Palliative Care for Mental Illness: A Podcast with Dani Chammas and Brent Kious

Eric 00:44

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:50

This is Alex Smith.

Eric 00:51

And Alex, who do we have with us today?

Alex 00:52

We are delighted to welcome first time guest Brent Kious, who is associate professor of Psychiatry at the Huntsman Mental Health Institute at the University University of Utah. He is both a psychiatrist and a philosopher. Brent, welcome to the GeriPal Podcast.

Dani 01:08

Thanks for having me. Really happy to be here.

Alex 01:10

And we’re delighted to welcome back Dani Chammas who is a palliative care psychiatrist at UCSF. Dani, welcome back.

Dani 01:17

Always a pleasure.

Eric 01:18

It’s like your 100th time, Dani, being on the podcast.

Alex 01:21

Something around that and not enough still.

Eric 01:25

When are you going to launch the Pal Y Psychs Psych Pal Y podcast.

Dani 01:30

The Pal. Maybe it can be a shoot off like under the umbrella of Jerry Palliative.

Eric 01:34

Oh, I love that.

Dani 01:36

More to talk about there.

Eric 01:37

Well, we have a lot to talk about today because today we’re going to be talking about palliative care and mental illness. But before we jump into that topic, Brent, I think you have a song request for Alex.

Dani 01:48

Yeah, I do. It is Only Children by the famed Americana artist Jason Isbelli.

Eric 01:57

And why did you pick this song? Brent?

Dani 02:00

Yeah, because it is, it’s a really moving song and I think relevant to the stuff we’re talking about today because it, it talks about how the problems of substance abuse and mental illness can affect a person’s life. There’s a secondary reason, which is that I play guitar a little bit too, but not nearly as well as Alex. And I definitely don’t sing as well as him. So I wanted to hear him do it so I could learn something.

Dani 02:28

There’s a tertiary reason too, which is that Alex said no to the first, like 10 things.

Dani 02:33

Brent.

Alex 02:35

Well, that’s because A, we’d done them or B, Dani was suggesting like three songs from Frozen 2. Unfortunately, Brent rescued me from having to do a song, Frozen 2 [laughter].

Alex 02:49

(singing)

Eric 03:34

That was wonderful. Brent, who sings that again?

Dani 03:37

Jason Isbell.

Alex 03:38

Jason Isbell. He’s a great folk. Yeah, Americana, kind of. I think the last time we had a request was from Bob Arnold for something about vampires. Oh, yeah, yeah. Good artist. Really tasteful. Thank you.

Eric 03:52

Well, we got a lot to cover today. So we’re going to be talking about palliative care for individuals with mental illness. And Dani, when I think about this topic and think about what we’re going to be talking about, I see a lot and I hear a lot about integrating psychiatry into palliative care. It’s one of the core things that we think about palliative care is you got the physical, psychological, social and spiritual symptoms. So combining those things, I don’t think I see a lot about integrating palliative care into psychiatry. When you think about the word palliative psychiatry, is that what we’re talking about?

Dani 04:32

Yeah, it’s an important distinction and I think the evolving terms that try to get at what you’re talking about. There’s palliative care psychiatry, which you started by referencing. We’re pretty familiar with that in palliative care. That’s how do we treat the mental health needs of patients with serious medical illness? Right. Everything from normative reactions like exist anticipatory grief to comorted psychiatric illness like depression, anxiety, ptsd, which we know is really prevalent in our populations, out to sort of patients with severe psychiatric comorbidities which we probably drop the ball on more.

There’s a lot of health discrepancies there and them getting high quality palliative care. But that’s palliative care psychiatry. Palliative psychiatry is a distinct idea where the focus of our palliation is the mental illness itself rather than any medical illness that’s our target. And we’re generally thinking about treatment resistant serious mental illness that we think is likely to result in a lot of morbidity and mortality when we talk about it. So in those cases, can we adopt an approach to mental health care that centers primarily around quality of life of patients and their families?

Eric 05:46

So I got a question. So when we think about palliating the mental illness, isn’t a lot of what we do, like when we’re treating depression, are we palliating that the symptom of that mental illness, or are we treating the disease? Or how should I think about that?

Dani 06:02

I might jump in there. Right. Because this is something I’ve worried about a lot as I’ve been kind of talking to people who are interested in delineating what palliative psychiatry might actually be. And yeah, there is a way in which everything we do in psychiatry is palliative with respect to the fact that it’s aimed at improving symptoms. Right. I can’t actually think of a single psychiatric illness that I can cure. I wish there was one.

But what I can do is achieve enough improvement in somebody’s symptoms that we then have kind of remission of the illness from a symptomatic standpoint, even though the underlying biological stuff or the social stuff is potentially still happening. So if you think of palliative care generally as being aimed at symptom remission or improvements in quality of life or maybe improvements in functioning, I feel like kind of all psychiatry is palliative in that way.

Eric 07:03

Yeah, it’s hard because you can also think about it, let’s say, because we see palliative heart failure clinics. So people like palliative cardiology clinics where honestly, heart failure management is a lot of symptom management. So it’s a lot of palliation. So we hear very similar thing with that is good palliative care for heart failure, is good heart failure management of their symptoms. And how different is it for severe or refractory like depression or any of these things? Your thoughts, Dani?

Dani 07:35

I mean, yeah, to add, though, a little bit more nuance, the symptoms that we are choosing to target, the symptoms that we’re choosing to decrease in psychiatry, tend to be decided upon by us as the providers. Right. And so I think there’s this one way where if we added palliative care philosophies to all of psychiatry alongside the standard of care, that could be beautiful for everybody because we’re going to take in the patient’s perspective maybe more than we were trained to. I think it gets more controversial though, whether are some places where it does become a trade off that people are conceptualizing a trade off between the standard of care and a more palliative approach.

And like you said, it’s very hard to define the lines of this. We don’t have a way of operationalizing which patients qualify. It’s incredibly difficult to prognosticate in psychiatry. Lack of response in the past doesn’t predict lack of response in the future. So we definitely don’t want to use this concept to warp it, to inappropriately justify non treatment or abandonment or letting off the hook a system that isn’t great always at meeting people’s needs because this is a really vulnerable patient population. But there is a place where, you know, maybe hearing less voices isn’t what’s most important to my patient.

Maybe what’s most important to them is not being in a hospital or being employed or staying at home. And that is somewhat of a shift from how we are classically trained to decide which symptoms we focus on in psychiatry. So this kind of a yes and answer.

Alex 09:07

Yeah.

Dani 09:07

I was going to ask Dani, you know, what if we incorporated recovery principles into the practice of psychiatry?

Eric 09:18

Right.

Dani 09:18

Where we really center the patient’s values and their goals of treatment. I think that muddies the distinction between ordinary psychiatry and palliative psychiatry even more.

Dani 09:30

Yeah, absolutely. And so I do think that in. In the places where we can just synergize the two. Like I just, I got a grant from ABPN to start teaching primary practitioners from whom the ABP American Board of Psychiatry and Neurology. It’s like our abim, but to have a palliative care curriculum for psychiatrists. This is one of our recognized subspecialties. So in ways that we can teach this to psychiatrists so they can synergize these principles, that substance.

Wonderful. When we get closer to the extremes where it becomes a trade off, do we want to keep treating people in our customary ways or not? Well, then I think there’s a lot of work to do to create models to operationalize what we’re talking about, to have safeguards in place to try to help people but also protect people.

Eric 10:14

Well, can I start off with easy stuff? Like what? What would be integrating palliative care principles into psychiatry? What does that look like?

Dani 10:22

I’ll take a stab at it. I mean, I think one thing that people who are grappling with this issue have proposed is just a much greater emphasis on harm reduction and stopping unhelpful treatments. So the unfortunate reality is that a lot of the time if you have treatment resistant depression or treatment resistant schizophrenia or anorexia, and you come to see a psychiatrist even though you’ve done everything already, they’re going to say, well, let’s just try that again, or try something that’s very similar to that. And maybe adopting a more palliative orientation would mean a lot of the time saying, we’ve tried all that stuff and there’s not a lot of point in doing it. Again, what we should focus on is improving your quality of life and maybe non medical ways.

Eric 11:21

Yeah, I guess this is the question is, does trying to focus on that mental health disorder and trying to treat that mental health disorder, does that improve quality of life, though?

Dani 11:32

So here’s something I’ll say though, is that I think there’s some implicit bias that goes on with psychiatric illness, not us having issues. But if I were to have posed that question to you in the medical. Yeah, you would have been like, well, every patient is different. We take the time to understand what quality of life means to them. We take the time to understand their goals, their ethos, their treatment history. And then we make these decisions based on our knowledge of their illness paired with our knowledge of them. And something happens when there’s like psychiatric illness, which is a ton of different illnesses. Right. That we sort of distill it to this one thing that is psychiatric illness.

Eric 12:11

And we consult psychiatry.

Dani 12:13

Yeah, like, exactly. And so, yeah, for some people, decreasing symptoms, if we can, is really helpful. For some people, it would be really helpful, and we can’t. So can we think of other things that we can do to them that’s a very palliative or do for them That’s a very palliative question. And for other people, they might come to me and say, you know, I’ve been on this medication. Sure, I’m hearing less voices, but I feel like a zombie. I can’t relate to people. I’m tired all the time. Like, give me my voices back over this. Right.

Eric 12:45

And honestly, it doesn’t feel that much different. Again, going back to the heart failure example, we have people who their number one symptom may be, I can’t go to the bathroom this much. I gotta get some sleep. I gotta think about changing these meds. So it could be about focusing on underlying disease like the heart failure, or it could be focusing on more managing the symptom. Like if they’re dyspnea, you’re kind of maxed out on the diuretics, maybe considering things like opioids. Am I thinking about it correctly? Yeah, I mean, reasonable analogy.

Dani 13:21

I think the trickier thing that comes up, and I would love to hear Brent’s thoughts, but the trickier thing that comes up in psychiatry is, number one, our prognostication isn’t as solid as it is in medical things. So it’s harder for me to say, like, this person might not get a lot better if I let them forego this with heart failure, you know, how good it might get in general. And number two is there’s always this question about capacity in the setting of psychiatry. And some people will have decision making capacity, some won’t. But when we say there’s not an algorithm, the compass is determined by the patient. Well, what does that mean for a patient who doesn’t have decision making capacity?

Eric 13:59

So the depression, the bipolar disease could be impacting somebody’s ability to make an autonomous medical decision. So the. As opposed to like heart failure, unless they’re delirious, doesn’t really affect their decision making capacity. Again, unless they’re delirious, like here, the disease actually can’t.

Dani 14:17

Yeah, Brent, go ahead, Brad.

Dani 14:19

I want to insert something there about capacity, though, and I’m sure that all of you are ultimately aware of this. A person with bipolar disorder in a manic episode or a severe psychotic episode in schizophrenia might still have capacity to make a lot of different decisions.

Eric 14:38

Yeah.

Dani 14:39

So it really depends on how their illness and the particular impairments that are associated with it bear on their decision making. I mean, we, we frequently admit people with severe psychosis to our inpatient hospital on a voluntary basis and we have detailed discussions with them about the risks and benefits of treatment and they decide what they want. Right.

Dani 15:02

Speaking to the fact that we are talking about such a massive array of illnesses, of presentations of symptom severity, and trying to speak in generalizations. Right. Which is so hard to do because it’s really hard.

Alex 15:15

I think the capacity issue comes to a head in particular when you’re talking about the desire to die and, or the expressed wish or expressions of, you know, suicidal ideation is the formal term. Is that right. When you’re talking about palliative care and psychiatry.

Dani 15:30

I think, I mean, I think really anything that is a choice like hospice or an express like hastened wish to death. And we’re always thinking about capacity, but the wish for hastened death is a really interesting one because there’s so many considerations. There’s the legality, there’s the morals of ourselves and our patients, then there’s the ethics, and they’re not always aligned. Depending on your geography, who you are as an individual, the ethical parameter you’re considering.

So here in California, if somebody uses end of life options, wants to die, and I’m doing their mental health assessment, I do have to make sure that they have decision making capacity. That’s a hard barrier which has a clear definition and has really big implications for access to maid for people with dementia or serious mental illness without Capacity. But the other piece of our law says that the patient must not be suffering from impaired judgment due to a mental disorder. That’s a tricky one. Right. So having depression isn’t going to be a contraindication to me that you might still be able to get it.

But the law does expect me to assess if their request whether or not it’s primarily driven by an untreated or an unmanaged mental health condition. And it’s not straightforward. That’s a really hard thing for me to assess. We know that the frequency of psychiatric symptoms is higher in people who make these requests, but we also know that when we treat the mental health condition, sometimes the request resolves, sometimes the request doesn’t resolve. So there’s a lot of subjectivity there. And even to add to the nuance, what if I do think that it is motivated by a primary mental health condition, but I don’t think there’s a good chance that that mental health condition is going to resolve before they die.

Alex 17:15

Yeah. Brent, you thought quite a bit about this. What are your thoughts?

Dani 17:19

Yeah, I mean, I would add to what Dani has said, which I think is entirely right, that this becomes especially hard when we talk about people with severe and treatment refractory psychiatric conditions that are often marked by suicidal ideation. So if someone with major depressive disorder, where suicidal ideation has been a long standing symptom for them, or somebody with borderline personality disorder, those are conditions where people have in fact received medical aid and dying, or other kinds of palliative death hastening interventions. I have a kind of philosophical stance on this, which is something like this. People want to ask, is the suicidal ideation the desire to die due to the illness, or is it the authentic wish of the person? I think that is a nonsense question. So I’m just going to say that.

Alex 18:16

Yeah, yeah.

Dani 18:17

And the reason I think it’s a nonsense question is that I don’t really think that we have any way of establishing authenticity. And especially hard cases where somebody has had very long standing desires. Because the usual things we would think about is marking authenticity, like a change in what you want that seems sudden or inexplicable just don’t really apply. So I think what we ought to ask in these situations is does the person’s desire to die make sense to us?

And in a lot of the cases Dani’s talking about where maybe somebody is asking for medical aid and dying for their cancer, but they also have depression if we treat the depression, and their outlook on life changes a lot and they’re not interested in dying anymore. That’s a case where their requested die doesn’t really make sense in some fundamental way. They still have good reasons for going on, probably, but where that wish is persistent. I feel like we can also often understand where the wish is coming from, given what’s happening with the patient.

Alex 19:25

I do want to stick with this topic and I also want to acknowledge that interest in your thoughts on this. My read is that the biggest issues in palliative care and psychiatry are really sort of the first things that we’ve talked about. People who have serious medical illness and have psychiatric complications as a result, or people who have coexisting psychiatric illness and serious medical illness and that this issue of maid sort of brings things. It’s interesting to talk about for a variety of reasons. It’s the fringe, but it is not the major issue which, by which, you know, the flags, tent pole issue I think is the phrase, you know, by which we should be organizing like palliative care, psychiatry around. Is that fair to say?

Dani 20:14

Or what, you know, what do you think important though? Because I actually think we get a ton of requests for hasten death and we are still working on how to best understand like where it’s coming from. And there’s a lot of non controversial waters that come before made that we can think about. I think the other piece is that different countries, different states, they don’t have the same requirements that we have. Right. And who’s making these decisions? Some people don’t.

In Canada, as long as you have a terminal illness, it doesn’t matter if your depression was driving the request. Right. And so some of us are more driven by the doing no harm, others more driven by autonomy and justice. And I think it puts us as humans in the provider role in a really difficult spot trying to reconcile the care that we’re giving and trying to figure out what is appropriate. And you’re right, it is on a continuum because how about dnr, dni? If somebody is very depressed and suicidal, are they allowed to say that they want to be dnrd? And I, we let them. But what if a few rounds of ECT later, they wouldn’t want that. And you know, in the interim they code.

Eric 21:25

Yeah.

Dani 21:26

I’ll just note in our hospital we don’t always let people who have been suicidal recently. This is a psychiatric hospital, of course, be dnr, dni. Right. So our policy is that that’s not necessarily guaranteed.

Eric 21:41

Yeah, it’s a struggle because like it gets to this question would oh, what if people would Change their mind in the future if we just did. X. Right. So if you talk to somebody and they adamantly don’t want an amputation and you’re all, you’re going to get it. Because I know the data would suggest people’s quality of life is generally viewed better post amputation than people think it’s going to be pre amputation. So we’re just going to do this to you because we know better. Is that that different than this?

Dani 22:12

Different than potentially allowing somebody who has a serious psychiatric condition to access medical aid and dying, you mean?

Eric 22:21

No, this idea that like if we just convince them to or if we just forcibly did something to them and their idea, their, their thoughts on this subject would change post, post intervention, post psychiatric treatment because, you know, their long standing chronic depression, this hope that it’s going to get better.

Dani 22:44

I think the difficult part here when we’re talking about decision making and judgment in the setting of mental illness being the target is that it’s quite possible that someone has capacity. But it’s very hard to say that mental illness isn’t impacting people’s judgment, people’s outlook. It’s different than having like a leg issue. But being fully like you’re, the way you’re viewing the world is still consistent to who you are versus being an episode of depression where there’s a complete lens on your view of the world that can go away.

It makes it really hard. And I think what we’re all struggling with here is like this is very gray territory. Right. We want clear boundaries and clear definitions and we try to impose them. But like, where does somebody’s mental illness and somebody’s personhood, like, what’s the line between those two? What if you’ve been depressed your whole life? Like, is it a part of your personhood? Like it doesn’t all fit into these very clear separations.

Alex 23:40

Yeah. Just to build on that and then we’ll go to Brent on this. One of the reasons that this issue of medical aid and dying for people who have severe psychiatric illness is so interesting is because of the issues that come to bear and the challenge, the competing ethical concerns that arise in these situations. And I’d add one more to the mix, which is, you know, we have a friend who evaluated somebody for medical aid and dying and felt seriously moral distress about this request.

And this is a person who had serious refractory mental illness, been treated for years, decades, and just didn’t feel like they could, this provider could sleep at night if they were to prescribe medical aid. And dying because they would feel like they were killing this person and not to helping that patient to gain control over the inevitable end of their life. So that moral distress is yet another factor that comes up for the providers. And Dani, I think you do some evaluations that may have come up for you as well. But Brent, I want to go to you on this for further thoughts.

Dani 24:46

So, you know, one thing I wanted to say in response to something Eric said earlier is there’s a way in which psychiatry is often in the business of making people do things that we think are going to help them feel better in the long run. Yeah, it’s. It’s a little less common in California than it is in Utah, but we, we treat a fair number of our patients involuntarily, and some of the time they thank us for it afterwards. Not always. Yeah, I think when we’re talking about the palliative realm in psychiatry, though, those kinds of considerations aren’t really on the table because we’re talking about people for whom typical involuntary treatments are very, very unlikely to be helpful anyway because they haven’t helped so far.

Alex 25:34

They’ve often received years, if not decades of treatment.

Dani 25:37

Yeah, yeah.

Dani 25:39

I have a thought on the moral distress, but I also feel like we’re pulling ourselves into like this idea of terminal mental illness. Is that actually a thing?

Alex 25:46

Yes.

Eric 25:46

We should talk about that too, that question.

Dani 25:49

Okay, well, let me just quickly take a question about moral distress. I want to expand it from just the maid area. I think it’s very present in maid. I think it’s present in this whole entire array where we are left as providers grappling with, you know, did I try enough things for this person? Has society failed to reach this person’s needs? Are there restrictions that are making me not give this person some kind of peace, that I give that option to other people? What if there’s a clinician out there that’s better equipped or trained than I am to tend to this person? Not long ago, I was attending on an inpatient psych unit, straight psychiatry.

And there was a patient, she was incredibly psychotic and she was lying on a bed in the corner of a room completely alone, moaning with pain from her. And it was heartbreaking to witness. And I remember the on call resident had this huge wave of relief when he found out that I was palliative care trained because he didn’t have to grapple with the fact that he was watching in distress that he didn’t feel totally equipped to address. So there’s examples across the board where Providers have moral distress. We haven’t thought through a lot of these oversellies.

Eric 27:04

Yeah, yeah, I guess, you know, another source of moral distress is going to this question, is this person really dying? Do they have a terminal illness from this depression, from this anorexia, from this bipolar disease?

Alex 27:22

This gets the question, is this a thing, terminal mental illness?

Eric 27:25

Because I do think I’ve actually had patients like this really bad depression, refractory. And the question is hospice comes up and I have to think like wait, does this person meet the prognostic requirement that we used called terminal in hospice? Which is very quick, clearly labeled six months or less.

Alex 27:46

And there are a couple cases that we can talk about because they’ve been in the lay press. There’s a Boguts case, a patient with anorexia who utilized medical aid and dying. And there’s another case, a woman named Naomi was in the New York Times. We’ll have links to those cases in our show notes. Naomi also had anorexia and they both in both cases decades of treatment.

Eric 28:05

So like in cancer we could say pull up studies like this person has metastatic pancreatic cancer, like 99.9% sure.

Dani 28:14

Can we go first or second?

Dani 28:16

I’ve got thoughts, I’ve got thoughts. Maybe I’ll jump in. I mean I think that the idea of terminal mental illness is a medico legal nicety that allows us or allows some psychiatrist or physicians to provide medical aid in dying to persons with severe and treatment refractory mental illness. Because it’s very clear even in the cases like Boguettes, the illness is not terminal in the way pancreatic cancer is. Terminal pancreatic cancer is going to kill you.

Regardless of what we do. Even with the best and most sophisticated medical interventions, death is going to happen relatively soon. And with anorexia nervosa, that’s really not the case even in the most treatment refractory cases because providing nutrition is always going to be an option. So I feel like that’s kind of a red herring. And is it though?

Eric 29:16

Because you could have somebody with, you know, pancreatic cancer hasn’t been treated yet, decides they don’t want treatment. Their prognosis without treatment is less than six months. But if they got treatment, it could be more.

Dani 29:30

Yeah, but right. And so I think this, this gets to the really critical issue. We, we look at that person with pancreatic cancer who as a prognosis less than six months because they’ve decided not to get treatment. And the reason we’re comfortable saying they have terminal Illness, I think, is that we can understand why they would make the choice they had made. Treatment would buy them a couple of extra months, but they’d be painful, uncomfortable, et cetera. It’s very reasonable for them to say, I’d like to forego treatment, even if that means a little less life.

Eric 30:05

Yeah.

Dani 30:06

And I think that’s the same standard we should apply to psychiatric illness without use of the word terminal, which is just obscuring things. Right. What we really ought to ask is, are things going badly enough for you, given all the interventions that you have tried, and how likely any additional interventions would be to help you that your wish to receive something like medical aid and dying or palliative sedation or to use VSED makes sense.

Dani 30:36

Although I would say, Brent, I’m with you. And I do think that some people would understand why Alyssa made the request that she did.

Eric 30:48

And we’ll have links to that in our show notes. So if you’re interested in reading, again.

Alex 30:52

It’s in the lay press, you can read about it. This is not revealing anything.

Dani 30:55

Yeah. But what I want to add to this terminal mental illness thing, because I think it’s getting a lot of traction and excitement, and this is such a fraught term. It’s so controversial in ways that are hard to reconcile. There are some people who feel incredibly strongly that it should not be used. It’s an inappropriate term. And I was even nervous to talk on this podcast today because I know it’s going to elicit strong and very valid feelings in some people.

But some of the nuance I would want to point out is that, like Brent mentioned, first of all, this is not a diagnosis. It’s not a defined entity in the dsm. It’s not something that we have, you know, statistics or anything around. When people talk about terminal mental illness, it’s very different than how we use the word terminal in medical illness. And I think they generally do really mean patients with serious mental illness for whom the treatments we have available are unable to, we think, ever help them achieve meaningful quality of life or symptom control. And there are two deeply important perspectives here.

On the one hand, we don’t have an empiric way to classify what’s an untreatable mental illness. Again, some people don’t respond for years and then do when we try something else. And in this really vulnerable population, we don’t want to disenfranchise people from treatment. That might make a difference in psychiatry. References we often have seen times when a patient says, I don’t want treatment, and we compel them to get it, and then they profoundly improved. So we never. There’s a risk to labeling somebody’s mental illness untreatable. And on the other hand, in psychiatry, we’ve also seen some people who get treatment their whole life but continue to suffer unrelentingly.

So this other very valid perspective is to say we don’t want people to suffer if we don’t have the tools to help them. Reflectory illness can be so impactful on quality of life. And that can get compounded if we’re compelling people to have treatments that they may experience as harmful or as traumatizing without necessarily having benefits. So I think the philosophical debate is really around the concept of untreatable mental illness. Is there untreatable mental illness? And if it is, how do we know that it is? And that’s not an empirically answered question at that point. I don’t even know if it’s an empirically answerable question.

Alex 33:11

Eric, you’ve thought about sort of different standards and you wrote, I think with Josh Briscoe in response to a piece by. Was it Thaddeus Pope about Vsed jag’s.

Eric 33:23

Article on Thaddeus Pope.

Alex 33:25

And we were actually going to have Thaddeus on. And you can talk. And with Josh, it’s good because I.

Eric 33:30

Don’T remember what I wrote.

Alex 33:31

Right, right. I’m going to ask you about it anyway. But I think in response you wrote something that is applicable here and that is about the standards by which we should allow somebody to be eligible for medical aid in dying. And you wrote about. You notice that in the terminology in all statutes across in the United States, at least in the state statutes, they include the words irreversible and incurable. Incurable. Could you say more about that in relation to.

Eric 34:03

Yeah, I mean, I think it gets to this question about. Brendan, I forgot what you called it, like medical legal nicety around terminal illness. But it’s more than that. It’s part of the law. Like if you were going to follow the law of medical aid and dying that somebody has to have an incurable irreversible illness and a prognosis of less than six months. And the question is, does if you were just not arguing it, whether or not that’s the right thing, they did a whole other podcast folks in Canada where it’s moved away from that. But if you were going to follow the law, does any mental serious mental health illness, can we ever claim that.

Dani 34:49

That there would be a psychiatric illness where, regardless of what we do, the prognosis is less than six months.

Eric 34:56

Yeah, I hear that potentially that we can say it’s maybe irreversible or incurable. We’ve tried everything probably to a similar extent that that’s the case for other medical illnesses, ALS or different kinds of cancer. But can we say, oh, yeah, it’s less than six months?

Dani 35:16

I’d be curious to hear what Dani has to say about this, but I really don’t think so. In the absence of some significant somatic medical comorbidities, I don’t think that psychiatric illnesses typically produce death directly.

Eric 35:31

Yeah.

Dani 35:32

If we do all the things that we could do to provide care for the patient’s basic needs. Right. I mean, if somebody has really bad depression and they stop eating and nobody bothers to feed them or make sure that they eat, then, yeah, they could die. But that’s not really just the depression. It’s a lot of other things that are happening too.

Eric 35:53

Yeah.

Dani 35:54

Dani, I was really happy you asked Brent that question.

Alex 36:01

That’s your answer.

Dani 36:04

I generally agree that there’s not a psychiatric illness, that if we did nothing, that a person would die within six months. It’s just, how far will we go? Like, if there’s somebody with anorexia who’s not going to eat, are we okay keeping them hospitalized against their will in perpetuity with feeding tubes, getting nutrition into their bodies? What. What are we willing to do to a person against their will if they truly don’t want it and they truly not are refractory? Where is that limit? But from the legality perspective, the strict legality perspective, it’s hard for me to conceptualize any mental illness that I could say, without treatment, you would die within six months from.

Alex 36:52

Yeah. So I think we can all agree that. Absolutely. People with maybe we could call it something like severe refractory mental illness to avoid the term terminal and characterize it more by its lack of response to treatment. People with severe refractory mental illness should have the option of having a palliative approach to treatment. In fact, most of their treatment is palliative by nature. And that two, there are patients with severe refractory mental illness who might be eligible for hospice. They might have a condition which is likely to result in death within six months if the disease takes its usual course.

But they don’t meet the definition for medical aid in dying, which requires that you have an incurable, irreversible. Right. Much stronger language here and are able to consent. Right. In Hospice, you don’t have to consent. You can have a surrogate decision maker make the decision for you. You cannot do that for medical aid and dying. So that we can and should have different layers of eligibility for these different services. Palliative care, much lower bar. Hospice, higher bar. Medical aid and dying, much higher bar.

Eric 38:06

I said that in my article. I sound smart.

Alex 38:08

Yeah, it’s good.

Dani 38:10

I’m smart, guys. And this is like where the Alyssa Boguette educational fund that we have at HPM came from, Right. She did elect to go into hospice because she did not want more suffering, more treatment for her anorexia. And the family found that the hospice providers were very kind and very thoughtful, but they didn’t feel like they had the skills or the nuance to tend to what she and the family needed psychologically to understand this construct of the fact that her death was secondary to her really severe mental illness.

And I think that that totally highlights the impact of siloing. Right. Psychiatry and palliative care have so much pertinence to each other, but they’re often incredibly siloed from each other. And there isn’t as much collaboration as you would think. And palliative care is a psychiatric subspecialty. And so why are we not educating psychiatrists and palliative care. Why are we not educated palliative care doctors in psychiatry? And why have we not built systems that bring those silos together so that this really huge need can be better tended to in people?

Dani 39:21

I’m convinced. Dani. I want to go do my palliative medicine fellowship now. I can’t. I can’t. My wife won’t let me.

Alex 39:29

Yeah.

Dani 39:33

I love it.

Eric 39:35

I’m going to go back to the initial question. I know we still a lot to cover, but, like, what does that actually look like? What does. Because I think we asked this in the beginning. We just touched upon it. What does that palliative approach to these serious mental illness? What are the things that you’re trying to teach?

Alex 39:52

What’s in the curriculum that you’re developing for the American Board of Psychiatric Something or other?

Dani 39:58

I’ll tell you once I’ve developed it.

Alex 40:02

That’s a good. That’s fair.

Dani 40:03

That’s fair.

Dani 40:04

It’s such a spectrum, right? Like, it’s. It’s crazy what a big thing we’re talking about, because I think that psychiatrists need bread and butter, palliative care. We know people with serious mental illness are not getting palliative care, so they need the primary palliative care. Just like the goals of Care and those types need to be there. We know that they might be the people giving primary palliative care. And then it’s all the way to the extreme though of like what hospice team do you know of has been taught how to manage someone who’s psychotic in a way that’s going to feel calming to them or how to manage somebody who has a really severe personality disorder that’s getting completely triggered in their death and their loss of control in a way that might be containing to them. And so it’s really all the way from what psychiatrists are doing with their patients to what we’re doing with our patients, because nothing fits particularly into a box.

Alex 40:57

Yeah. And I’ll say we were clinically at the VA doing inpatient palliative care consults. I would say I’m interested in whether you think this is accurate. Like 80 to 90% of patients we see have a psychiatric diagnosis. These are people with serious mental illness. Yeah. Ptsd, depression, anxiety. Very, very common. Or even if it’s not a formal diagnosis, they have depressive symptoms or anxious symptoms. They have demoralization. All of these things are incredibly common. And they’re issues that we rely on our interdisciplinary team to help us with. You know, and I think that’s okay.

But a lot of people out there who are working without the benefits of an interdisciplinary team, they don’t like. We don’t have a psychiatrist on our team, for example. We have psychologists, we have social worker who’s very attuned to these issues. We do not have a psychiatrist, but we have consultants.

Eric 41:52

We have psychiatrists, not palliative care psychiatrists. Did I get that right, Dani? Yeah, palliative care psychiatrists, not palliative psychiatrists.

Dani 42:02

I mean, these are, I love it. These are evolving terms. None of these are in a textbook somewhere, but this is. You’re. You’re witnessing us trying to organize around a really last need. And yes, so what? You don’t have a palliative care psychiatrist there. And most psychiatry units don’t have a palliative psychiatrist. Yeah. And there are, there’s low hanging fruit of, you know, why would a palliative care fellow not do a psychiatry rotation if you, if we’re all agreeing that the majority of our patients have these struggles, why would a psychiatrist not do a palliative care rotation if it’s a recognized psychiatric subspecialty? Those are in my mind, the lower hanging fruits. And then just systematic. Can we.

Eric 42:48

But it is different for the, I mean, I can see the psychiatrist doing palliative Care rotation. But really for the palliative care fellow, what you’re interested in is doing, is in a palliative psychiatry rotation, it’s not just doing a psychiatry rotation, but doing the thing in the subspecialty that you’re interested in. It’s like you’re not just going to send them to a cards clinic, you’re going to send them to maybe a pallet of cardiology clinic.

Dani 43:14

Yes. And the moment that we have evolved enough since like to all have palliative care psychiatry clinics and palliative. Are there any palliative care psychiatry clinics? Yes, I think psycho onc is really a form of a palliative care psychiatric clinic. Right. But that’s specific to cancer center. Dan Shalev, for example, is at Cornell as now a pilot where he has. He’s trained in psychiatry and palliative care. He has embedded clinics within palliative care, larger palliative care clinics where he tends to the psychiatric needs of the palliative care population.

Eric 43:47

The population that we’re talking about for this podcast, people with serious mental illness. Are there palliative care clinics for them?

Dani 43:54

No, it doesn’t. I mean, there are some amazing providers out there who are integrating these philosophies in what they do face a lot. But no, it doesn’t exist.

Dani 44:03

Yeah, I don’t actually think that there are any people out there. Maybe there are some internationally that I don’t know who are practicing palliative psychiatry is the bulk of what they do clinically. Maybe all of us are to some extent doing some palliative interventions in our ordinary psychiatric practice. I hope so.

Eric 44:25

Yeah. That primary palliative care in psychiatry versus, like the specialty palliative care in psychiatry.

Dani 44:31

Right.

Dani 44:32

And I think we need to start like labeling, though. I think you’re right. Like, what would. Brent, what would the impact be if we labeled some of the things that we’re doing as palliative just in terms of our mindset of understanding when why we’re doing what we’re doing?

Dani 44:44

See, I think that that is a really hard question and actually needs some research because, you know, on the one hand, there could be a real rhetorical benefit from doing that. Right. Because it would change the way we think about what we’re doing in much the way that like maybe talking about the recovery model can help reorient people’s goals and the way they’re approaching.

Eric 45:12

This is the second time I heard the recovery model. Real quick, what is the recovery model, if you can do it in a.

Dani 45:17

Recovery model, is something that’s been around for decades now where basically recovery is defined as working towards the patient’s self defined goals with the support of often a multidisciplinary treatment team. So recovery for one person might mean I was able to get a job and recovery for another person might mean my depression was reduced by 50%.

Eric 45:45

Right.

Dani 45:46

So it’s just a very patient centric approach to psychiatric care and mental health care generally.

Alex 45:51

Yeah, I think these terms are really important and that there’s a risk. Right. Like we’ve done some beating up on the term palliative chemotherapy, you know, on the When We Were blog and then sometimes on the podcast. You know, on the one hand it has the potential to like help people think about care in terms of the patient’s goals. On the other hand, it may dilute what palliative care means.

Eric 46:18

Like I would argue though, it does not have, has nothing to do with patients goals because when people use it, it just means non curative chemotherapy.

Alex 46:26

Exactly.

Eric 46:27

It’s like using palliative care for a psychiatry. It’s just non curative psychiatry.

Alex 46:33

Everything there.

Eric 46:33

Yeah.

Dani 46:34

One closing thought. I’m trying to put myself in the, the mindset of the people who are listening to this podcast out there. Thank you for listening if you did. But it might feel like we posed more questions than gave answers, you know, and that we were going around. And if it, if it feels like that to you, if you feel like your clarity is less, I would say that that’s success, that that’s a good thing. Because these are not easy questions. If they were, we would have them answered. I think we really need to spend a lot more time pondering the gray, breaking down the silos so that the expertise. We don’t even have an eating disorder specialist here today. Right. So the expertise can come together. Increasing our education for the sake of our patients, for the sake of ourselves. So thanks for being in the gray with us all.

Eric 47:18

I love that. Brett, any other closing thoughts for you as far as where you see this all going?

Dani 47:24

I just totally agree with what Dani said. I think that these are really complicated issues and I just have to acknowledge that I always kind of find myself wanting to sit on the fence. You know, I think there’s a lot of things you can say in favor of palliative psychiatry or medical aid and dying for psychiatric illness. But a lot of things about both of those topics that really give me pause, which would really make me worried about, you know, bringing medical aid and dying to my patients, for example.

Eric 47:58

Well, Brent and Dani, I want to thank you both for being on this podcast. But before we end is the song Only Children? Yes, Only children – Cold Coffee on the Fire.

Alex 48:08

(singing)

Eric 48:53

Dani and Brent, thanks for joining us on this podcast.

Dani 48:57

Thanks for having us. Awesome.

Brent

Thank you.

Eric 48:58

And to all of our listeners, thank you for your continued support.

This episode is not CME eligible.