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

The Supportive Oncology Collaborative: Expanding upon Collaborative Care to Increase Supportive Care Access in Underserved Populations

Background: Access to supportive services in community-based oncology is challenging but essential, particularly for underserved populations. Methods: We developed the Supportive Oncology Collaborative (SOC), built upon the tenets of Collaborative Care, an existing model used to increase access to behavioral health in community settings. Using a population-health-based approach with screening, a registry, and shared care, we added palliative care specialists to a team of social workers and a consulting psychiatrist. We provided integrated psychosocial and palliative care at community-based sites of a large comprehensive cancer center. Results: We implemented the model in 2020 at a community site with a racially and ethnically diverse patient population. Encounters grew from 527 in our first year to 2,130 in 2022. Using screening tools, we identify the highest-risk patients for discussion in team meetings. Discussion: We are expanding the SOC across the Dana-Farber Cancer Institute regional campuses and believe it can increase access to integrated psychosocial and palliative care in cancer centers across the country.

Patients with both cancer and psychosis-to what extent do they receive specialized palliative care

BACKGROUND

Schizophrenia and advanced cancer are complex conditions that impact life expectancy. This study aimed to examine the receipt of specialized palliative care (SPC) in patients with metastatic cancer and a coexisting diagnosis of psychosis compared to patients with cancer only. Secondary objectives included analyzing differences in emergency visits and place of death in relation to receipt of SPC.

PATIENTS AND METHODS

This retrospective, observational registry study utilized health care consumption data from the Stockholm Regional Council. We included 23,056 patients aged >18 years who died between 2015 and 2021 with a diagnosis of metastatic cancer, hematologic malignancy, or malignant brain tumor in the Stockholm Gotland region. Among them, 320 patients had a concomitant diagnosis of psychosis.

RESULTS

Patients with cancer and psychosis were less likely to receive SPC compared to patients with cancer only (61% vs. 74%, p < 0.001). Additionally, they were, on average, four and a half years younger at the time of death (68.5 years vs. 73.1 years, p < 0.0001), more likely to reside in nursing homes (25% vs. 11%, p < 0.0001), and had a higher prevalence of low area-based socioeconomic status (46% vs. 32%, p < 0.0001). Receipt of SPC was associated with reduced frequency of emergency visits and a higher probability of place of death to be at home or in a care facility outside the acute hospital.

CONCLUSIONS

Patients with a coexisting diagnosis of psychosis and metastatic cancer have a lower probability of receiving SPC. Receipt of specialized palliative care was associated with reduced number of unplanned emergency visits and a lower risk for death at an acute hospital. Efforts are needed to ensure equitable provision of SPC for patients with cancer and psychosis.

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.

Palliative care research utilising intersectionality: a scoping review

BACKGROUND

Access to palliative care is recognised as a human right, yet clear disparities exist. There have been recent appeals to examine people's contexts and interactions with social systems which for many, adversely influence their utilisation of palliative care. Intersectionality provides a way to understand these drivers of inequity and ultimately advocate for change.

AIM

To identify and describe published studies utilising intersectionality in relation to need, access and experience of palliative care.

DESIGN

A scoping review.

DATA SOURCES

Medline, PsycINFO, CINAHL and Google Scholar databases and a manual search were undertaken for studies published up to January 2023. Included studies were evidence based articles where palliative or end of life care was the focus and intersectionality was identified and/or applied to the research that was undertaken.

RESULTS

Ten published studies were included. An analytic framework was developed to identify the extent that intersectionality was utilised in each study. A wide range of different groups were researched across the studies, with most focusing on aspects of their participant's identity in relation to palliative care access and experience. Common topics of power, heterogeneity of people within the health system and barriers to palliative care were illuminated across the studies.

CONCLUSIONS

Very limited research to date has utilised intersectionality to understand access, utilisation and experience of palliative care. This scoping review demonstrates intersectionality can provide a way to illuminate rich understandings of inequity in palliative care. It is imperative that future palliative research incorporates an intersectionality focus to further clarify the needs and experiences of structurally marginalised groups.

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.

Mapping the ethical aspects in end-of-life care for persons with a severe and persistent mental illness: A scoping review of the literature

Persons with severe and persistent mental illness (SPMI) make up a vulnerable group within mental healthcare and society. Not only do they suffer from long-term, serious psychiatric disorders; they often also experience considerable problems in their psychosocial functioning. Research has disclosed that the care needs of this target group are complex, and that the life expectancy of these persons is significantly lower than in the general population. Given (1) the lower life expectancy of persons with SPMI, (2) the higher suicide risk related to mental disorders, and (3) the legalization and practice of medical assistance in dying in an increasing number of countries, it is of utmost importance to map the ethical aspects and challenges of end-of-life care needs in persons with SPMI. Therefore, we charted the way end-of-life care is provided for them by means of a scoping review of the scientific literature, with an emphasis on the ethical aspects surrounding it. We explore existing ethical dilemmas; the underlying ethical values, principles and attitudes; and the locus and stakeholders of ethical dialog regarding end-of-life care in persons with SPMI. The results indicate that the four guiding principles of biomedical ethics can well be identified in the literature, and are each addressed in their own specific way: Autonomy in relation to questions regarding the decision-making capacity of persons with SPMI; Justice in relation to access to quality care and the presence of stigma; and Non-maleficence and Beneficence in relation to the ongoing debate regarding the benefits and obstacles in applying palliative care approaches in the context of psychiatry, and the status of the futility-concept therein. Personal virtues and attitudes in care professionals, like compassion, non-abandonment and upholding dignity are key, as care professionals are the main advocates of persons with SPMI, which often lack an extensive social network. Further, we find that the ethical dialog is mainly focused on care professionals and relatives, rather than the persons with SPMI themselves. This is reflected in the existing research that often had the voices of the latter missing. Future research may benefit from the inclusion of persons with SMPI’s first-hand accounts. End-of-life care for persons with SPMI may benefit from identifying and integrating (locally developed) good practices like cross-sectoral education, specific care models, and ethics support.

Mental Healthcare Providers Understanding and Experiences of Palliative Care: A Qualitative Analysis

Objective: To understand the experiences and perceptions of mental health providers about palliative care. Background: Little attention is paid to the experience of people with chronic persistent mental illness (CPMI) and life-threatening diseases and how their dying experience might differ from those without a CPMI. Methods: Interpretive description informed the project. Sixteen mental health care providers were interviewed using a semi-structured interview template. The interviews were recorded, transcribed, and analyzed using a reflexive, inductive-deductive thematic approach, guided by Braun & Clarke's framework for thematic analysis. Results: Four themes were identified from the data: intersectionality, limited collaboration, misconceptions about palliative care, and relationships. Mental health providers identified gaps in their knowledge of palliative care practices along with their knowledge of death and dying.

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.

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.

Hospice care access inequalities: a systematic review and narrative synthesis

BACKGROUND

Inequalities in access to hospice care is a source of considerable concern; white, middle-class, middle-aged patients with cancer have traditionally been over-represented in hospice populations.

OBJECTIVE

To identify from the literature the demographic characteristics of those who access hospice care more often, focusing on: diagnosis, age, gender, marital status, ethnicity, geography and socioeconomic status.

DESIGN

Systematic literature review and narrative synthesis.

METHOD

Searches of Medline, PsycINFO, CINAHL, Web of Science, Assia and Embase databases from January 1987 to end September 2019 were conducted. Inclusion criteria were peer-reviewed studies of adult patients in the UK, Australia, New Zealand and Canada, receiving inpatient, day, outpatient and community hospice care. Of the 45 937 titles retrieved, 130 met the inclusion criteria. Narrative synthesis of extracted data was conducted.

RESULTS

An extensive literature search demonstrates persistent inequalities in hospice care provision: patients without cancer, the oldest old, ethnic minorities and those living in rural or deprived areas are under-represented in hospice populations. The effect of gender and marital status is inconsistent. There is a limited literature concerning hospice service access for the LGBTQ+ community, homeless people and those living with HIV/AIDS, diabetes and cystic fibrosis.

CONCLUSION

Barriers of prognostic uncertainty, institutional cultures, particular needs of certain groups and lack of public awareness of hospice services remain substantial challenges to the hospice movement in ensuring equitable access for all.

Palliative Care in Severe and Persistent Mental Illness: A Systematic Review

Severe and persistent mental illnesses refer to a group of psychiatric disorders causing severe dysfunction in patients and include diagnoses such as schizophrenia, bipolar disorder, and major depression. Patients with severe and persistent mental illnesses have a complex symptomatology and face complicated medical disparities creating a difficult care process and reduced quality of life. Palliative care, a holistic approach to care that aims to reduce symptoms and stress of illness in persons living with chronic diagnoses, is appropriate within this population to address the complexity of care needs but is currently underutilized. The purpose of this review was to systematically review the literature to determine what is currently known about palliative care utilization in the severe and persistently mentally ill population. The databases systematically searched include PubMed, Cumulative Index for Nursing and Allied Health Literature, PsycINFO, and MEDLINE, to find all articles relevant to the research question. Keywords include "palliative care," "end-of-life care," and "severe and persistent mental illness," including all subsets. Literature was reviewed per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The results of this systematic review helped synthesize current information about this developing topic to inform clinicians on how to best integrate palliative care to this population.

Palliative Care Training for Geriatric Psychiatry Fellows: A National Survey Project

OBJECTIVES

Palliative care is an essential part of the standard of care for individuals with serious medical illnesses. Integration of palliative care and mental health is important for elderly patients with medical and psychiatric comorbidities. Geriatric psychiatrists are natural stewards of palliative care-mental health integration, however this is contingent on palliative care training. Currently, palliative care training in geriatric psychiatry fellowship programs is uncharacterized. We surveyed geriatric psychiatry fellowship program directors in the United States to assess current palliative care training practices.

METHODS

Web-based anonymous survey of geriatric psychiatry fellowship training directors RESULTS: Forty-six percent (28/61) of program directors responded. Seventy one percent (20/28) of programs provide didactics on palliative care. Seventy-seven percent (20/26) of programs provide clinical experiences in palliative care. Sixty-three percent (15/24) have formalized interactions between geriatric psychiatry and palliative care fellows.

CONCLUSIONS

Palliative care training for geriatric psychiatry fellows is robust but unstandardized. Operationalizing palliative care training for geriatric psychiatrists may improve mental health integration into serious illness care.

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.

Severe and persistent mental illness (SPMI) in pregnancy and breastfeeding: focus on second-generation long acting injectable antipsychotics

Introduction: Pregnant women and fetuses are more likely than ever to be exposed to antipsychotic drugs (APs) during pregnancy and postpartum period. Second-generation APs (SGA) are increasingly used among women in reproductive age. Key outcomes (i.e., congenital malformations, pregnancy and maternal outcomes, neonatal/infant risks, and developmental/long-term outcomes) following the exposure to APs remain limited in number and size and yield of inconsistent findings overall, particularly regarding long-acting injectable AP (LAI-APs) formulations.Areas covered: The review aims at providing a summary of current knowledge on potential risks and safety profile of LAI-APs during pregnancy and breastfeeding, specifically focusing on SGA.Expert opinion: The management of safety and tolerability of long-acting injectable AP (LAI-APs) is far from having solid scientific evidence. In fact, due to ethical reasons, there is a lack of randomized clinical trials that limits the reliability and generalizability of the available data on LAI-APs safety profile during the perinatal period, being limited in the scientific literature only to isolated case reports. Therefore, it seems to be important for the future pathways to perinatal mental health care, providing a network of specialized clinicians and systematically collecting data of pregnant/puerperal women on oral and/or LAI APs-therapy about mother and infant outcomes.

Natural cause mortality of mental health consumers: A 10-year retrospective cohort study

People with mental illness have substantially lower life expectancy than the general population, with mortality from natural causes most commonly attributed to cardiovascular diseases. The study aim was to identify characteristics of consumers who died of natural causes between 2009 and 2018 at one of Australia's largest publicly funded mental health services. Data were collected with a retrospective medical record review of 102 consumers. Mean mortality age was 52.4 years (SD = 10.7) (with females 51.9 years [SD = 12.0], and males 52.7 years [SD = 9.9]), which was more than 30 years lower than the Australian population. Cardiovascular diseases were the most frequent mortality cause (39%), followed by respiratory conditions (23%), cancers (20%), and all other causes (19%). Sixty (61%) consumers had at least three co-occurring physical health conditions. Seventy-five (74%) smoked tobacco. Consumers who died from cardiovascular diseases were less likely to attend specialist medical follow-up for their condition (P = 0.004), and more likely to die at home (P = 0.001). Consumers whose mortality age was above 55 years were more likely to have three co-occurring physical health conditions (P = 0.034). Consumers whose mortality age was below 55 years were more likely to have sub-optimal nutritional intake (P = 0.014) and higher body mass index (P = 0.008). There is a critical need to close the life expectancy gap for consumers. This requires dedicated focus on reducing mortality risk due to modifiable clinical characteristics which lead to consumer mortality. Mental health nurses play a key role in helping reduce consumers' mortality and morbidity risk through prevention and early intervention strategies.

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.

Working at the Intersection of Palliative End-of-Life and Mental Health Care: Provider Perspectives

OBJECTIVE

Palliative, end-of-life care (PEOLC) providers are poorly resourced in addressing the needs of patients with mental health challenges, and the dying experiences of this cohort-particularly those with a comorbid, chronic and persistent mental illness (CPMI)-are poorly documented. We sought to explore the experiences of PEOLC providers with regard to caring for patients with mental health challenges, and gather insights into ways of improving accessibility and quality of PEOLC for these patients.

METHOD

Twenty providers of PEOLC, from different disciplines, took part in semi structured interviews. The data were coded and analyzed using a reflexive, inductive-deductive process of thematic analysis.

RESULTS

The most prominent issues pertained to assessment of patients and differential diagnosis of CPMI, and preparedness of caregivers to deliver mental health interventions, given the isolation of palliative care from other agencies. Among the assets mentioned, informal relationships with frontline caregivers were seen as the main support structure, rather than the formal policies and procedures of the practice settings. Strategies to improve mental health care in PEOLC centered on holistic roles and interventions benefiting the entire palliative population, illustrating the participants saw little point in compartmentalizing mental illness, whether diagnosed or not.

SIGNIFICANCE OF RESULTS

Continuity of care and personal advocacy can significantly improve quality of life for end-of-life patients with mental health challenges, but bureaucracy and disciplinary siloing tend to isolate these patients and their caregivers. Improved interdisciplinary connectivity and innovative, hybridized roles encompassing palliation and psychiatry are 2 strategies to address this disconnect, as well as enhanced training in core mental health care competencies for PEOLC providers.

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.

Defining Severe and Persistent Mental Illness-A Pragmatic Utility Concept Analysis

The concept of severe and persistent mental illness (SPMI) lacks a consensual definition. Variations in definitions stem above all from different meanings about the constituent features of the concept and how to operationalize them. Our objective was to clarify the concept of SPMI and to explore the level of concept maturity through pragmatic utility (PU) concept analysis. Our findings suggest that SPMI is a partially mature concept that needs further clarification. We argue that the lack of a uniform definition is inherent to the problem: SPMI refers to a patient population rather than a disease entity, and the term has to be useful for different stakeholder purposes. Therefore, while an agreement on the principle three dimensions included in a definition may be possible (diagnosis, disability, and duration), their operationalization will have to be context-dependent and specific for the task at hand.

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.

Are We Evolving Toward Greater and Earlier Use of Palliative Home Care Support? A Trend Analysis Using Population-Level Data From 2010 to 2015

CONTEXT

The need for increased use and earlier initiation of palliative home care has been advocated by several international organizations.

OBJECTIVES

To investigate time trends in the use and timing of initiating palliative home care support (PHCS).

METHODS

We conducted an observational study using routinely collected population-level databases linked with health claims data for the entire population living at home that died of diseases indicative of palliative care needs in Belgium between 2010 and 2015 (n = 230,704). Trends and trends by cause of death and age were measured through changes over time in prevalence of use of PHCS. Rates were standardized for age, sex, and cause of death distribution in 2010. The median number of days before death when PHCS was initiated was calculated for each year.

RESULTS

Uptake of PHCS increased from 31.7% to 34.9% between 2010 and 2015. Trends were similar in size for all groups, except for people who died of dementia (smallest increase with 1.9 percent point). The timing of initiating PHCS advanced from 41 to 46 days before death, with the smallest increase observed among people who died of dementia (+2.5 days). The proportion of people receiving PHCS only in the last week of life changed from 15.3% to 13.9%.

CONCLUSION

This population-level study found a slight trend toward more and earlier initiation of PHCS between 2010 and 2015. However, uptake of PHCS remained below estimated needs in the population and the proportion of people receiving PHCS in their very late life remained stable over time.

Social disparities and symptom burden in populations with advanced cancer: specialist palliative care providers' perspectives

Disparities in access to palliative care services for populations with social disparities have been reported in Western countries. Studies indicate that these populations tend to report higher symptom distress than other population groups. We need to further investigate how social disparities influence symptom burden to improve symptom relief in these populations.

PURPOSE

To examine the perspectives of specialist palliative care providers concerning the relationship between social disparities and symptom burden in populations with advanced cancer.

METHODS

Two sequential qualitative studies that followed a combination of interpretive and critical methodologies. The interpretive approach was outlined by van Manen's hermeneutic phenomenology while the critical component was informed by the works of Paulo Freire. Participants involved two specialist palliative care teams from a large acute care hospital and a large cancer center in Western Canada. Participants included 11 palliative care providers including registered nurses, nurse practitioners, physicians, and pharmacists.

RESULTS

Participants perceived that social conditions that might aggravate symptom burden included low income, low education, lack of social support, language barriers, and rurality. The relationship between income and symptom burden reflected diverse views. Participants identified populations prone to complex symptom burden including homeless individuals, Indigenous people, people with a history of addictions, and people with mental health or psychosocial issues.

CONCLUSION

Participants perceived that social disparities may increase symptom complexity in populations with advanced cancer. Participants did not identify ethnicity and gender as influencing symptom burden. Further research is needed to examine the interactions of social disparities, patient individuality, and symptom burden.

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.

Morbidity burden and community-based palliative care are associated with rates of hospital use by people with schizophrenia in the last year of life: A population-based matched cohort study

Objective

People with schizophrenia face an increased risk of premature death from chronic diseases and injury. This study describes the trajectory of acute care health service use in the last year of life for people with schizophrenia and how this varied with receipt of community-based specialist palliative care and morbidity burden.

Method

A population-based retrospective matched cohort study of people who died from 01/01/2009 to 31/12/2013 with and without schizophrenia in Western Australia. Hospital inpatient, emergency department, death and community-based care data collections were linked at the person level. Rates of emergency department presentations and hospital admissions over the last year of life were estimated.

Results

Of the 63508 decedents, 1196 (1.9%) had a lifetime history of schizophrenia. After adjusting for confounders and averaging over the last year of life there was no difference in the overall rate of ED presentation between decedents with schizophrenia and the matched cohort (HR 1.09; 95%CI 0.99–1.19). However, amongst the subset of decedents with cancer, choking or intentional self-harm recorded on their death certificate, those with schizophrenia presented to ED more often. Males with schizophrenia had the highest rates of emergency department use in the last year of life. Rates of hospital admission for decedents with schizophrenia were on average half (HR 0.53, 95%CI 0.44–0.65) that of the matched cohort although this varied by cause of death. Of all decedents with cancer, 27.5% of people with schizophrenia accessed community-based specialist palliative care compared to 40.4% of the matched cohort (p<0.001). Rates of hospital admissions for decedents with schizophrenia increased 50% (95% CI: 10%-110%) when enrolled in specialist palliative care.

Conclusion

In the last year of life, people with schizophrenia were less likely to be admitted to hospital and access community-based speciality palliative care, but more likely to attend emergency departments if male. Community-based specialist palliative care was associated with increased rates of hospital admissions.