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

Physicians of all specialties are increasingly aware of the pain our patients experience. Pain is the "fifth vital sign," always to be assessed and treated. Pharmaceutical companies advertise their willingness to assist: "Together, let's treat the pain" (1). The 2002 annual meeting of the American Psychiatric Association (APA) featured workshops and lectures on palliative care and pain management; clinical journals such as Clinical Geriatrics and Annals of Long-Term Care frequently feature articles on pain management (2,3,4). A position statement on "Core Principles for End-of-Life Care With Annotations and Additions for Psychiatry" was adopted by the APA board of trustees last year (5). The Accreditation Council on Graduate Medical Education (ACGME) has proposed that training in palliative care be a required component of fellowships in geriatric psychiatry (6).

Psychiatrists have always known that patients with psychiatric illnesses suffer medical illnesses and somatic pain as well as psychic pain. It is a common belief, although not always justified, that the somatic complaints of psychiatric patients in emergency departments are dismissed. It has also been shown that psychiatrists themselves do not sufficiently recognize medical illness and may focus more on psychological symptoms than physical symptoms (7). Some research has indicated that psychiatric illness may be accompanied by a higher tolerance for pain, making it more difficult for clinicians to detect and treat medical illness and pain (8).

The relatively new specialty of palliative care treats both kinds of pain and emphasizes a holistic approach in which the patient's physical, emotional, and social needs are evaluated and treated—essentially the biopsychosocial approach that psychiatry has always endorsed. Psychiatry has both something to learn from and something to offer palliative care.

Palliative care is not the same as hospice care, treatment of intractable pain, or care for terminal illness. The Center to Advance Palliative Care defines it as "interdisciplinary care that aims to relieve suffering and improve quality of life simultaneously with all other appropriate treatment for patients with advanced illness, and their families" (9). The goal of palliative care is to alleviate symptoms rather than to treat the underlying disease; pain is one of the primary symptoms that palliative care seeks to treat. Palliative care is appropriate not only in hospice care but whenever an underlying illness cannot be cured or effectively managed and is causing suffering.

The "Core Principles for End-of-Life Care With Annotations for Psychiatry" were adopted "as an interim step while the role of psychiatrists in end-of-life care is developed" (5). They state that psychiatry aims to "ensure the alleviation of pain, suffering, and other physical and mental symptoms"; "assess and manage psychological, social, cultural, spiritual, and religious concerns and problems"; "provide timely access to palliative and hospice care"; and "provide access to any therapy which may realistically be expected to improve the patient's quality of life." Psychiatry and palliative care have very similar goals and philosophies. We believe that each can make contributions to the other and that our patients will benefit from the collaboration of specialists—they are not simply duplicating one another's efforts.

What palliative care can offer psychiatry

Understanding the physiologic basis of pain

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.

Assessing pain

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.

Use of analgesics

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.

Experience and comfort with death

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.

What psychiatry can offer palliative care

Assessing psychiatric illness and mental status

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.

Using psychopharmacologic medication

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.

Providing psychotherapy and psychological insight

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.

Acknowledging the physician's emotions

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.

Conclusions

Few outcome studies have evaluated the usefulness of psychotherapy for palliative care patients; a few examine therapy for oncology patients with pain. Group therapy has been found helpful among patients with metastatic breast carcinoma (19). Both cognitive-behavioral therapy and relaxation techniques have been shown to be effective (20). Life review, interpersonal therapy, cognitive-behavioral therapy, and supportive therapy all have a role in helping palliative care patients and their families. More research is needed to better understand which patients can be helped and by which interventions.

First, however, both psychiatrists and specialists in palliative care would benefit from collaboration. We do not always appreciate the medical factors that may explain patients' complaints of pain and lack of response to therapy; we sometimes do not look far enough beyond psychodynamic factors. The challenge of psychiatry is to treat the whole patient without falsely separating mind and body. Palliative care faces a similar challenge. We can benefit from each other's strengths.

Dr. Spiess is associate professor (clinical) in the department of internal medicine and director of the palliative care service at University of Iowa Hospitals and Clinics in Iowa City. Dr. Northcott is assistant professor (clinical) in the department of psychiatry at the University of British Columbia in Vancouver. Dr. Offsay is assistant clinical professor of psychiatry at the Institute of Living of Hartford Hospitals in Hartford, Connecticut. Dr. Crossett is associate professor (clinical) in the department of psychiatry and director of geriatric psychiatry at the University of Iowa Hospitals and Clinics, 2880 JPP, 200 Hawkins Drive, Iowa City, Iowa 52242-1009 (e-mail, [email protected]). Marion Z. Goldstein, M.D., is editor of this column.