In a recent article Joshua James Hatherley argues that, if physician-assisted suicide (PAS) is morally permissible for patients suffering from somatic illnesses, it should be permissible for psychiatric patients as well. He argues that psychiatric disorders do not necessarily impair decision-making ability, that they are not necessarily treatable and that legalising PAS for psychiatric patients would not diminish research and therapeutic interest in psychiatric treatments or impair their recovery through loss of hope. However, by erasing distinction between somatic and psychiatric disorders on those grounds, he also erases distinction between healthy adults and patients (whether somatic or psychiatric) essentially implying that PAS should be available to all, for all reasons or, ultimately no reason. Furthermore, as psychiatric patients are much more likely to be a source of usable organs for transplantation, their broad inclusion would strengthen the link between PAS/euthanasia and organ donation, potentially undermining both as well as diminishing already declining general trust in medical authorities and professionals and public health authorities and activists.
This article will focus on the following objectives specific to end-of-life care for professional case management:
Discuss recent industry topics that influence care processes.
Explore the opioid epidemic's impact on pain management.
Identify terms associated with end-of-life and life-limiting care.
Understand types of advance directives and care defining tools.
Define the purpose of psychiatric advance directives.
Discuss the shifting diagnostic face.
Discuss how inclusion manifests for the lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ) population.
Explore challenges working through adolescent decision making and treatment.
Review regulation and reimbursement shifts across the industry.
Identify the use of artificial intelligence.
Discuss the value of ethics committees in health care organizations.
Define the Four Cs of Care Considerations.
Identify ethical principles for consideration by the workforce.
Dementia management is complicated by neuropsychiatric symptoms such that the longitudinal care of a psychiatrist or other mental health provider is often an essential part of patient care and a major source of family support. Given the importance of end-of-life continuity of care, the involvement of psychiatry in palliative and hospice services affords an important opportunity for growth. Common challenges involve sharing prognostic information with patients and families to aid in advance planning, and management of persistent pain and nutritional issues. Future research will yield important new insights and guidelines for care.
Background: Provision of palliative care is part of the standard of care for patients with serious, life-limiting medical illnesses. Patients in the palliative care setting have high rates of psychiatric co-morbidity. However, integration of mental health care into palliative care remains a significant gap. With appropriate training, consultation-liaison (CL) psychiatrists are well-positioned to improve integration of mental health into palliative care.
Purpose: To understand current palliative care training practices for CL psychiatry fellows in the United States.
Method: We invited all U.S. CL psychiatry fellowship program directors to participate in a 17-item online structured survey aimed at understanding palliative care training in their fellowship programs.
Results: 37/61 (61%) of CL psychiatry fellowship program directors responded to the survey. 86% of programs provide some palliative care didactics, but the topics covered vary widely. Programs are closely split between offering required, elective, or no clinical palliative care experiences. Only about half (45%) of programs identify formal opportunities for interaction between palliative care and CL psychiatry fellows. Program directors identified topics such as goals of care discussions, systems issues in end-of-life care, and pain management as important for fellows to learn. Barriers to teaching these topics included time, lack of teaching faculty, and disciplinary siloes.
Conclusions: Although CL psychiatry fellowship program directors identify a number of key teaching topics in palliative care for CL psychiatry fellows, there are wide discrepancies in the depth and content of existing palliative care didactic and clinical experiences in CL psychiatry fellowships.
In the September issue of the American Journal of Bioethics, Kious and Battin present their arguments on why physician aid-in-dying (PAD) due to severe suffering should also be allowed in non-terminal psychiatric diseases. The authors argue that a crucial aspect of PAD is the assessment of the decision-making capacity. Furthermore, they elaborate on the incompatibility of current PAD regulations and compulsory treatment because of suicidality, emphasizing differences between European, Canadian, and US-American policies. They differentiate between possible pathways the discussion about laws and policies concerning medically assisted dying could lead to. Firstly, keep the status quo, requiring a terminal illness, without considering the suffering caused by mental illness. Secondly, a change toward a partial opening of PAD for people with mental illness if their decision-making capacity is intact. This approach would require a change in policies regarding assisted dying while at the same time changing the involuntary civil commitment practices. The third approach devises a metric to measure suffering. While allowing patients who reach the threshold of unbearable suffering to access PAD, people with lower scores of suffering would fall under the policies of involuntary civil commitment and treatment. This third approach poses difficult questions concerning the nature of an instrument to determine suffering, the definition of suffering and its thresholds, and about the authority of the gatekeeper determining whether a person qualifies for PAD.
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BACKGROUND: Severe persistent mental illness (SPMI) currently affects an estimated 11.2 million adults in the United States (National Institute of Mental Health, 2019). Affected individuals are known to experience inequities in care, and on average, they die earlier than individuals without SPMI. Currently, little is known about hospice use among individuals with SPMI, including what factors contribute to the use of hospice services. OBJECTIVE: The aim of this integrated review was to identify factors associated with the use of hospice services by individuals with SPMI. STUDY DESIGN: A review of the available literature on this topic was performed in accordance with PRISMA guidelines. The databases Cumulative Index to Nursing and Allied Health Literature, PubMed, and PsycInfo were searched, and relevant records were identified. Ultimately, eight studies were identified and selected for analysis.
RESULTS: Themes illustrating the factors associated with hospice use and, within them, challenges to obtaining hospice care were discovered. The three themes identified within the eight studies were fragmentation of care, inadequate communication, and the need for advance care planning. These patterns indicated that multiple barriers to utilizing hospice care exist for individuals with SPMI when compared with the general population.
CONCLUSIONS: By recognizing and addressing factors influencing the use of hospice care, as well as barriers to receiving hospice, improved provision of timely end-of-life care that is consistent with individuals' preferences may be facilitated.
BACKGROUND: The significance of palliative care consultation in psychiatry is unclear.
ACTUAL CASE SERIES: Analysis of the introduction of palliative care consultation in a large psychiatric hospital.
POSSIBLE COURSES OF ACTION: Continue without offering, survey the need for or offer palliative care consultation, and analyse its introduction.
FORMULATION OF A PLAN: Palliative care consultation was established and details including patient age, department, diagnosis, main problem, solution and discharge were analysed during the first 2 years.
OUTCOME: Two consultations in the first year and 18 consultations in the second year were requested (18 geriatric, 2 addiction, 0 general, clinical social and forensic psychiatry) involving two domains: delirium associated with dementia or another condition (75%) and mental illness (e.g. alcoholic psycho-syndrome, psychosis, suicidal tendency, schizophrenia, depression) and cancer (25%). Recommendations of consultations were realized in 95%.
LESSONS FROM THE CASE SERIES: Implementation of palliative care consultation in psychiatry is one possible method of how to introduce palliative care in a field of medicine with lack of palliative care.
VIEW: Future research should focus on reasons for reservations about palliative care in psychiatry, include more patients with severe persistent mental illness and assess the value of palliative care consultation in resolving this problem.
Physician-assisted death is becoming legal in an increasing number of jurisdictions, but psychiatric patients are often explicitly excluded. However, in some countries, including the Netherlands, physician-assisted death of psychiatric patients is allowed. This Open Forum describes a patient with schizophrenia and symptoms diagnosed as refractory musical hallucinations. The patient requested assistance in dying only to recover after a mandatory second opinion, where his complaints were recognized as intrusive thoughts and treated accordingly. This case is used to reflect on how to deal with uncertainty about physician-assisted death of psychiatric patients and to argue for implementation of a due-diligence procedure, such as the one proposed in the Dutch Psychiatric Association's recent guideline concerning this issue.
Three Belgian doctors have been acquitted of unlawfully poisoning a 38 year old woman almost 10 years ago, in a landmark trial centred on Belgium’s assisted dying law.
During the high profile case the court heard that Tine Nys, who had severe psychiatric problems and had survived earlier suicide attempts, had repeatedly asked to be helped to die under the country’s 2002 legislation.
The law requires the independent opinion of three medical professionals. The two GPs and psychiatrist on trial agreed that Nys met the criterion of unbearable physical and psychological suffering from an incurable illness.
Background: A psychiatric advance directive (PAD) is designed to prevent involuntary mental health interventions by enabling people with serious mental illnesses to plan ahead for their own treatment during a future incapacitating crisis. This study implemented PAD facilitation in assertive community treatment (ACT) teams.
Aims: We examined ACT clients’ attitudes toward PAD facilitators, satisfaction with PAD facilitation, the short-term impact of PAD completion on subjective sense of empowerment and attitudes toward treatment, and whether the type of PAD facilitator made a difference.
Methods: Participants were randomly assigned to be offered PAD facilitation by a peer support specialist or non-peer ACT team clinician, and interviewed at baseline (n = 145) and post-facilitation 1–2-month follow-up (n = 116), to assess perceived consumer-directedness of PAD facilitation, empowerment and various treatment attitudes. Mean scores before and after the intervention were compared for PAD-completers, non-completers, and those who completed a PAD with a peer vs. non-peer. The effect of PAD completion was assessed using logistic and linear regression analysis.
Results: There was no evidence of bias against peer-facilitators. There was a modest positive impact of PAD facilitation on treatment attitudes and empowerment.
Conclusions: PAD facilitation by peer support specialists and others working in community mental health settings supports recovery.
Background: Mental health advance directives support service users' autonomy and provide a voice in their care choices when they may not have capacity to give informed consent. New Zealand's Southern District Health Board has recently introduced advanced directives in mental health services.
Method: Completed advance directives (n = 53) and additional demographic data were accessed from clinical records.
Analysis: Each advance directive was read and analysed by three members of the research team. The advance directive instrument has eight possible fields which could be completed, covering such topics as who should be contacted in a crisis; people service users do, or do not, want involved in their treatment; what service users would, or would not like to have happen should they become unwell; management of personal affairs; other specific preferences; and provision of further relevant information. The number of preferences stated in each field was also calculated.
Results: The advance directives provided expressions of preferences which were personally meaningful for service users and provided practical guidance for clinicians. Service users expressed mainly positive preferences, though some expressed negative treatment preferences, and many service users expressed preferences relating to personal affairs. Friends, family members and clinicians were nominated as preferred contacts in a crisis.
Conclusions: Service users will engage with advance directives if supported to do so. This study's results should help promote the wider availability of advance directives in New Zealand and the current reform of our mental health legislation.
J'ai professé, en tant qu'infirmier, pendant plus de 20 ans en service d'oncologie, puis de soins palliatifs. Enseignant et psychothérapeute depuis 10 ans, j'ai la chance de continuer de travailler avec des étudiants infirmiers dans des services de soins palliatifs et de psychiatrie, ainsi que de superviser des équipes de soins. Ethicien de formation, je fais partie d'un comité d'éthique dans un hôpital neuropsychiatrique. Ces différentes casquettes me donnent le grand privilège de rencontrer à la fois des patients en fin de vie ou souffrant de troubles psychiques, des soignants et des étudiants confrontés à des situations difficiles, et de relire, en comité d'éthique, des situations cliniques de grande souffrance.
La question de l'euthanasie est très régulièrement évoquée et suscite de nombreux débats, aussi passionnels que passionnants.
People with mental illness may be unable to provide critical input about the care they wish to receive during a psychiatric crisis because of altered mental states. It is therefore imperative that clinicians seek to understand service users' wishes for care while they are well and able to provide meaningful input into the discussion. Achieving such an end may be done by discussing and completing a psychiatric advance directive. However, very few Asian countries have legislation that supports such advance directives. The present article seeks to give physicians more information about advance psychiatric directives and the potential role they could play to improve the healthcare provided in Asia to people at risk of losing capacity due to a mental illness. The degree to which mental health legislation supports psychiatric advance directives is documented for each country of South East Asia and Eastern Asia.
Background: Compulsory admission to psychiatric hospital is rising despite serious ethical concerns. Among measures to reduce compulsory admissions, Psychiatric Advance Directives (PAD) are the most promising, with intensive PAD (i.e. facilitated and shared) being the most effective. The aim of the study is to experiment Psychiatric Advance Directives in France.
Methods: A multicentre randomized controlled trial and qualitative approach conducted from January 2019 to January 2021 with intent-to-treat analysis.
Setting: Seven hospitals in three French cities: Lyon, Marseille, and Paris. Research assistants meet each participant at baseline, 6 months and 12 months after inclusion for face-to-face interviews.
Participants: 400 persons with a DSM-5 diagnosis of bipolar I disorder (BP1), schizophrenia (SCZ), or schizoaffective disorders (SCZaff), compulsorily admitted to hospital within the last 12 months, with capacity to consent (MacCAT-CR), over 18 years old, and able to understand French.
Interventions: The experimental group (PAD) (expected n = 200) is invited to fill in a document describing their crisis plan and their wishes in case of loss of mental capacity. Participants meet a facilitator, who is a peer support worker specially trained to help them. They are invited to nominate a healthcare agent, and to share the document with them, as well as with their psychiatrist. The Usual Care (UC) group (expected n = 200) receives routine care.
Main outcomes and measures: The primary outcome is the rate of compulsory admissions to hospital during the 12-month follow-up. Secondary outcomes include quality of life (S-QoL18), satisfaction (CSQ8), therapeutic alliance (4-PAS), mental health symptoms (MCSI), awareness of disorders (SUMD), severity of disease (ICG), empowerment (ES), recovery (RAS), and overall costs.
Discussion: Implication of peer support workers in PAD, potential barriers of supported-decision making, methodological issues of evaluating complex interventions, evidence-based policy making, and the importance of qualitative evaluation in the context of constraint are discussed.
Trial registration: ClinicalTrials.gov identifier: NCT03630822. Registered 14th August 2018.
During a mental health crisis, patients with psychiatric diagnoses tend to suffer a loss of cognitive function and decision-making faculties. Psychiatric advance directives (PADs) are designed to ensure that these patients maintain some level of autonomy over their medical decisions even if they cannot retain decision-making power during a mental health crisis. This article explores the regulatory landscape surrouding PADs, including their legal foundation and barriers to their effective use in practice.
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Severe, persistent mental illnes (SPMI) presents a unique but not uncommon challenge to palliative care providers across manypractice settings, andpotentially at every stage of advanced illness. The cases below describe 2 patients with severe mental illness, both of whom had been admitted to inpatient orensic psychiatry units for a number of years, who pre-sented to an outpatient palliative care clinic. This article seeks to explore the barriers faced by these patients in accessing palliative care, and the challenges faced by providers in offering adequate supports to ensure equitable and appropriate care for both symptom management and advance care planning.
BACKGROUND: Euthanasia and physician-assisted suicide (EAS) in psychiatry are permitted in the Netherlands under certain legal conditions. Doctors may help patients who suffer unbearably and who have no prospect of improvement from psychiatric illnesses. Although this practice is permitted, it remains controversial, and the acceptability of EAS and the conditions under which it should be allowed are still debated. As the number of psychiatric patients requesting EAS is increasing, Dutch psychiatrists are becoming more reluctant to consider EAS.
OBJECTIVE: This study aims for a better understanding of Dutch psychiatrists' considerations for supporting or rejecting EAS for psychiatric patients.
METHODS: The data for this qualitative study were collected through 17 in-depth interviews with Dutch psychiatrists. These interviews were held from January until June 2016 as a part of the Third Evaluation of the Dutch Termination of Life on Request and Assisted Suicide Act.
RESULTS: Irrespective of their own position in the debate, most Dutch psychiatrists consider reasons for and against EAS, including moral (justice and equality, professional responsibility, compassion), epistemologic (how can one ever know the suffering is without prospect), practical, and contextual (mental health care provisions) reasons.
CONCLUSIONS: The variation in views on EAS in psychiatry seems to be related to a difference in views on the nature of psychiatric diseases. Some psychiatrists stress the similarity between psychiatric and somatic diseases, whereas others stress the fundamental difference. These opposing views could be bridged by a pragmatic view, such as a 2-track approach to EAS.
The Canadian province of Quebec enacted in 2014 a legislation that permitted medical assistance in dying (MAID) under specific conditions and the rest of Canada followed suit in June 2016. In this article, which is the second in a set of case series of requests for MAID in Canadian psychiatry, we present the cases of two patients who made a request for MAID to their treating psychiatrist in an outpatient clinic. While one is advanced in age and suffering from intense physical and psychic pain with little if any psychiatric comorbidity, the other is a young and medically healthy woman who nonetheless suffers from extensive psychiatric comorbidity. This article discusses both cases in light of recent scientific literature and case law that is slowly emerging in Canada, focusing on the concepts of the end of life and its legal definition as well as psychic suffering and its management in those wishing to receive physician-assisted dying. In our conclusion, we stress the need to clarify the definition of treatment resistance, the necessity to determine each physician's role when many are involved, as well as the importance of treating psychic pain holistically, which can sometimes require going beyond standard psychiatric care.