Acceptability of palliative care approaches in mental health care
In this survey of psychiatrists in Switzerland, almost all respondents believed that SPMI can be a terminal illness, and that curing the illness has a lower priority than other care goals such as reduction of suffering and functioning in daily life. These findings align with previous conceptual work which suggested that some existing clinical approaches in contemporary psychiatry can be considered palliative because their primary aim is not remission or illness modification [2]. The broad consensus about the fatality of certain severe cases of mental illness is particularly noteworthy given the ‘loud silence’ with regard to death and dying (other than suicide and its prevention) in mental healthcare. Premature mortality is a neglected aspect in mental health care. Accepting it as an unchangeable outcome [25], or completely ignoring it in the development of new treatment approaches is harmful to the most vulnerable of all patients. It is hoped that by acknowledging that this group of patients is at greater risk of dying [26], additional resources can be freed up in order to improve the care of these patients. In summary, our findings suggest widespread agreement among the respondents on the suitability of general palliative care approaches in treating SPMI. One issue raised by several participants in the comment section of the survey was the concern expressed by some experts about the possible impact of characterising mental health treatments as ‘palliative’, which might be seen to imply ‘giving up’ on patients [17,18,19, 27]. Indeed, the term ‘palliative’ may not be ideal, given its associations with terminal illness [3]; almost half of our respondents felt that it was closely related to end-of-life care, indicating a heterogeneous understanding of palliative care, even among health care professionals.
It is important to stress that the use of palliative care in psychiatry (as in other areas of healthcare) does not exclude other treatment approaches. The features of palliative care approaches, such as the ongoing alliance with patients and their relatives [3], exquisite symptom management and pursuit of patient and family goals for care and for life in general are, for example, compatible and consistent with the principles of the recovery model [4]. In this sense, palliative care approaches may offer psychiatrists additional tools in the care of SPMI, particularly where patient needs and goals cannot be met by current psychiatric interventions. However, the discomfort about introducing approaches that used to be reserved for a terminally ill population in psychiatric treatment of SPMI patients has to be taken seriously and has to be critically accompanied scientifically. Specifically, it has to be evaluated whether using a less loaded term such as supportive care can improve acceptance of the concept [28].
With regard to the case vignettes, participants prioritized quality of life over patients’ remaining life expectancy, and in all three cases, the great majority doubted that further interventions to cure the illness would be successful. This finding aligns with conceptual questions concerning the importance of curing SPMI as compared to other goals of care such as reduction of suffering and functioning in daily life. The overall consensus that curative approaches would most likely be futile in certain specific cases of SPMI confirms the need to further explore the concept of medical futility in psychiatry. Objections to the applicability of this concept in cases of chronic psychiatric illness are multifaceted [17, 19]. However, even if one accepts these arguments and concludes that the concept is not relevant in the context of mental illness, the question remains of how best to deal with the reality of unremitting or progressively declining mental illness. In summary, while it could be argued that the recovery-based model and the harm reduction approaches already seek to minimize symptoms in acute and maintenance phases, we believe that the considerations above have implications that go beyond of what is currently available, especially with regard to futility and last resort therapeutic interventions.
Lack of specificity of the conceptual framework
It seems clear that the concepts and framework underpinning palliative care approaches in a psychiatric context require further elucidation, including the issue of how specific palliative care interventions might be implemented. In particular, advocates need to elaborate how palliative care might be applied to psychiatric illness, including the prevention and relief of suffering, prevention of futile and burdensome interventions and improvement of quality of life. Any such investigation of the feasibility of specific palliative care interventions lies beyond the scope of the present study. It should also be noted that the WHO definition of palliative care provided in the survey (see Table 2) was described by several respondents as vague and applicable to many (if not all) forms of psychiatric treatment. The high variability in the results might be one indication for a lack of consensus on what palliative care approaches in this context would comprise. This aspect hast to be taken into consideration when interpreting the data, and it will be crucial to develop a minimum consensus regarding the definition of palliative care approaches in order to further develop this area.
Strengths and limitations
The present study has a number of strengths. Previously, palliative care approaches in psychiatry have been discussed mainly at a conceptual level by ethicists and experienced clinicians. We are aware of only one other study that tackles the topic empirically through qualitative interviews [29], focusing on commonalities between contemporary mental healthcare and palliative care philosophies. It is argued here that the similarities between mental health services and palliative care principles can serve as a foundation for integrating these approaches into mental health services.
The present study is the first survey to use quantitative methods to explore mental health professionals’ attitudes to the treatment of SPMI patients in general, and to the use of certain palliative care approaches in particular. In light of the controversy surrounding that discussion, this insight is an important first step towards establishing the relevance of the palliative care concept in mental health care.
The study also has several limitations. Although Likert scale items are an accepted means of conducting quantitative surveys, the options offered can only approximate complex multidimensional concepts.
In assembling the study’s advisory group, our rationale was to include on the one hand persons who were able to advise us with relevant knowledge on the research questions and the content of the survey including experts and trainees in psychiatry, psychology, and palliative care, and on the other hand, professionals with regard to survey design issues and statistics (psychologist and biostatistician). However, it’s a limitation that no other stakeholders such as patients, family, or policy makers have been part of the advisory board. The present evidence depends on only 457 completed surveys. This corresponds to about 10% of psychiatrists in Switzerland. In addition, the sample was confined to German-speaking members of the SSPP and may not be representative for all psychiatrists practicing in Switzerland. Furthermore, the results are not generalizable to other mental health care professionals who might be involved in the care of patients with SPMI such as nurses and psychologists. The nonresponse rate raises the possibility of response bias. It might be possible that psychiatrists with particular pre-existing normative beliefs were disproportionally represented. However, the demographics correspond to the total of all psychiatrists in Switzerland and the results have a high variability, suggesting a minor impact of the response bias on our data. Lastly, it is important to note that an available case analysis was used in order to minimize loss of data.
Lastly, it is important to note that an available case analysis was used in order to minimize loss of data but that the known disadvantages of this, e.g., that the standard of errors computed by most software packages uses the average sample size across analyses, do not apply for our study because we haven’t used inferential statistics and used available cases for SD’s and confidence intervals as well.
Implications for clinical practice
The present findings indicate that many psychiatrists—at least in Switzerland—consider that palliative care approaches may be suitable for certain cases of SPMI. For clinical practice, this means that palliative care represents a possible option in the treatment of SPMI patients and the psychiatric profession’s readiness to introduce some of these tools to clinical care. To explore this option, the psychiatric profession must design a framework for use and a common language for the field, and must subsequently create an evidence base capturing the impact on clinical outcomes for SPMI patients. Most importantly, palliative approaches must be seen as an addition to rather than a replacement for other novel and promising person-centred approaches, such as the recovery movement [4, 21]. It remains open whether the term ‘palliative’ will have majority appeal or whether palliative care principles will merely inform a modern concept of psychosocial support for SPMI patients.
Future research
While this study offers some insight into how the surveyed psychiatrists appraise the implementation of palliative care approaches in mental healthcare, it is mainly to be interpreted as a starting point of the discussion. It remains unclear how the concept might be assessed by affected patients, and the specifics of palliative care interventions remain to be defined. The next step will be to develop a framework for differential indication—that is, to identify which patients would qualify for or benefit from a palliative care approach. It will be crucial for further development to adequately involve patients and put their needs first.