidence was sparse and heterogeneous, demonstrating variability in patterns and reporting of health care use and with little consensus on where people with serious mental illness are likely to die. Given that people with serious mental illness have increased mortality risk, this gap in the knowledge around end-of-life care outcomes is concerning; this area of research needs further development.