Palliative psychiatry in a narrow and in a broad sense: A concept clarification

Even with optimal treatment, some persons with severe and persistent mental illness do not achieve a level of mental health, psychosocial functioning and quality of life that is acceptable to them. With each unsuccessful treatment attempt, the probability of achieving symptom reduction declines while the probability of somatic and psychological side effects increases. This worsening benefit-harm ratio of treatment aiming at symptom reduction has motivated calls for implementing palliative approaches to care into psychiatry (palliative psychiatry). Palliative psychiatry accepts that some cases of severe and persistent mental illness can be irremediable and calls for a careful evaluation of goals of care in these cases. It aims at reducing harm, relieving suffering and thus improving quality of life directly, working around irremediable psychiatric symptoms. In a narrow sense, this refers to patients likely to die of their severe and persistent mental illness soon, but palliative psychiatry in a broad sense is not limited to end-of-life care. It can - and often should - be integrated with curative and rehabilitative approaches, as is the gold standard in somatic medicine. Palliative psychiatry constitutes a valuable addition to established non-curative approaches such as rehabilitative psychiatry (which focuses on psychosocial functioning instead of quality of life) and personal recovery (a journey that persons living with severe and persistent mental illness may undertake, not necessarily accompanied by mental health care professionals). Although the implementation of palliative psychiatry is met with several challenges such as difficulties regarding decision-making capacity and prognostication in severe and persistent mental illness, it is a promising new approach in caring for persons with severe and persistent mental illness, regardless of whether they are at the end of life. Keywords: Severe and persistent mental illness; end of life; futility; goals of care; irremediability; palliative psychiatry; quality of life; sufferin

The Influence of Using Novel Predictive Technologies on Judgments of Stigma, Empathy, and Compassion among Healthcare Professionals

Background: Our objective was to evaluate whether the description of a machine learning (ML) app or brain imaging technology to predict the onset of schizophrenia or alcohol use disorder (AUD) influences healthcare professionals’ judgments of stigma, empathy, and compassion. Methods: We randomized healthcare professionals (N = 310) to one vignette about a person whose clinician seeks to predict schizophrenia or an AUD, using a ML app, brain imaging, or a psychosocial assessment. Participants used scales to measure their judgments of stigma, empathy, and compassion. Results: Participants randomized to the ML vignette endorsed less anger and more fear relative to the psychosocial vignette, and the brain imaging vignette elicited higher pity ratings. The brain imaging and ML vignettes evoked lower personal responsibility judgments compared to the psychosocial vignette. Physicians and nurses reported less empathy than clinical psychologists. Conclusions: The use of predictive technologies may reinforce essentialist views about mental health and substance use that may increase specific aspects of stigma and reduce others

Giving away used injection equipment: missed prevention message?

Abstract Background Our objective was to examine factors associated with distributive injection equipment sharing and how needle exchange programs (NEPs) can help reduce distributive sharing among injection drug users (IDUs). Methods 145 English speaking Canadian IDUs ages 16 years and over who had injected in the past 30 days were recruited for a cross-sectional survey. Participants were asked about their socio-demographic characteristics, HIV risk behaviours, social support, drug treatment readiness, program satisfaction, health and social service use and NEP drug use. Bivariate statistics and logistic regression were used to characterize the population and examine correlates of sharing behaviour. Results More IDUs reported distributive sharing of cookers (45%) than needles (36%) or other types of equipment (water 36%; filters 29%; swabs 8%). Regression analyses revealed the following factors associated with distributing used cookers: a history of cocaine/crack injection, an Addiction Severity Index (ASI) score indicative of a mental health problem, and older than 30 years of age. Factors associated with giving away used water included: male, injected methadone, injected other stimulants and moved 3+ times in the past 6 months. Factors associated with giving away used filters included: injected cocaine/crack or stayed overnight on the street or other public place. Factors associated with giving away swabs included: an ASI mental health score indicative of a mental health problem, and HCV negative status. Conclusions Our findings show that more IDUs give away cookers than needles or other injection equipment. While the results showed that correlates of sharing differed by piece of equipment, each point to distributive sharing by the most marginalized IDUs. Targeting prevention efforts to reduce equipment sharing in general, and cookers in particular is warranted to reduce use of contaminated equipment and viral transmission

Unacknowledged Pain and Disenfranchised Grief: A Narrative Analysis of Physical and Emotional Pain in Complex MAiD Bereavement Stories

ABSTRACTBackground Pain can influence an individual’s choice to pursue medical assistance in dying (MAiD) and may also influence how family members experience that decision. Family conflict or discordance surrounding a loved one’s MAiD decision can cause unique challenges affecting grief and bereavement, including disenfranchised grief. There is limited knowledge of how individuals with complex MAiD bereavement experiences describe the role of physical and emotional pain in their bereavement stories.Aims This article explores the role of physical and emotional pain in the stories of family members with complex MAiD bereavement and identifies opportunities to improve care for individuals and families experiencing disagreement around MAiD.Methods We conducted qualitative interviews and utilized a narrative and ethics of care approach to analyze the data.Results We conducted N = 12 narrative interviews with participants in three provinces: Ontario, British Columbia, and Alberta. Descriptions of physical pain were used to justify the morality, or immorality, of MAiD in the context of patient suffering. Emotional pain described experiences where participants’ feelings about MAiD went unacknowledged by their family or friends, institutions, and sociopolitical environments. We conceptualize this unacknowledged emotional pain as disenfranchised grief and make recommendations to improve care for individuals experiencing complex MAiD bereavement.Conclusions Experiences of physical and emotional pain leave a lasting impact on family members with complex MAiD bereavement. Health care professionals should continue to improve care for family members following MAiD, especially where there is disagreement or family conflict

News Media Representations of Responsibility for Alcohol-Related Liver Disease Requiring Liver Transplantation

Alcohol-related liver disease (ARLD) is a common indication for liver transplantation yet it is considered ethically controversial in academic, clinical and public discourses. Various social groups consider people with ARLD as personally responsible for their condition and question whether they should have access to a scarce resource. How the news media constructs responsibility for ARLD may influence public opinions toward those who are ill as well as related healthcare policies. Since the organ transplantation system relies on the willingness of individuals to donate organs, understanding how the media portrays controversial issues is a matter of vital importance for public health and health policy. We investigated how responsibility for ARLD requiring liver transplantation is presented for public consumption in the news media. Using a keyword search of two online news databases, we selected 81 articles from the United Kingdom, Canada and the United States. We analyzed the articles using a discursive psychological approach. We found that the news media ascribed responsibility for ARLD to three main actors: individuals with ARLD, biological predisposition, and policy and industry representatives. How responsibility for ARLD requiring liver transplantation is presented in the news media may have implications for people diagnosed with other substance-related disorders who present for transplant candidacy or are on the transplant waiting list. Investigating how responsibility for ARLD is constructed in news media may provide insights into how responsibility is understood in other stigmatized health conditions and its potential implications for population health equity.Les maladies hépatiques liées à l’alcool (MHLA) sont une indication courante pour la transplantation du foie, mais elles sont considérées comme éthiquement controversées dans les discours universitaires, cliniques et publics. Divers groupes sociaux considèrent les personnes atteintes d’une MHLA comme personnellement responsables de leur état et se demandent alors si elles devraient avoir accès à une ressource rare. La manière dont les médias d’information établissent la responsabilité de la MHLA peut influencer l’opinion publique à l’égard des personnes malades ainsi que les politiques de santé qui s’y rapportent. Étant donné que le système de transplantation d’organes repose sur la volonté des individus à donner leurs organes, comprendre comment les médias présentent les questions controversées est une question d’importance vitale pour la santé publique et les politiques de santé. Nous avons donc étudié la manière dont la responsabilité des personnes souffrant de MHLA nécessitant une transplantation de foie est présentée au grand public dans les médias d’information. En utilisant une recherche par mot-clé dans deux bases de données d’information en ligne, nous avons sélectionné 81 articles du Royaume-Uni, du Canada et des États-Unis. Nous avons analysé les articles en utilisant une approche psychologique discursive. Notre analyse révèle que les médias d’information attribuent la responsabilité des MHLA à trois acteurs principaux : les individus ayant une MHLA, les prédispositions biologiques et les représentants des politiques et de l’industrie. Elle révèle également que la manière dont la responsabilité des MHLA nécessitant une transplantation de foie est présentée dans les médias peut avoir des implications pour les personnes diagnostiquées avec d’autres troubles liés à la consommation qui se présentent pour une candidature à une transplantation ou qui sont sur la liste d’attente de transplantation. Enfin, cette étude peut aussi nous donner une idée sur la manière dont le concept de responsabilité est compris pour d’autres maladies stigmatisées ainsi que ses implications potentielles sur l’équité en matière de santé des populations

Medical assistance in dying legislation: Hospice palliative care providers’ perspectives

BackgroundAfter over 4 years since medical assistance in dying legalization in Canada, there is still much uncertainty about how this ruling has affected Canadian society.ObjectiveTo describe the positive aspects of medical assistance in dying legalization from the perspectives of hospice palliative care providers engaging in medical assistance in dying.DesignIn this qualitative descriptive study, we conducted an inductive thematic analysis of semi-structured interviews with hospice palliative care providers.Participants and settingMulti-disciplinary hospice palliative care providers in acute, community, residential, and hospice care in Vancouver and Toronto, Canada, who have engaged in end-of-life care planning with patients who have inquired about and/or requested medical assistance in dying.Ethical considerationsThe research proposal was approved by University of British Columbia Research Ethics Board in Vancouver and University Health Network in Toronto. Participants were informed regarding the research goals, signed a written consent, and were assigned pseudonyms.ResultsThe 48 participants included hospice palliative care physicians (n = 22), nurses (n = 15), social workers (n = 7), and allied health providers (n = 4). The average interview length was 50 min. Positive aspects of medical assistance in dying legalization were identified at (1) the individual level: (a) a new end-of-life option, (b) patients' last chance to express control over their lives, (c) patient and family comfort and relief, and (d) a unique learning experience for hospice palliative care providers; (2) the team level: (a) supportive collegial relationships, (b) broadened discussions about end-of-life and palliative care, and (c) team debriefs provide opportunities for education and support; and (3) the institutional level: (a) improved processes to facilitate the implementation logistics.ConclusionWhile being involved in the medical assistance in dying process is complex and challenging, this study sheds light on the positive aspects of medical assistance in dying legalization from the hospice palliative care provider's perspectives. Medical Assistance in Dying legalization has resulted in improved end-of-life conversations between hospice palliative care providers, patients, and their families. Improved communication leads to a better understanding of patients' end-of-life care plans and bridges some of the existing gaps between hospice palliative care and medical assistance in dying