Palliative Care for Patients With SMI and Life-Threatening Medical Illness Inadequate
Interviews with patients having serious mental illness and severe medical illness show they have the capacity and the desire to participate in decision-making about their care—but palliative care for this population is lacking.
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Patients with serious mental illness (SMI) who also have severe or life-threatening medical illness are poorly served by current models of palliative care, said Daniel Shalev, M.D., during a session at the annual meeting of the Academy of Consultation-Liaison Psychiatry in Miami in November. He is assistant professor of medicine and medicine in psychiatry at Weill Cornell Medical College.
“Patients with SMI experience disparities in access to palliative care,” Shalev said. “Every study of the subject reveals they experience greater fragmentation of care, are institutionalized at higher rates, and are less likely to have an advance directive. They are also less likely to have physical pain assessed and treated.”
“By any measure the care that she got was not just inadequate but kind of appalling,” said Daniel Shalev, M.D., describing the case of a woman with SMI and metastatic cancer.
At the same time, Shalev said, multiple qualitative studies interviewing patients with SMI reveal that they have the capacity and the desire to participate in decision-making about their serious medical illness and that their preferences for care do not differ from those of individuals without serious mental illness.
“Palliative care clinicians are uncomfortable providing care to people with SMI,” Shalev said. “Fewer than 20% of U.S. physician-fellowship programs provide didactic content on care of people with SMI. Conversely, geriatric and consultation-liaison psychiatrists have limited exposure to palliative care, and geriatric psychiatrists often have to provide primary palliative care in psychiatric settings without access to palliative care specialists.”
Shalev presented data from a study published in the September 2024 edition of the Journal of Geriatric Psychiatry in which he and colleagues conducted 45 interviews with palliative care, geriatric medicine, and consultation-liaison/geriatric psychiatry clinicians in a large urban academic health system about the provision of palliative care for patients with SMI. The study found three overarching themes:
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Current paradigms of serious illness care don’t meet the needs of patients with SMI. These patients have complex clinical and psychosocial needs that are bidirectionally informed by both their medical and psychiatric diagnoses yet are not addressed by current structures of care. Additionally, their care may entail managing medicolegal and ethical complexities for which clinical teams are unprepared. Finally, stigma at all levels contributes to these challenges.
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Clinicians feel motivated to care for patients with SMI and serious medical illness but experience challenges because of gaps in training and interprofessional practice.
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There is a need for closer structural integration of psychiatric and serious illness care services to adequately meet the needs of individuals with comorbid SMI and serious medical illness. Clinicians say that leveraging resources in both the community and the institution is challenging but necessary to provide appropriate care.
Shalev described a case that revealed the starkly inadequate nature of palliative care for patients with SMI. “When I was a medical student, I was on the palliative care rotation, and I took care of a woman who had a chronic psychotic disorder,” he said. “She had come to the emergency department with severe abdominal pain and was found to have widely metastatic small cell lung cancer.
“She was admitted to the medical service and had multiple teams consulting on her—gastroenterology, oncology, psychiatry, palliative care,” Shalev continued. “Over the coming days, there were just constant meetings to figure out how to take care of her.”
Shalev said the oncology team was “adamant” that the standard of care was radiation and chemotherapy—but a host of clinical, billing, and logistical issues made this impossible. Radiation would require daily treatments for several weeks, typically delivered and reimbursed on an outpatient basis; however, the team felt it was not viable to begin such treatment without a plan to discharge the patient and have her return for daily treatments.
“Meanwhile, on the palliative care service, I saw that the clinicians on my team were really struggling to figure out how to engage with her around her symptoms,” Shalev said. “She was obviously very physically uncomfortable, but she also had chronic paranoia that made it very difficult for her to share that discomfort with us. She remained in the hospital for weeks not getting adequate symptom relief or any disease-directed treatment for her cancer.”
Shalev concluded: “By any measure, the care that she got was not just inadequate but kind of appalling. That case made a profound impression on me as a medical student. Her case has really stayed with me as a reminder of how far we have to go to provide appropriate serious illness care to people with SMI.” ■
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Published online: 20 December 2024
Published in print: January 1, 2025 – January 31, 2025
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