Providing High-Quality Palliative Care to Individuals with Serious Mental Illness: A Multisite Qualitative Study of Clinician Perspectives

Abstract: Background/Significance: Approximately 4% of the population lives with serious mental illnesses (SMI), psychiatric conditions that impose chronic impairment such as psychotic disorders. Individuals with SMI experience premature mortality and high burdens of serious medical illnesses such as cancer, cardiovascular disease, and pulmonary disease [1,2]. The burden of life-threatening medical illnesses among individuals with SMI indicates a need for high-quality palliative care aimed at supporting quality-of-life. However, existing data demonstrate significant disparities in palliative and end-of-life care for individuals with SMI [3,4].

Methods: This qualitative study sought to integrate the perspectives of behavioral health and medical clinicians across five hospitals to better characterize barriers and facilitators to high-quality palliative care for people with SMI. We conducted semi-structured interviews with interdisciplinary (geriatrics, psychiatry, and palliative care) and interprofessional (nursing, social work, chaplaincy, physicians) clinicians. Interviews were transcribed and analyzed using a thematic analysis approach. A codebook was generated using a hybrid inductive-deductive approach. Two reviewers coded transcripts, and the study team reviewed the codes to generate and refine themes.

Results: 46 interviews were completed. Participants were physicians (N=28), nurse practitioners (N=6), social workers (N=9), and chaplains (N=3) practicing in palliative care (N=32), geriatrics (N=13), and psychiatry (N=13) settings (with some overlap in geriatrics and palliative care). We identified three major themes. First, current paradigms of palliative care do not meet the needs of patients with SMI. Second, clinicians across disciplines feel motivated to care for patients with SMI and life-threatening medical illnesses but experience challenges because of gaps in training and scope-of-practice limitations. And thus there is a need for closer structural integration of psychiatric and palliative care services to adequately meet the needs of individuals with SMI and life-threatening medical illnesses. Facilitators we identified included structural integration and informal collaboration between psychiatry and palliative medicine, care paradigms that can address social determinants of health, and specialized training for clinicians caring for individuals with SMI. Barriers included stigma, poor access to mental health services, inadequate clinician training, and limitations in integration between medical and psychiatric care.

Conclusions: Our study leverages the perspective of clinicians in psychiatry, palliative medicine, and geriatrics to understand barriers and facilitators to providing high-quality palliative care to people with SMI and life-threatening medical illnesses. Despite challenges experienced by clinicians, we identified potential strategies to improve care at the clinician, institution, and systemic levels.