mmunity Psychiatrist

Volume 39, Number 1

A fresh view on goals of care

Christine DeCaire, MD Psychiatry Resident, Maimonides Health, Brooklyn NY

Case: MG is a 50-year-old patient with coronary artery disease, advanced heart failure, tobacco use disorder, and persistent, unremitting schizophrenia who experienced several inpatient psychiatric stays over the last decade. Dr A is a psychiatrist who has become familiar with a pattern that has repeated during that time: (1) MG stops taking whatever antipsychotic medication MG is prescribed at the time, (2) MG loses ability to perform activities of daily living, (3) MG behaves erratically, and (4) MG is transported by law enforcement personnel to the organization’s emergency department or a regional jail. MG’s networks of resources and support erode during each cycle, making recovery diminishingly likely with each inpatient admission. Dr A wonders whether a palliative approach to MG is appropriate and what that would look like.

Essay Prompt: According to which health outcomes measures should palliative psychiatric prognosis, progress, and success be defined?

"No one had locked me up against my will. I entered the hospital voluntarily. If I were going to be a mental patient, at least it would be my choice and no one else’s.”1 In her novel The Center Cannot Hold, Elyn Saks details her life-long battle with schizophrenia.1 Not unlike our patient MG, she too had multiple hospitalizations, numerous medical co-morbidities, and challenges in finding the right type of treatment.1 As healthcare discrepancies become more apparent for people with severe mental illness (SMI), there has been a surge in research and initiatives to formulate and implement a palliative psychiatry framework to ensure better care of this unique population.2

Historically, palliative care has been implemented for patients with cancer, severe heart and lung disease, chronic pain, and other illnesses with poor prognoses.3 However, psychiatric patients comprise a very high-risk population, who’s physical ailments are typically misattributed to their mental illness. Of note, they experience 3.7-times higher all-cause mortality rates and have less access to medical care overall.4

Spring 2023

Volume 39, Number 1

A fresh view of goals on care- Continued

In attempts to expand palliative care to psychiatric patients, Trachsel et al., proposed that palliative psychiatry “focuses on harm reduction and avoidance of burdensome psychiatric interventions with questionable impact.”2 This definition will serve as a guide to demonstrate that a palliative approach is appropriate for our patient MG. It is also important to identify health outcomes which can be used to measure the progression of a patient’s condition. Specific to MG, prominent measures include rate or number of hospital readmissions, medication adherence, quality of life, and overall mortality. In addition, it is equally as important to highlight the bioethical principles of autonomy (patients make their own informed decisions), beneficence (acting in the best interest of the patient), and non-maleficence (the duty to do no harm)5 and how they are closely integrated into the palliative model of care.

In order to assess MG’s prognosis, it is not as simple as searching mortality statistics for a certain type of cancer. While MG’s coronary artery disease (CAD), heart failure (HF), and tobacco use may have associated prognoses, these are confounded by his diagnosis of schizophrenia. Psychiatric illnesses fall on a spectrum and are influenced by many factors including a patient’s own mindset, education level, employment status, social supports, and living situation.6 This makes prognosis very dynamic and modifiable.6 Given his multiple diagnoses, his prognosis may look bleak; however, with a new palliative approach and emphasis on autonomy, beneficence, and non-maleficence, the focus shifts from prognosis to progress.

“I received a diagnosis: chronic paranoid schizophrenia. My prognosis, I was told, was listed as ‘grave.’ In short, I’d never have a life. It felt more like a death sentence than a medical diagnosis.” –E. Saks

Given that there is no universally accepted approach to palliative psychiatry, the remainder of this paper will propose a framework to be utilized by providers to care for patients, emphasizing overall improvement as opposed to remission. To begin, it would be of great utility to complete a Psychiatric Advance Directive (PAD), to establish MG’s treatment goals.

Spring 2023