Psych · Consultation-liaison psychiatry
Palliative care psychiatry
Also known as Psychiatry in palliative care · End-of-life psychiatry · Hospice psychiatry · Terminal illness psychiatry · Palliative psychiatry
Exam-exhaustive fellowship topic on palliative care psychiatry for consultation-liaison practice — syndrome map (adjustment, demoralisation, major depression, anxiety, delirium, grief), desire for hastened death, dignity therapy and meaning-centred/CALM psychotherapy, Agar limits on antipsychotics in palliative delirium, antidepressant evidence in palliative care, early palliative care trials (Temel, Zimmermann, Bakitas), capacity and goals-of-care, family distress, and VAD-adjacent assessment. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- New fluctuating confusion in advanced illness — treat as delirium until proven otherwise; do not start antidepressants alone
- Desire for hastened death with untreated major depression, hopelessness, uncontrolled symptoms, or delirium — reassess after treating reversible drivers
- Routine scheduled antipsychotics for palliative delirium without non-drug care — Agar RCT showed worse symptom scores than placebo
- Major treatment-limitation or VAD-adjacent decisions processed while delirious or severely affectively distorted without capacity assessment
- Normalising pervasive anhedonia, worthlessness, and suicidality as 'understandable' end-of-life mood
- Ignoring pain, dyspnoea, constipation, retention, hypercalcaemia, or opioid toxicity as psychiatric presentations
- Family crisis and carer suicidality missed while focusing only on the index patient
Meet the patient
A 69-year-old with metastatic lung cancer is admitted with worsening breathlessness and pain. The palliative team refer him because he "wants to die", has stopped eating, and is "terminal and depressed". At the bedside he is drowsy, inattentive, and his answers drift off mid-sentence. His calcium came back high this morning.[2][9]
The registrar will treat this as one problem — "depression at the end of life" — and reach for an antidepressant. It is at least three: a desire for hastened death that may be driven by depression and hopelessness, a delirium that is almost certainly driven by the hypercalcaemia, and uncontrolled symptoms that are themselves a target. Everything below is how you hold all three at once without moralising or missing the treatable.[2][8][9][17]
References18ShowHide
- [1]Mitchell AJ, Chan M, Bhatti H, et al. Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies Lancet Oncol, 2011.PMID 21251875
- [2]Agar MR, Lawlor PG, Quinn S, et al. Efficacy of Oral Risperidone, Haloperidol, or Placebo for Symptoms of Delirium Among Patients in Palliative Care: A Randomized Clinical Trial JAMA Intern Med, 2017.PMID 27918778
- [3]Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer N Engl J Med, 2010.PMID 20818875
- [4]Zimmermann C, Swami N, Krzyzanowska M, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial Lancet, 2014.PMID 24559581
- [5]Bakitas M, Lyons KD, Hegel MT, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial JAMA, 2009.PMID 19690306
- [6]Chochinov HM, Kristjanson LJ, Breitbart W, et al. Effect of dignity therapy on distress and end-of-life experience in terminally ill patients: a randomised controlled trial Lancet Oncol, 2011.PMID 21741309
- [7]Chochinov HM Dignity-conserving care--a new model for palliative care: helping the patient feel valued JAMA, 2002.PMID 11980525
- [8]Chochinov HM, Wilson KG, Enns M, et al. Desire for death in the terminally ill Am J Psychiatry, 1995.PMID 7625468
- [9]Breitbart W, Rosenfeld B, Pessin H, et al. Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer JAMA, 2000.PMID 11147988
- [10]Clarke DM, Kissane DW Demoralization: its phenomenology and importance Aust N Z J Psychiatry, 2002.PMID 12406115
- [11]Robinson S, Kissane DW, Brooker J, et al. A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research J Pain Symptom Manage, 2015.PMID 25131888
- [12]Rayner L, Price A, Evans A, et al. Antidepressants for the treatment of depression in palliative care: systematic review and meta-analysis Palliat Med, 2011.PMID 20935027
- [13]Rayner L, Price A, Hotopf M, et al. The development of evidence-based European guidelines on the management of depression in palliative cancer care Eur J Cancer, 2011.PMID 21211961
- [14]Breitbart W, Rosenfeld B, Pessin H, et al. Meaning-centered group psychotherapy: an effective intervention for improving psychological well-being in patients with advanced cancer J Clin Oncol, 2015.PMID 25646186
- [15]Breitbart W, Poppito S, Rosenfeld B, et al. Pilot randomized controlled trial of individual meaning-centered psychotherapy for patients with advanced cancer J Clin Oncol, 2012.PMID 22370330
- [16]Rodin G, Lo C, Rydall A, et al. Managing Cancer and Living Meaningfully (CALM): A Randomized Controlled Trial of a Psychological Intervention for Patients With Advanced Cancer J Clin Oncol, 2018.PMID 29958037
- [17]Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium Ann Intern Med, 1990.PMID 2240918
- [18]Ostuzzi G, Matcham F, Dauchy S, et al. Antidepressants for the treatment of depression in people with cancer Cochrane Database Syst Rev, 2018.PMID 29683474