Psychiatric Palliative Care: What Is It and Does It Work?

Editor's Note:

In 2006, in collaboration with The Institute for Palliative Medicine at San Diego Hospice, Dr. Scott Irwin started the first full-time psychiatric palliative care program in the country. Medscape spoke with Dr. Irwin about this young discipline and about what clinicians can do to help implement palliative care psychiatry into their institutions and practice.

What Is Palliative Care Psychiatry?

Medscape: Dr. Irwin, can you explain to our readers what psychiatric palliative care is exactly?

Dr. Irwin: Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness. This is accomplished through the prevention and/or relief of suffering by early identification, assessment, and treatment of physical, psychosocial, and spiritual issues. Palliative care psychiatry focuses on the emotional and social issues that arise in someone with an advanced illness, often in someone who is receiving hospice or palliative care (hospice being one end of the palliative care spectrum, which offers enhanced palliative care to patients with a short prognosis). Because patients with advanced life-threatening illnesses can have complex psychiatric issues and are often referred to palliative care teams, these teams need access to psychiatry and psychiatrists as consultants to provide exquisite interdisciplinary palliative care that addresses the complexities of this burden of suffering. Often what we bring to the table are expert diagnostic skills in regard to any psychiatric, psychological, and psychosocial issue, and then expert clinical decision-making including management of advanced psychotherapeutic and psychopharmacologic interventions.

Medscape: In your standard American hospital, how often is the psychiatric component considered a part of palliative care?

Dr. Irwin: I would say that all palliative care clinicians have the basics of the psychiatry that they need. All physicians are trained to some extent in psychiatry, and palliative care is an approach that takes into account the physical, psychosocial, and spiritual suffering of patients. However, many treatment teams lack access to skilled psychiatrists who can help them when things get complex, which happens quite frequently in their patients who have psychiatric needs. Therefore, the palliative care psychiatrist brings the next level of expertise beyond what the palliative care clinicians are able to do first-line.

Medscape: How new is this field, and is there a significant body of research in this area?

Dr. Irwin: The field is fairly new and still in its infancy. You can trace some of its roots to psycho-oncology, which addresses the psychiatric and psychosocial issues of patients with cancer. Our program grew out of the need for expertise in these areas for patients receiving hospice and palliative care -- no matter the diagnosis. There are a handful of psycho-oncology fellowships in the country and a few more psycho-oncology programs; often these are housed within large cancer centers. There's a Textbook of Psycho-oncology^[1] and a Handbook of Psychiatry in Palliative Medicine,^[2] but the evidence base is sparse. This year we trained the very first fellow in palliative care psychiatry, and he is going to go back to his program of origin to start another palliative care psychiatry program.

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