Is death our business? Philosophical conflicts over the end-of-life in old age 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.

The Human Rights of Older People With Mental Health Conditions and Psychosocial Disability to a Good Death and Dying Well

The human right to a good death and dying well is as important as the right to life. At stake at the end of life are human rights to dignity, autonomy, self-determination and respect for will and preferences, equitable access to quality health care that is needs-based, and respect for family and relationships. Older people with dementia, those with serious mental illness, and those with intellectual disability are vulnerable to "bad deaths" due to violations of these rights. In this paper we explore why this is so and examine existing and potential solutions. A human rights-approach to end-of-life care and policy for older persons with mental health conditions and psychosocial disability is one that is needs-based, encompassing physical and mental health, palliative care, social, and spiritual support services provided in the context of inclusive living. Most importantly, end of life care must be self-determined, and not "one size fits all." An important remedy to existing violations is to strengthen human rights frameworks to cater specifically to older persons' needs with a UN convention on the rights of older persons. Finally, as health professionals we have important contributions to make at the coalface by accepting our responsibilities in the area of death and dying. With the concept of the palliative psychiatrist gaining traction and recognition that death is our business, we add that human rights is also our business.

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.

Towards a palliative care approach in psychiatry: do we need a new definition?

Psychiatry today is mainly practised within a curative framework. However, many mental disorders are persistent and negatively affect quality of life as well as life expectancy. This tension between treatment goals and the actual illness trajectory has evoked a growing academic interest in 'palliative psychiatry', namely the application of a palliative care approach in patients with severe persistent mental illness. Recently, Trachsel et al presented a working definition of palliative psychiatry. This first official attempt to capture the concept is based on WHO's widely accepted definition of palliative care but modified and limited to include only severe persistent psychiatric illness. While this is a welcome step in the discussion on palliative care approaches in psychiatry, it also opens up for new questions. One of the most evident is whether psychiatry actually needs its own definition of palliative care or, put differently, whether there is something about mental disorders that differs so radically from other medical conditions that it calls for a separate definition. We acknowledge the need to discuss the goals of psychiatric care in patients with severe persistent psychiatric illness. However, we question whether a separate definition of palliative care exclusive to psychiatry is the right way to go. In this paper, we discuss why.