Palliative Care is Failing its Patients: The Case for Care That is Actually Holistic


Rose Lee (PPS ‘24)

Rose Lee (PPS ‘24)

Raven is wheelchair-bound and has triple-negative breast cancer — a menacing diagnosis. Despite Raven’s challenges, she’s surprisingly positive, owing her emotional stability to Nicole, a psychiatric professional, on her palliative care team. “In order to get good medical care, you have to have a trusting relationship,” she said. However, others aren’t as lucky to have someone like Nicole caring for their mental health.

More hospitals should incorporate psychiatrists into their palliative care teams. Patients facing serious illness are likely to experience mental health issues, and psychological symptoms harm quality of life and adherence to medical treatment. However, only a mere 10% of palliative teams employ a full-time psychiatrist. Integrating psychiatrists into these teams could improve patient outcomes and reduce the burden on palliative care clinicians to diagnose complex patient cases.

Palliative care helps manage the symptoms of mainly older patients with chronic diseases, and a staggering 71.6% of these patients experience depressive symptoms. As patients’ physical functioning deteriorates, the incidence of mental health issues increase. Depression in palliative care is connected with worse survival rates, longer hospitalizations, and increased desire for hastened death.

Nevertheless, patients still are not receiving the psychological support they need. Psychiatrists provide services to only 24% of palliative care inpatients and 19% of outpatients in major cancer centers. Further, researchers found that most patients in palliative care do not experience improvements in anxiety or depression.

Moreover, many hospitals don’t formally train psychiatrists to provide palliative or end-of-life psychotherapeutic services. There are only a few palliative care training programs in psychiatry outside of the Veterans Health Administration (VHA), and there is no certification for practicing in palliative care psychology.

Incorporating psychiatrists into palliative care teams, however, may improve patient outcomes. Serious illnesses often involve complex symptoms of cognitive decline, and psychiatrists can help differentiate between signs of trauma, mental illness, and disease-related symptoms. In addition, psychiatrists are experienced in goal-setting and motivational interviewing, so they are able to support patients in navigating grief and existential issues.

Clinicians widely acknowledge the importance of integrating psychiatry into palliative care. In one study, the majority of palliative care teams felt strongly that psychiatry benefits patients, and most desired greater access to psychiatrists. The Clinical Practice Guidelines for Quality Palliative Care also recommends palliative care teams incorporate members that treat and diagnose anxiety, depression, and PTSD.

Due to these guidelines, non-profit organizations have increasingly supported psychiatry in palliative care. In fact, the American Association of Hospice and Palliative Medicine formed a psychosocial and mental health special interest group. The Society of Behavioral Medicine also created an interest group that allows psychologists, psychiatrists, and providers to collaborate in palliative care.

Therefore, leaning into this trend, hospitals should use the VHA as a model to integrate mental health into palliative care. The VHA palliative care consult team (PCCT) consists of interdisciplinary professionals from medicine, social work, psychiatry, and chaplaincy. The VHA requires each PCCT to have a mental health professional.

Like the VHA, hospitals should also create fellowships that provide hospice and palliative training. The VHA instructs psychiatrists about their role on palliative care teams, which has improved patient outcomes. Some of these roles include assessing patient goals of care and discussing psychosocial or spiritual issues.

Even with these changes, however, reimbursement guidelines for mental health services continue to limit patients’ access to psychotherapy services. Medicare does not allow psychologists to bill for services for patients receiving care under the Medicare hospice benefit. Billing for psychiatry outside of palliative care is also complicated. Providers and patients poorly understand the process, so less patients use psychiatric services.

Some opponents also suggest that physical symptoms are most important and should thus be prioritized over mental health needs. This argument is fundamentally flawed. Mental and physical health are intimately tied. Poor mental health is a risk factor for chronic health conditions and worsening physical symptoms. Thus, it is crucial palliative medicine incorporates psychiatry for holistic patient care.

With America’s increasingly aging population, it is more important than ever to strengthen mental health supports for palliative care patients. The number of Americans 65 and older will more than double over the next 40 years. Palliative care prides itself on being holistic, but it ironically continues to treat mental issues as invisible. Patients will never be able to truly recover until hospitals acknowledge that mental and physical health are entirely inseparable.

Rose Lee (PPS ‘24) is from Rockville, Maryland and an Undergraduate at Duke University’s Sanford School of Public Policy. This piece was submitted as an op-ed in the Spring ‘23 PUBPOL 301 course. This content does not represent the official or unofficial views of the Sanford School, Polis, Duke University, or any entity or individual other than the author.