Group Report: Psychological Aspects of Palliative Care
- This working group report describes a conceptual model of the psychological aspects of palliative care that support patients' adaptive coping
- The patient–clinician relationship is core to palliative care; key goals are to help patients identify unmet emotional needs and distressing emotions, and grieve for their formerly healthy selves and other losses
- Palliative care clinicians can encourage patients to hold the opposing ideas of living well and the possibility of dying, and they understand how a patient's baseline coping skills influence their experience of illness
- Referring clinicians, as well as patients, benefit from palliative care support
- Palliative care clinicians should know when to refer patients for specialist mental health care
Although palliative care is not psychotherapy, it contains psychological elements. These are key drivers of the benefits of palliative care encounters, such as improved quality of life and lower symptom burden.
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Over two days in May 2019 at Harvard University, 23 experts in palliative care, oncology, psychology and psychiatry, most from the northeastern U.S., met to create a conceptual model of the psychological aspects of palliative care that support patients' adaptive coping. Among the authors of the group's report in the Journal of Palliative Medicine are Leah B. Rosenberg, MD, physician in the Division of Palliative Care and Geriatrics at Massachusetts General Hospital, and Vicki A. Jackson, MD, MPH, chief of the Division of Palliative Care and Geriatric Medicine.
Key Psychological Aspects of Palliative Care
The core of palliative care is the patient–clinician relationship. This connection can be difficult to build because palliative care clinicians represent loss and grief. However, a shared understanding of the patient's illness experience will help patients cope more effectively. The relationship needs to be resilient—if the clinician makes wrong assumptions or suggestions, the pair needs to talk things over and seek again to make a safe connection.
Palliative care clinicians can facilitate a healing alliance. Over time, the clinician's empathy, attentiveness and non-judgmentalism can help patients identify unmet emotional needs and distressing emotions. Patients supported in using intense emotions constructively have a better chance to remain ''whole'' or ''themselves'' during terminal illness.
Support for grieving helps patients cope. The serious illness can cause patients to grieve for their formerly healthy selves, and it often triggers a series of other losses and increasing dependence. Support for grief work allows patients to develop adaptive coping responses such as meaning-making, working on legacy projects and having important conversations with loved ones.
Patients should be encouraged to hold opposing views of living well while acknowledging the possibility of dying. Guiding patients to balance hope and worry can help them address competing priorities, organize mixed feelings and tolerate uncertainty.
Baseline coping strategies strongly affect the illness experience. Palliative care clinicians assess on an ongoing basis, "How has this person lived in this world?" or "How have they coped with stress and crises?" They can support the patient's current coping skills while suggesting new skills that will keep them engaged in the world as the illness progresses.
Palliative care support extends to referring clinicians. The presence of palliative care allows referring clinicians to safely experience the vulnerability and uncertainty of caring for those with serious illness. It also creates opportunities for a ''second look'' by the referring clinician or a different type of conversation with the patient.
Collaboration with mental health professionals is essential. Specialist mental health care is essential for seriously ill patients who are dealing with comorbid mental illness, active psychiatric symptoms or poor coping abilities that influence their quality of life or their ability to engage with care.
The Path Forward
The participants also discussed the educational needs of palliative care clinicians and key topics that would benefit from formal research. They hope their meeting will be a catalyst for broader U.S. and international seminars.
During the fall and winter of 2021–2022, members of the working group will publish a series of articles in the Journal of Palliative Medicine that more fully explore psychologically informed palliative care.
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