PsychiatryTalk

Psychiatry in Palliative Medicine

Posted on March 31st, 2010 by Dr. Blumenfield

Handbook of Psychiatry in Palliative Medicine, 2nd ed., by Harvey Max Chochinov, M.D. and William Breitbart, M.D. New York, Oxford University Press, 2009, 592 pp., $89.50.

Book Review and Q & A with Editor

Harvey M. Chochinov, M.D.  Co-editorHarvey M. Chochinov, M.D. Co-editor

I have reprinted the review of this book which I wrote in the April issue of Journal of the American Psychiatric Association. At the conclusion of the review I have added a five question and answer interchange which I had with Dr. Breitbart.

Palliative Care

What Do Dying People Want?

Potential readers of this book no doubt will be concerned about what dying people want, which is a theme examined throughout the book. It is discussed and answered by Khul in his chapter on this subject as follows:

“People at the end of life want adequate pain and symptom management, and desire to participate in a process of clear decision making to achieve a sense of control, to relieve burden, to be affirmed as a whole person, and to strengthen their relationships with loved ones.”

Who Should Read This Book?

This book offers an excellent introduction to those who have any interest in palliative care or who,  from time to time, deal with issues of death and dying. It will even be more useful to those who work in the field on a regular basis. It certainly is a necessary reference book to both of these groups of professionals, and it provides the in-depth discussion on just about all the pertinent subjects in this fast-growing specialty. While the title of the book indicates that psychiatric issues are the main focus, the editors have used a wide-angle lens to examine this subject. In addition to psychiatrists, other physicians, nurses, and any mental health professional will feel comfortable with this book.

The volume editors are well-known sensitive giants in a field that requires a balance of scientific evidence-based thinking and empathic humaneness, which are not easy to combine. They have brought together on the pages of this book outstanding contributors who embody these characteristics and who know their subject matter extremely well. There is some duplication and overlap, but some subjects, such as existential approach to patients, benefit from multiple discussions.

Second Edition Makes New Contributions

The first edition of this book came out 8 years ago, and many new chapters have been added to this second edition. These new contributions have homed in on hospice, persons with serious mental illness, patients with substance use disorders, and patients with personality disorders. They also include a new look at interdisciplinary teamwork, cultural diversity, families, spiritual issues, and an interesting view of special care considerations for the seriously ill older patient.

Many of the chapters will take the reader to the cutting edge of science, as well as clinical and ethical issues. You will learn that two renowned ethicists, Pellegrino and Sumansy, believe that intensive comprehensive palliative care is the rational alternative to euthanasia and physician-assisted suicide.

Many of us who did not have the opportunity to train under or work with Ned Cassem will get an invaluable view of his clinical insight and very humane approach to patients in his chapter on the management of the patient at the end of life. Examples of some of the questions he often asks patients and discusses in his outstanding chapter are: “As you look back what are you proudest of?” “Did you play mischievous pranks on others?” What are the most meaningful joys in your life? The things that you wish you could do again?”

Palliative Care-1Diagnosis and Management of Depression in Palliative Care

There is a comprehensive chapter on everything you might want to know and should know about the diagnosis and management of depression in palliative care by Wilson, Lander, and Chochinov. They provide a very good review of medications for depression but also state that medication without ongoing contact is often experienced as abandonment and is not an acceptable approach. Roth and Massie do a similar good job with anxiety in palliative care, noting that between a quarter and a third of patients with advanced cancer receive anti-anxiety medication during their hospitalizations. They also make a plea for testing new psychotherapies (such as meaning-centered or dignity-conserving therapies) for effectiveness in decreasing anxiety in the palliative care setting. Breitbart’s vast experience with AIDS and cancer is reflected well in the chapters on delirium and pain management in which he is the lead author. Throughout the book, studies are cited, reporting that as many as 90% of patients with terminal cancer or other advanced diseases experience unrelieved pain. The likelihood of insufficient treatment of cancer pain is higher if the patient is female, elderly, a member of an ethnic minority, a child, or a substance abuser, according to one study cited. An equally high percentage of disturbing pain has been reported in patients with AIDS.

Full Spectrum of Psychotherapy

The full spectrum of psychotherapy approaches is covered comprehensively in various chapters, including  psychodynamic, cognitive-behavioral, narrative-writing, family-focused therapy and group therapy. In regard to this latter treatment, Spiegel and Leszcz discuss the follow-up of Spiegel and colleague’s early groundbreaking research, which raised the possibility that psychotherapeutic group interventions may affect survival time as well as quality of life. Subsequent research has been mixed in this regard, but the authors cite a recent trial finding that among 227 women with primary breast cancer, those randomly assigned to a 1-year program of training in active coping, communication skills, and symptom management had significantly lower rates of relapse and mortality at 11-year follow-up.

Countertransference

Countertransference is discussed by Vachon and Muller in their chapter on burnout in staff working in palliative care, as well as by Stuber and Bursch in their chapter on psychiatric care of the terminally ill child, and it is also covered in Kissane’s chapter, which included co-authorships by the two co-editors. It would probably be quite worthwhile if the editors in future editions could coax more discussion of how the experienced contributors to this book handle their personal reactions to working in this field.

However, do not wait for the next edition, as this book should be currently in the hands of anyone who does work in consultation-liaison psychiatry or any aspect of palliative care. You may be able to Google some of the factual material contained here, but you can never find the empathic, in-depth presentations and discussion on the Internet that are packed into the 592 pages of this book.

TAKE FIVE WITH THE AUTHOR- Dr. Bill Breitbart answers five questions which I asked him about the subject of this book

  • William Breitbart, M.D. co-author
  • William Breitbart, M.D. co-editor
  • #1  Do you feel that most patients with terminal illness in this country get adequate palliative care and what can be done to improve it?
    `The development of academic palliative care in the US had lagged well behind the UK, Australia and Canada, However the last 10-15 years has seen great advances with the establishment of Academic palliative care medicine Departments and with ACGME accredited fellowship programs in Palliative Medicine. While these academic and hospital based palliative care programs are great  resources for clinical research in palliative care and in- hospital palliative care programs, they still fall quite short of accessing all hospitalized patients who need palliative care , or who die in hospitals and nursing homes. A great deal of palliative care is provided by hospice care programs with care provided at home. Despite the fact that there are over 4,000 hospice programs in the US, we still have fewer hospices per capita than countries like Canada, the U.K. and Australia. In terms of whether most terminally patients receive adequate palliative care, the answer depends on what one considers “adequate” palliative care. For the most part, palliative care and hospice teams are most competent and have the skill set required to focus on pain and physical symptom control. That of course is fundamental to all palliative care. I believe  what remains inadequate is the ability of the interdisciplinary palliative care or hospice team to expand the concept of adequate palliative care to include psychiatric, psychosocial, existential and spiritual aspects of palliative care. Part of the problem is that most teams are not truly fully interdisciplinary. They do not include a psychologist or psychiatrist. The second problem is a knowledge, skill and intervention development gap. That is why we edited this textbook on Psychiatry in Palliative Medicine; to teach assessment and management skills pertinent to psychiatric and existential issues, and to inform clinicians of new intervention development in addressing psychiatric and existential despair near the end of life.

    #2  What grade would you give each of the following medical specialties in so far as they train residents in palliative care : Internal Medicine, Oncology Fellowship Program, Pediatrics, Psychiatry, Family Medicine ?
    It’s difficult to give any of these residency programs a passing grade overall, however I believe that there are unique programs in each of these disciplines that expose trainees to palliative care and are examples of what is possible.

    #3 How do you feel national health care might change the delivery of palliative care?
    Palliative care, like psychiatry has its reimbursement problems. They are both time and communication intensive without high cost interventions. It is difficult for hospital based palliative care programs to sustain themselves financially merely based on billing. Hospice care is a Medicare benefit, and one hopes that health care reform does ot negatively impact on hospice reimbursement. There are encouraging signs that health care reform may help the delivery of palliative care. The element of the Health Care Reform Act that was labeled “Death squads” in fact was a dictate to reimburse clinicians for the time spent in discussing care options including hospice care. I believe that was a step in the right direction.

    #4 Why do women and minorities get poorer palliative care than others?
    Minorities are underrepresented in hospice programs . Most people think this is a result of a discriminatory historical legacy where minorities had less access to acute care or advanced treatments (and were subject to unethical research experimentation). This legacy has led to a mistrust of the health care system, and minorities sometimes see referral to hospice as being deprived of available, potentially curative treatments. I am not sure that women get poorer palliative care, but studies of my own suggest that both women and minorities get undertreated for pain. Women seem to get undertreated for pain because their somatic complaints are sometimes seen as hypochondriacal or exaggerated. Minorities are often stereotyped as potential opioid abusers. Both stereotypes are unjustified and are quite destructive.

    #5 Do you have any advice how physicians might deal with personal reactions or countertransference to terminal illness  which could interfere with them providing optimal palliative care for their patients?
    We all have personal reactions to working with patients who are dying, especially if we can identify with them ( same age, same gender, similar family structure, similar profession etc.). The reactions can range from denial and avoidance of dealing with the suffering these patients experience, to become anxious, panicky or depressed. Having the skills to be able to make some impact on suffering is very helpful. Anytime we can be effective and helpful I think we feel we are doing something meaningful as physicians. So learning how to treat pain, or learning how helpful it is for patients to reflect on the lives they have led and transmit a message that the patient continues to have a life of dignity, meaning and value , even in the last months of life, can be very rewarding. Most physicians will tell you that it is the moments of connection on a human level with patients ; recognizing that we are both human beings, sharing the human condition despite being physician and patient ( An I thou moment as Buber might describe it), that are the most rewarding in a life time of practice. We learn great lessons from our patients, We see courage that inspires. We see acceptance of death that can comfort us. Compassion has infinite rewards for physicians.

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