By Anna Lindblad
It first occurred to me during a house visit. Sitting next to a very old and very frail person shaking with anxiety, I realised that there was not much for me, the psychiatrist, to offer. Pharmacotherapies had not relieved the symptoms of depression. Electroconvulsive therapy was no option due to somatic comorbidity. In-patient hospital care had been tried without success. We were at the end of the road. In another discipline, this would have been the time to have a conversation about prognosis; about switching from a curative to a palliative approach. It would have been the time to engage a palliative team. However, when it comes to severe mental disorder, there are no palliative care resources to call.
Psychiatry today mainly operates in a curative framework where prevention of suicide is a main goal and death is generally considered an adverse event. This creates a tension between treatment goals and actual illness trajectory which is evident not only in old age psychiatry, but also in cases of chronic psychosis and severe anorexia nervosa, only to mention a few.
In recent years, there has been a growing interest in what could be called “palliative psychiatry”. A first official attempt to capture the concept has been presented by Trachsel and colleague (2016) in their paper “Palliative psychiatry for severe persistent mental illness as a new approach to psychiatry? Definition, scope, benefits and risks”. This is an ambitious piece of work, and surely a good starting point for discussions on treatment goals in psychiatry. However, the authors offer no explanation as to why psychiatry needs its own definition of palliative care.
In our paper, we question the need for a separate definition. Instead, we argue that the WHO definition for palliative care is wide enough to include mental disorders. However, still bearing that particular house visit in mind, we acknowledge the need to discuss the goals of psychiatric care in patients with severe persistent psychiatric illness and join Trachsel and colleagues in their call for further research on the clinical and ethical implications of a palliative care approach in psychiatry.
Reference: Trachsel M, Irwin SA, Biller-Andorno N, Hoff P, Riese F. Palliative psychiatry for severe persistent mental illness as a new approach to psychiatry? Definition, scope, benefits, and risks. BMC Psychiatry 2016;16:260.
Authors: Anna Lindblad, Gert Helgesson, Manne Sjöstrand
Affiliations: Stockholm Centre for Healthcare Ethics (CHE), Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
Competing interests: None declared.