title: Palliative psychiatry for severe persistent mental illness as a new approach to psychiatry? Definition, scope, benefits, and risks.
abstract: As a significant proportion of patients receiving palliative care suffer from states of anxiety, depression, delirium, or other mental symptoms, psychiatry and palliative care already collaborate closely in the palliative care of medical conditions. Despite this well-established involvement of psychiatrists in palliative care, psychiatry does not currently explicitly provide palliative care for patients with mental illness outside the context of terminal medical illness.
  
  
  
  Based on the WHO definition of palliative care, a, a working definition of palliative psychiatry is proposed. Palliative psychiatry focuses on mental health rather than medical/physical issues. We propose that the beneficiaries of palliative psychiatry are patients with severe persistent mental illness, who are at risk of therapeutic neglect and/or overly aggressive care within current paradigms. These include long-term residential care patients with severe chronic schizophrenia and insufficient quality of life, those with therapy-refractory depressions and repeated suicide attempts, and those with severe long-standing therapy-refractory anorexia nervosa. An explicitly palliative approach within psychiatry has the potential to improve quality of care, person-centredness, outcomes, and autonomy for patients with severe persistent mental illness.
  
  
  
  The first step towards a palliative psychiatry is to acknowledge those palliative approaches that already exist implicitly in psychiatry. Basic skills for a palliative psychiatry include communication of diagnosis and prognosis, symptom assessment and management, support for advance (mental health) care planning, assessment of caregiver needs, and referral to specialized services. Some of these may already be considered core skills of psychiatrists, but for a truly palliative approach they should be exercised guided by an awareness of the limited functional prognosis and lifespan of patients with severe persistent mental illness.
authors.affiliation: Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, CH-8006, Zurich, Switzerland. manuel.trachsel@uzh.ch.|Department of Psychiatry, Cedars-Sinai Health System, Los Angeles, CA, USA. manuel.trachsel@uzh.ch.
authors.forename: Manuel
authors.identifier: 0000-0002-2697-3631
authors.initials: M
authors.lastname: Trachsel
authors.affiliation: Supportive Care Services, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Health System, Los Angeles, CA, USA.|Department of Psychiatry, Cedars-Sinai Health System, Los Angeles, CA, USA.
authors.forename: Scott A
authors.initials: SA
authors.lastname: Irwin
authors.affiliation: Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, CH-8006, Zurich, Switzerland.
authors.forename: Nikola
authors.initials: N
authors.lastname: Biller-Andorno
authors.affiliation: Psychiatric University Hospital Zurich, Zurich, Switzerland.
authors.forename: Paul
authors.initials: P
authors.lastname: Hoff
authors.affiliation: Psychiatric University Hospital Zurich, Zurich, Switzerland.|URPP "Dynamics of Healthy Aging", University of Zurich, Zurich, Switzerland.
authors.forename: Florian
authors.initials: F
authors.lastname: Riese
mesh_terms: D017028:Caregivers / Q000523:psychology; D002908:Chronic Disease / Q000523:psychology / Q000628:therapy*; D003299:Cooperative Behavior; D006801:Humans; D001523:Mental Disorders / Q000523:psychology / Q000628:therapy*; D010166:Palliative Care / Q000379:methods*; D011570:Psychiatry; D011788:Quality of Life / Q000523:psychology*; D012017:Referral and Consultation; D012306:Risk
keywords: End of life; Futility; Palliative care; Palliative sedation; Psychiatry; Quality of life; Severe persistent mental illness; Terminal care