End-of-life (care) perspectives and expectations of patients with schizophrenia

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.

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.

Severe mental illness and palliative care: patient semistructured interviews

OBJECTIVES

To explore perceptions, experiences and expectations with respect to palliative care of patients with severe mental illness (SMI) and an incurable, life-limiting chronic illness.

METHODS

Face-to-face semistructured interviews were conducted with 12 patients (10 of them living in a mental healthcare institution) with severe mental and physical health issues in the Netherlands. A semistructured interview guide was used to elicit perceptions of, experiences with and expectations regarding palliative care. Data were analysed using inductive content analysis.

RESULTS

Analysis of the data revealed eight categories: perceptions on health and health issues, coping with illness and symptoms, experiences with and wishes for current healthcare, contact with relatives and coresidents, experiences with end of life of relatives and coresidents, willingness to discuss end of life and death, wishes and expectations regarding one's own end of life and practical aspects relating to matters after death. These categories were clustered into two separate themes: current situation and anticipation of end of life. Interviewees with SMI appeared not accustomed to communicate about end-of-life issues, death and dying due to their life-threatening illness. They tended to discuss only their current situation and, after further exploration of the researcher, the terminal phase of life. They seemed not engaged in their future palliative care planning.

CONCLUSIONS

Findings of this study highlight inadequacies in advance care planning for patients with SMI. Results suggest using values, current and near wishes, and needs as a starting point for establishing a gradual discussion concerning goals and preferences for future medical and mental treatment and care.

NDIS Participants with Psychosocial Disabilities and Life-Limiting Diagnoses: A Scoping Review

This research aimed to map evidence about system supports and gaps for Australians with psychosocial disabilities and life-limiting diagnoses. A scoping review of available policy documents, academic, and grey literature was completed to discover key characteristics of this concept and provide context around the phenomenon. Our focus was on Australia's National Disability Insurance Scheme (NDIS), a key reform providing support to the disability population nationally. No peer-reviewed or grey literature was retrieved on the phenomena. Therefore, three lines of enquiry were developed: experiences of NDIS participants living with psychosocial disabilities; the death, dying, and palliative care supports and experiences of NDIS participants of any disability type; and the experiences for people living with severe and persistent mental illness (SPMI) and life-limiting diagnoses. Five themes were identified: (1) the person; (2) advocacy; (3) informal supports; (4) formal supports; and (5) existing research. NDIS participants living with SPMI and their informal and formal support systems are still struggling to navigate the NDIS. While there are no specific publications about their end-of-life experiences, people with SPMI often experience poor end-of-life outcomes. Rigorous research into their death, dying, and palliative care experiences is needed to inform improved support to them, including their end-of-life care.

Improving control over euthanasia of persons with psychiatric illness: Lessons from the first Belgian criminal court case concerning euthanasia

BACKGROUND

Belgium is one of very few countries that legally allow euthanasia for suffering caused by psychiatric illness. In the first criminal trial in Belgium of physicians involved in euthanasia, three physicians recently faced the accusation of "murder by poisoning," for allegedly having failed to comply with several requirements of the Belgian Euthanasia Law in granting the euthanasia request a woman suffering from psychiatric illness. Although all three physicians were acquitted, the case generated much debate among policy makers, medical professionals, and the general public.

METHOD

We use this trial as the starting point for a critical analysis of the adequacy of the three-level control system established in the Euthanasia Law, as it is applied in the evaluation of euthanasia requests from persons who suffer unbearably from a psychiatric illness. This analysis is based on information presented during the criminal trial as well as information on the euthanasia that was published in the press.

RESULTS

Our analysis highlights substantial problems in the assessment and granting of the euthanasia request. The patient was euthanized without it having been substantiated that her psychiatric illness had no prospect of improvement and that her suffering could not be alleviated. The three-step control system enshrined in the Law and promoted by the Federal Control and Evaluation Commission for Euthanasia appears to have failed at each level.

CONCLUSION

To evaluate requests for euthanasia for mental suffering caused by psychiatric illness, the requirements of the Belgian Euthanasia Law should be complemented by mandating the advice of two psychiatrists, and face-to-face discussions between all physicians involved. In parallel with the process of evaluating the euthanasia request, a treatment track should be guaranteed where reasonable evidence-based treatments and recovery-oriented options are tried.

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.

End-of-life care in schizophrenia: a systematic review

OBJECTIVE

Schizophrenia is a severe and persistent mental illness with profound effects on patients, families, and communities. It causes immense suffering on personal, emotional, and socioeconomic levels. Individuals with schizophrenia have poorer health outcomes and die 10-20 years younger than the general population. Economic costs associated with schizophrenia are substantial and comprise 2.5% of healthcare expenditures worldwide. Despite psychosocioeconomic impacts, individuals with schizophrenia are subject to inequitable care, particularly at end of life. A systematic review was conducted to examine disparities in end-of-life care in schizophrenia and identify factors that can be targeted to enhance end-of-life care in this vulnerable population.

DESIGN

A comprehensive search was conducted using the databases Ovid MEDLINE(R), Ovid EMBASE, Ovid PsycINFO, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus from 2008-2018. Keywords included schizophrenia, palliative, end-of-life, and hospice. Two authors independently reviewed titles and abstracts; disagreements were resolved by consensus.

RESULTS

The search identified 123 articles; 33 met criteria: 13 case reports, 12 retrospective studies, 5 literature reviews, and 3 prospective studies. Articles were divided into major themes including healthcare disparities, ethics, and palliative care. Palliative care was the most frequent theme comprising >50% of the articles, and there was considerable thematic overlap with ethics and palliative care. Almost half the articles (45%) were related to schizophrenia and comorbid cancer.

CONCLUSIONS

Increased awareness of potential healthcare disparities in this population, creative approaches in multidisciplinary care, and provision of adequate palliative services and resources can enhance end-of-life care in schizophrenia.

Schizophrenia in the context of mental health services in Palestine: a literature review

BACKGROUND

Mental health conditions remain a significant cause of disability in the Arab World. Palestinians are predominantly at a higher risk for mental health problems due to their chronic exposure to political violence, prolonged displacement, and others as limited professional, educational, financial opportunities and mental health services. Schizophrenia is an overwhelming mental illness that affects nearly one percent of the various populations throughout the world. Studies have shown patients with schizophrenia die prematurely and have lower life expectancy compared to the general population. Moreover, antipsychotic medications and client's lifestyle play a significant role in increased morbidity and mortality in these patients. The present study willingly undertakes a literature review on schizophrenia in the context of mental health services in Palestine.

METHODS

Studies were identified through PubMed, Science Direct, Google Scholar, CINAHL, Semantic Scholar and Elsevier.

RESULTS

Twenty-four studies were included in this review; 11 articles related to schizophrenia and thirteen articles related to mental health services in Westbank and Gaza. Results revealed the life of patients with schizophrenia in Palestine is complicated. Barriers as lacking awareness about mental illness, stigma, inconsistent availability of medications, absence of multidisciplinary teamwork, insufficient specialists, fragmented mental health system, occupation, and other obstacles stand in the face of improving the quality of life among these patients.

LIMITATIONS

Palestine is a state that is seeking independence with a scarcity of resources. It has been described as "uncharted territories'' due to a lack of data, resources and records. As a result, there is insufficient data regarding schizophrenia in Palestine. Therefore, a thesis study that estimated 10 years' risk of coronary heart diseases in patients with schizophrenia was included.

CONCLUSIONS

Recommendations include ending the occupation as the leading cause of mental illness for Palestinians and implementing efficient and effective mental health nursing care through the multidisciplinary work and raising awareness regarding mental illness to fight the stigma.

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.

Differences in the Opioid Consumption of Terminally Ill Schizophrenic and Nonschizophrenic Cancer Patients: Analysis of Secondary National Population Data

CONTEXT

It is uncertain whether terminally ill schizophrenic cancer patients are hypoalgesic or have disparities in pain management.

OBJECTIVES

The objective of this study was to analyze the dosage of opioids used in terminally ill cancer patients with and without schizophrenia.

METHODS

This is a population-based retrospective cohort study based on data derived from the Taiwan National Health Insurance Research Database. Patients aged >20 years and newly diagnosed between 2000 and 2012 with at least one of the six most common cancers were included. After 1:4 matching, 1001 schizophrenic cancer patients comprised the schizophrenia cohort, while 4004 cancer patients without schizophrenia comprised the nonschizophrenia cohort. The percentage of opioid use, accumulated dose, and average daily dose near the end of life were analyzed for each cohort using multiple logistic and linear regression models.

RESULTS

The percentage of opioid use was lower in the schizophrenic cohort than the nonschizophrenic cohort during the last month before death (69.6% vs. 84.8%, odds ratio = 0.40, 95% CI = 0.34-0.48). The accumulated dose of opioid consumption was also lower in the schizophrenic cohort (2407 mg vs. 3694 mg, P value < 0.05).

CONCLUSION

Near the end of life, cancer patients with schizophrenia use less opioid than their nonschizophrenic counterparts. Cognitive impairment may be a cause in the disparity in end-of-life care for terminally ill schizophrenic cancer patients. Thus, we should formulate a more accurate pain scale system and pay attention to their need for pain treatment.

[Psychiatrists in palliative care of people with severe psychiatric illnesses and an oncological comorbidity]

People with severe psychiatric illnesses and an additional oncological illness represent great challenges to therapists in the palliative setting. Behavior patterns often appear incomprehensible or disconcerting. Depressive withdrawal or delusion in the context of a chronic psychosis can be frightening. This article outlines the epidemiological data as well as the particularities in the experience of this group of people. Following selected case studies from a psychological perspective, thoughts on the tasks of the psychiatrist in the palliative setting are presented.

Effects of chronic physical illness on treatment outcomes among patients with schizophrenia

PURPOSE OF REVIEW

Previous research has demonstrated the high prevalence of medical comorbidity and multimorbidity among patients with schizophrenia. However, little is known regarding the potential effects of chronic physical illness (CPI) on schizophrenia treatment outcomes. In the present report, we aim to provide an updated review of the relevant literature.

RECENT FINDINGS

We searched MEDLINE for studies published between 2017 and 2018. After screening 683 articles, we included six studies of adequate quality. Five of these studies reported significant associations between several CPIs and different schizophrenia treatment outcomes, whereas the remaining study did not. Significant effects were low to moderate in size. CPIs with significant effects on treatment outcomes included metabolic syndrome, cardiovascular disease, and asthma. No significant effects were observed for diabetes, chronic obstructive pulmonary disease, hepatitis, hypertension, hyperlipidemia, or lung conditions. One study reported a significant association between the total number of CPIs and the overall number of psychiatric rehospitalizations.

SUMMARY

In addition to increasing the risk of premature mortality, accumulating evidence indicates that various CPIs affect schizophrenia treatment outcomes. Thus, researchers and healthcare practitioners should increase efforts to raise awareness regarding the importance of physical health among patients with schizophrenia. Further high-quality studies are required, particularly those targeting the potential effects of individual CPIs.

A systematic review of palliative care tools and interventions for people with severe mental illness

BACKGROUND

Increasing attention to palliative care for the general population has led to the development of various evidence-based or consensus-based tools and interventions. However, specific tools and interventions are needed for people with severe mental illness (SMI) who have a life-threatening illness. The aim of this systematic review is to summarize the scientific evidence on tools and interventions in palliative care for this group.

METHODS

Systematic searches were done in the PubMed, Cochrane Library, CINAHL, PsycINFO and Embase databases, supplemented by reference tracking, searches on the internet with free text terms, and consultations with experts to identify relevant literature. Empirical studies with qualitative, quantitative or mixed-methods designs concerning tools and interventions for use in palliative care for people with SMI were included. Methodological quality was assessed using a critical appraisal instrument for heterogeneous study designs. Stepwise study selection and the assessment of methodological quality were done independently by two review authors.

RESULTS

Four studies were included, reporting on a total of two tools and one multi-component intervention. One study concerned a tool to identify the palliative phase in patients with SMI. This tool appeared to be usable only in people with SMI with a cancer diagnosis. Furthermore, two related studies focused on a tool to involve people with SMI in discussions about medical decisions at the end of life. This tool was assessed as feasible and usable in the target group. One other study concerned the Dutch national Care Standard for palliative care, including a multi-component intervention. The Palliative Care Standard also appeared to be feasible and usable in a mental healthcare setting, but required further tailoring to suit this specific setting. None of the included studies investigated the effects of the tools and interventions on quality of life or quality of care.

CONCLUSIONS

Studies of palliative care tools and interventions for people with SMI are scarce. The existent tools and intervention need further development and should be tailored to the care needs and settings of these people. Further research is needed on the feasibility, usability and effects of tools and interventions for palliative care for people with SMI.

A scoping review of palliative care for persons with severe persistent mental illness

Objective

People with severe persistent mental illness (SPMI) experience a greater burden and severity of chronic disease, late diagnosis, and premature death compared with the general population. Those with SPMI also receive fewer medical treatments, poor quality of care, and are less likely to receive palliative care. A systematic scoping review was undertaken to determine the extent, range, and nature of research activity about people with SPMI requiring palliative care, and to identify gaps and opportunities for future research.

Method

A systematic scoping review was undertaken in September 2017 and updated in May 2018 to map literature on this topic, determine the extent and range of what has been published, and report the findings. This five-stage framework was conducted by (1) identifying the research question; (2) identifying relevant studies; (3) determining study selection; (4) charting the data; and 5) collating, summarizing, and reporting the results. A narrative approach to analysis was used to synthesize and interpret findings. A search of multidisciplinary healthcare databases resulted in 46 included articles.

Result

Four major themes were identified from the included studies: complexity of care; limited access to care (both through systems and healthcare providers); competence and autonomy; and the potential for relationships between mental health and palliative care.

Significance of results

This review reveals a highly vulnerable population with complex needs that are not reliably being met by the healthcare system and providers. Research in this area must continue to develop using rigorous qualitative and quantitative study designs, and interventions should be developed and tested based on existing knowledge to inform care. The voices of people with SPMI in need of palliative care must be represented in future studies to address gaps. To expand a body of literature addressing mainly individuals, system perspectives and sociocultural analysis can bring much to contextualizing the experience of living with SPMI in the palliative phase of care. Adoption of a palliative approach, which promotes the principles of palliative care across nonspecialized care settings provided by nonspecialist palliative providers, has the potential to increase access to high-quality palliative treatment for people with SPMI.

Access to specialist palliative care services by people with severe and persistent mental illness: A retrospective cohort study

Compared to the general population, people with pre-existing serious and persistent mental illness (SPMI) have higher rates of physical illness and die at an earlier age, raising questions about their palliative and end-of-life care needs when they are diagnosed with an incurable physical illness. In the present study, we explored access to specialist palliative care services within one New Zealand health district. Routinely-collected, de-identified patient information on a cohort of people diagnosed with SPMI, and receiving specialist palliative care services from the Capital and Coast District Health Board (CCDHB), was compared to the general population from the same health district. People with SPMI are 3.5 times less likely to receive specialist palliative services compared to the general population from the Capital and Coast District Health Board. The proportion of people identifying as Māori is 1.2 times higher in the SPMI cohort than the general CCDHB population. The SPMI cohort experiences a higher level of deprivation compared to the general population in the CCDHB. The present study confirms that those diagnosed with an SPMI are less likely to use specialist palliative care services at the end of life. Research using a national dataset is needed to determine whether the study findings are applicable to the national population.

Dealing With Existential Suffering of Patients With Severe Persistent Mental Illness: Experiences of Psychiatric Nurses in Flanders (Belgium)

Residential psychiatric patients with severe persistent mental illness are often confronted with unbearable existential suffering. This qualitative study aims to describe how psychiatric nurses in Flanders (Belgium) deal with these patients. In view of the data we describe the nursing support for the existential suffering of these patients in terms of a process-related development. In this process of care four phases can be distinguished: meeting and knowing the patient, acknowledging the patient as an individual and as a sufferer, building a personal caring relationship based on a bond of trust and on respect for the patient as person, and a concluding phase. The personal caring relationship between nurse and patient is the fundamental element in the care practices. Next we describe the contextual framework inasmuch it can influence the caring process in a restricting or stimulating way.

Attitudes of Psychiatric Nurses about the Request for Euthanasia on the Basis of Unbearable Mental Suffering(UMS)

INTRODUCTION

When psychiatric patients express a wish for euthanasia, this should first and foremost be interpreted as a cry for help. Due to their close day-to-day relationship, psychiatric nurses may play an important and central role in responding to such requests. However, little is known about nurses' attitudes towards euthanasia motivated by unbearable mental suffering.

OBJECTIVES

The aim of this study was to provide insight into the attitudes and actions taken by psychiatric nurses when confronted with a patient's euthanasia request based on unbearable mental suffering (UMS).

METHOD

A questionnaire was sent to 11 psychiatric hospitals in the Flemish part of Belgium.

RESULTS

The overall response rate was 70% (N = 627). Psychiatric nurses were frequently confronted with a request for euthanasia, either directly (N = 329, 53%) or through a colleague (N = 427, 69%). A majority (N = 536, 84%) did not object to euthanasia in a psychiatrically ill population with UMS. Confounding factors were the psychiatric diagnosis and the type of ward where the nurses were working. Most participants acknowledged a lack of knowledge and skills to adequately address the euthanasia request (N = 434, 71%). Nearly unanimously (N = 618, 99%), study participants indicated that dealing with euthanasia requests and other end-of-life issues should be part of the formal training of nurses.

CONCLUSION

The results highlight the need for ethically sound and comprehensive provision of care. Psychiatric nurses play an important role in dealing with the complex issue of requests for euthanasia. There is also a need for education, training and clear guidelines on the level of health care organizations.