Practical Geriatrics: Palliative Care: Something Else We Can Do for Our Patients

The determination of acute or chronic pain and the categories of nociceptive, neuropathic, and mixed pain are familiar, but current research on pain is demonstrating the role of central and peripheral neurotransmitters and pathways. For example, the demonstration of the involvement of the N-methyl-D-aspartate (NMDA) receptor in the phenomenon of "wind-up" and the development of chronic pain has led to new effective clinical interventions (10,11). Our ability to treat pain, like our ability to treat depression, is enhanced by our understanding of the neurophysiology we are affecting.

Asking whether a patient has any pain and asking the patient for a rating on a scale of 1 to 10 is not sufficient to help a patient who is experiencing more than trivial pain. Providing palliative care requires psychiatrists to obtain complete descriptions and a history of pain symptoms—skills that are routine for palliative care physicians. Palliative care physicians' specialized knowledge of the physiology of pain helps them recognize syndromes and plan effective treatment—and psychiatrists can learn from such knowledge. Obtaining a more detailed history fosters better communication and collaboration with a palliative care service.

Opioid analgesics are underused—a finding among cancer patients and increasingly among patients with AIDS (12,13). Psychiatrists see patients with both conditions; however, they may be reluctant to endorse pain relief, particularly among patients with a history of substance abuse. Although the use of adjuvants, such as NMDA receptor blockers, is a relatively new approach, the basic categories of analgesics have not changed. However, understanding of their use, dosage forms, and delivery systems has improved. PCA pumps, fentanyl "lollipops," and transdermal and inhalation aerosol delivery systems have all changed the way that analgesics can be effectively administered.

Physicians are not regarded as very good at helping patients face death, and medical students do not feel well prepared or well supported during their early experiences with dying patients (14). Because palliative care physicians treat dying patients, they can serve as role models and teachers for the profession.

The multiaxial system of DSM-IV (15) is considered to "cover all forms of psychosocial suffering" (16); all psychiatric diagnoses involve suffering. The diagnosis of psychiatric illness is complicated by medical illness, but expertise in diagnosis is our stock in trade, and consultation-liaison psychiatrists are especially skilled in this area. Providers of palliative care often use rating scales, such as the well-regarded PRIME-MD of Spitzer and colleagues (17). Psychiatrists ask patients about anhedonia and persistence of depressed mood to predict response to treatment. They use—and develop—rating scales and other instruments, but the diagnostic interview is the standard against which the specificity and sensitivity of scales are measured. We can help with diagnosis, particularly when the line between symptoms that represent clinical illness and symptoms that do not is unclear.

The use of antidepressants as adjuncts in the treatment of pain is well known, but they are underused by other specialties (13). Psychiatrists use antidepressant medications regularly and understand their actions and side effects and patient management. Antipsychotic medications such as olanzapine are also being used as adjuvants for pain control and as antiemetics; again, psychiatrists understand these medications better than do other disciplines.

Providers of palliative care consider the psychological needs of patients, and provision of counseling is an important part of their work. Psychotherapy is the special expertise of psychiatry, and our knowledge of psychotherapeutic approaches can benefit patients. Patients value achieving a sense of completeness at the end of life and communicating with their doctor when they are suffering; both are areas in which psychiatrists' skills can facilitate care (18). Our skills are particularly useful with patients who have personality disorders or other conditions that may pose barriers to the relationship between patient and physician.

Training in psychiatry also includes learning to recognize our own responses, emotional as well as intellectual, to our patients and their problems. Psychiatrists may refer to a patient as "really crazy"—our residents certainly do—and groan at another readmission, but we do so to acknowledge and cope with our feelings. We are sensitized to counter-transference and learn to manage our responses not by suppressing but by recognizing and working through them. These skills help us deal with patients who can be frustrating and who have illnesses that we cannot cure and symptoms that we cannot wholly relieve. These skills can help us to help other physicians and members of the medical team deal with their patients and themselves.