The Role of Palliative Care in Severe and Persistent Mental Illness

Abstract

This PhD dissertation arises from a research project investigating the suitability of palliative care approaches in the treatment of patients with severe and persistent mental illness. Specifically, the project was designed to initiate the discussion of alternative avenues of care for patients with a severe and persistent mental illness and an unlikely chance of ever recovering significantly. At the heart of this dissertation and as a basis for subsequent considerations lies a survey among German speaking psychiatrists in \nSwitzerland. \nThe original research conducted throughout the PhD is organized by thematic \nfocus, resulting in two paper series (sections). The first section is concerned with the acceptability and suitability of palliative care approaches for severely and persistently mentally ill patients. In the above-mentioned survey study, psychiatrists working in Switzerland were questioned regarding their attitudes towards palliative care approaches for and general concepts of severe and persistent mental illness. A number of 457 psychiatrists completed the survey (response rate 34.9 percent). Our findings revealed that the responding psychiatrists regard certain forms of severe and persistent mental illness as terminal, and believe that interventions with curative intent may in some cases be futile. Furthermore, a vast majority of the respondents believed that palliative care approaches can be suitable in the care of patients with severe and persistent mental illness. Drawing upon these findings, two subsequent papers conceptually examine the role of palliative care approaches in general, and palliative sedation specifically. Concerning the latter, it is argued that if one a) accepts that closeness to death is an unsuitable criterion for the initiation of palliative sedation and that b) intolerable suffering can result from both physical and non-physical symptoms, there is a weighty argument in favor of palliative sedation for the relief of intolerable suffering from non-physical symptoms. Such symptoms may potentially result from severe forms of treatment refractory mental disorders. \nIn the second section, the focus lies on the practice of (medical) assistance in dying in the context of severe and persistent mental illness. The first paper reports on items concerning (medical) assistance in dying (‘Sterbehilfe’) from the survey study. Psychiatrists were asked about their agreement with the practice and their willingness to actively support patients in their requests. A majority of respondents (about 50 percent) oppose (medical) aid in dying requests based on the suffering from a severe and persistent \nROLE OF PALLIATIVE CARE IN SPMI 2 \nmental illness. However, there was great variability between respondents, with a third of all respondents supporting the practice to some degree, and about a fifth of respondents remaining neutral. Willingness to support specific patients was higher in the specific case vignettes, whereas support was highest for the patient suffering from severe and enduring anorexia nervosa. Notable is the large variance in response patterns, impressively reflecting the lack of consensus regarding the controversial practice of (medical) assistance in dying despite Switzerland’s liberal legal framework. \nIn the final chapter of this dissertation, the implications of these findings are discussed and integrated into a broader ethical debate. The dissertation concludes with an elaboration of potential underlying reasons for psychiatry’s hesitancy in discussing end- of-life options in the context of severe and persistent mental illness, most notably preconceptions regarding the autonomy of (chronically) mentally ill patients and clashing professional obligations of psychiatrists with regard to patients who refuse further medical treatment.