Depression: A palliative care subspecialty
"I’ve been working the last five or six years on developing an area of palliative care called psychiatric palliative care," says William Breitbart, MD, chief of the psychiatry service at Memorial Sloan-Kettering Cancer Center in New York City and a faculty scholar of the Project on Death in America. "My clinical research work has focused on symptoms that either are frankly psychiatric or have an important psychiatric/psychological component. Depression, delirium, and anxiety are the three most common of the frank psychiatric symptoms in terminal patients," he reports.
Often the tools developed to assess terminally ill patients’ symptoms fail to cover psychiatric issues. "Yet very often these are the most prevalent and disturbing symptoms. They have not been emphasized in the literature, and the medical advances often are not picked up. Instead, what’s focused on is the physical," he says. "Hospice has been a little ahead of the curve, in that it emphasizes the role of the multidisciplinary team and sensitivity to patients’ existential and spiritual issues. What hospice has lacked is expertise in psychiatry. It has used a different conceptual framework of existential or spiritual healing for understanding its work."
Breitbart runs a cancer pain training program called the Network Project at Memorial Sloan-Kettering, bringing people identified as local pain experts to the Cancer Center for observations. "One of the things I’ve noticed when I talk to hospice people, as they start to learn more about delirium and depression, they realize they’re seeing a lot of it. They just didn’t have the level of diagnostic expertise to identify it," he relates.
"Another issue I get into with hospice medical directors concerns the treatment of delirium, when the patient is disoriented, confused, and hallucinating. The doctor might not want to get rid of the hallucinations," because of spiritual assumptions about what they mean. "I know a lot of about delirium, and one of its basic characteristics is fluctuation and variability of symptoms. Pleasant or comforting hallucinations can very easily change to frightening ones. I believe it’s very important to treat delirium, so that the patient is awake, clear-headed and able to communicate. Otherwise, you’re imposing a particular religious view on that delirium," Breitbart says.
Recommended articles
Two articles which might be helpful for hospice teams in learning more about treating depression and other common psychiatric symptoms of terminal illness are:
r Masand PS, Tesar GE. Use of stimulants in the medically ill. Psychiatric Clinics of North America 1996; 19: 515-47.
r Breitbart W, Jacobsen, PB, Psychiatric symptoms in terminal care. Clinics in Geriatric Medicine 1996; 12(2): 329-347.
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