Connecting the Dots Between Psychiatry and Palliative Medicine

As a psychiatric trainee in South Korea, I once treated a 30-year-old man with tongue cancer. His tongue was fully resected as part of treatment. This meant loss of taste, texture, and the ability to swallow and speak. For nourishment, he had to carry heavy bottles of liquid food every time he went out, because he was unable to swallow solid foods. He had to use the restroom frequently as a result. Thick mucus and halitosis rendered him asocial. Eventually, he separated from his fiancé and secluded himself because of extreme self-consciousness and very low self-esteem. He developed suicidal thoughts, which led to his presentation at the psycho-oncology clinic where I was working at the time.

I started him on psychotropic medications and scheduled him for weekly psychotherapy, which lasted over a year. His struggle against hopelessness was hard, but he gradually felt more comfortable socializing in public. On my last day of the clinic rotation, he said to me, "Working with you was like reading a great book." By this, I think he meant that the process of therapy gave him opportunities to explore different perspectives on his suffering—like perspectives afforded by the imagination through reading—and this helped him to overcome his depression.

My experience with him motivated me to learn more about psycho-oncology because I wanted to offer more psychiatric support to patients fighting cancer. This led to my relocation to the United States for training in palliative medicine. However, as an international medical graduate, I needed to first complete an American residency. I was fortunate to match at Vanderbilt University.

During the third year of my general psychiatry residency at Vanderbilt, I worked closely with a palliative medicine team. I came to see that my interest in end-of-life care relates to the paradoxical notion that although physical death is detrimental, the reality of death fosters hope of opportunities for redemption. By that I mean that the approach to accepting death may serve to motivate individuals to reflect on their past, reorganize their priorities in the present, and reconfigure their plans for the future. Upon completion of residency, I started a fellowship in palliative medicine at UCLA, and my passion for treating patients with advanced cancer expanded to caring for patients with other incurable, life-limiting illness.

As a fellow, I participate in open discussions with patients and their families about fears and anxieties surrounding death and dying, which affords them the opportunity to confront unresolved conflicts. I recently met a 68-year-old man with a history of treatment-resistant major depression, obsessive-compulsive disorder, and schizoid personality disorder. He also had a history of multiple suicide attempts, starting in childhood. He presented to the hospital with an untreated necrotizing skin cancer in one arm. His primary doctors and oncologists recommended total left-upper extremity amputation followed by systemic chemotherapy, but he refused this life-saving approach. He stated, "Losing an arm is unacceptable to me, and I have bigger issues than my cancer." When he requested physician aid-in-dying, his doctors sought the assistance of the palliative care team.

He was deemed to have decision-making capacity and to be in a great deal of physical pain and psychological distress. Ketamine, a drug known for its analgesic and antidepressant properties, was initiated. Over the course of daily visits, I sought to create a strong therapeutic relationship with this patient. I believe that it was persistent, compassionate care and adequate pain control that eventually convinced him to proceed with surgery. On my final visit with him before his discharge from the hospital, he expressed gratitude for the procedure that enabled him more time in life to be with his loved ones.

Such experiences with patients affirm my desire to be a palliative care psychiatrist. In this role, I educate patients and their families about adaptive coping skills for transitioning to new life stages, address comorbid psychiatric disorders that may exacerbate physical pain, help patients search for meaning in the face of existential crisis, explore individual and family psychodynamics that inform decision making, and adeptly manage delirium in the setting of terminal conditions. Basic skills in empathetic listening put patients at ease and often yield beautiful stories of lives lived—narratives that inspire me in return. Like a great book that is physical in form but whose ideas rise in my imagination, so too does my work with patients who are dying afford me moments of transcendence.