Palliative Care for People Who Experience Severe Persistent Mental Illness

Abstract There are many complexities in psychiatric care of people with severe and persistent mental illness (SPMI) and care of people at end-of-life. The combination of the two can be particularly challenging with major issues including access to care, care planning, care setting, patient decision-making capacity and autonomy, medication interactions, and patient vulnerability. The significant diversity in SPMI requires a tailored approach to each syndrome and individual. With schizophrenia, there is likely to be greater focus on decision-making capacity. Patients with substance use disorders often require a trauma-informed approach to care, as do patients with personality disorders who also underline need for thoughtful communication between team members. With the highest mortality rate among psychiatric illnesses, anorexia nervosa often demonstrates the similarities between life-limiting psychiatric illness and life-limiting non-psychiatric illness. This chapter also addresses other areas of overlap between psychiatry and palliative care. SPMI can be mimicked by phenomena such as delirium and steroid-induced psychosis or mood lability in acute medical settings. As well, interactions between psychiatric and non-psychiatric medications can be a concern. The authors expect clinical training and provision of care models that combine mental health and palliative care expertise will continue to evolve, with future changes likely having as much to do with ethics and models of care as with more direct management of physical symptoms and mental status.