Palliative Care Can Bridge Gaps Between Mental Illness and Hospice

Individuals with serious mental illness (SMI) face an array of complicated barriers in accessing health care when they reach life’s final stages, leading to significant disparities. Inadequate collaboration among clinicians and lack of psychiatric-specific care are large contributing factors. Providing palliative care services can be a bridge for hospices to close gaps in care and improve outcomes for patients with SMIs and their families, according to the authors of a recent review.

The unique needs of patients with SMI can add layers of complexity that are outside the scope of traditional hospice care. Individuals with SMI can have shortened life expectancy and increased risk of developing comorbid medical illnesses, according to recent research published in the American Journal of Hospice and Palliative Medicine, which outlined key features of three SMI diagnoses such as bipolar disorder, major depressive disorder, and schizophrenia.

These complex health conditions can take a heavy toll on these patients and providers alike, according to research co-author Jordana Meyerson, M.D., clinical director of palliative care for the Veterans Affairs Boston Healthcare System and adjunct instructor in the Department of General Internal Medicine at the Boston University School of Medicine. 

“An area of need is ensuring that there are no gaps in transitions between different care settings.

Palliative care can model those types of communication skills for others and also help to improve the care of [the SMI] population,” said Meyerson. “Having these processes in place ensures that those transitions of care are as smooth as possible and that as few people fall through the cracks as possible.”

Roughly 5 to 8 million older adults in the United States have one or more mental health conditions, according to research from a 2018 supplement to the Journal of the American Geriatrics Society, with projections that this number will triple over the next three decades. Many health care professionals, including hospice providers, do not specialize in providing care to this patient population.

These patients often have difficulty accessing care at the end of life due to complex socioeconomic factors that place them at greater risk of dying from chronic or undiagnosed conditions, according to the authors, who told Hospice News that communication and deeper integration of psychiatric-palliative care are avenues for hospice providers to improve both access and quality for patients with SMI.

The research indicated that interdisciplinary palliative care teams are uniquely positioned to lend assistance to patients with SMI, given their expertise in serious illness communication, goal-concordant care and psychosocial support. Yet, a lack of familiarity with the fine details of SMI diagnoses persists among hospice and palliative care staffs.

“Teaching our colleagues and each other how to use more kind and collaborative language — that in and of itself can help providers view the [SMI] population through a more appropriate lens,” Meyerson told Hospice News. “Palliative care teams are really skilled at being liaisons. Palliative care teams are trained and skilled at communication in various disciplines and receive some sort of expert-level communication skills training.”

Patients with SMI may not seek end-of-life care due to mistrust in the medical system based on negative past experiences, according to Meyerson. Chronic illnesses can progress differently for patients with SMIs. Additionally, hospice providers may not have the necessary psychiatric expertise when it comes to matters such as how certain medications used to manage serious mental illnesses can cause metabolic disorders and other serious health complications.

Psychologists and psychiatrists need to be available to hospice teams, according to co-author Kate Hinrichs, psychologist of palliative care for VA Boston Healthcare System and assistant professor of psychology for the Department of Psychiatry at Harvard Medical School.

“Even if they’re not part of the core team, having access to mental health providers and being able to consult with hospice teams would be really helpful in these sorts of patient cases,” Hinrichs told Hospice News. “We want providers to be less afraid and more comfortable in taking care of these folks. Part of that core is having palliative care skills that are totally translatable to work with the serious mental illness population.”

Psychiatry is not generally not covered by the Medicare Hospice Benefit, though social workers and chaplains tend to patients’ psychosocial and spiritual needs. Incorporating psychological and psychiatric care into the Medicare hospice benefit could lead to improved care for patients with serious mental illness approaching the end of life, according to Hinrichs. Hospice teams often feel less comfortable taking on patients with serious mental illness, Hinricks said.

Providing palliative care services can help hospices navigate these issues and serve as an important intersection between mental illness treatment and end-of-life care. Many of these patients face a common barrier in a lack of psychosocial support among their families, friends or other trusted caregivers. Patients with SMI are more likely to lack the same degree of support needed to help navigate end-of-life decisions, according to the research.

“The way that we communicate matters, dignity matters and a person’s own values matter,” Hinrichs said. “A prime opportunity to do all of those beautiful things is in palliative care settings. We get to work with folks to elicit their goals, and really help them figure out for themselves what is their right path.”