Journal Article Annotations
2022, 1st Quarter
Annotations by Barbara Lubrano, MD and R Garrett Key, MD
Three key areas of challenge for providing palliative care for patients with addiction were identified by the
Interpersonal/organisational relationships. People who use drugs and/or alcohol are reticent to engage in advance care planning and require discussions to occur within a trusted relationship. In relation to organisational challenges, a perception that mainstream palliative care services were quiet and serene inhibited access to people who use drugs and/or alcohol, who sensed they did not fit in because of their incompatible lifestyle.
Holistic care. Enforced abstinence from drugs and/or alcohol at the end of life may be unrealistic and potentially inhibits access to essential end-of-life care. A harm-reduction model is suggested as more appropriate. Clinicians need to tolerate a level of drug or alcohol use in order to provide individuals a better sense of security and achieve better outcomes.
Collaborating with other services and training/education. Providing timely end-of-life care for people who use drugs and/or alcohol is compounded by the presence of difficult behaviours, multiple comorbidities, and/or mental illness. Working alongside different specialities increases the likelihood of an out of hospital death and improved quality of life.
Strength and weaknesses:
This review highlights the paucity of research investigating palliative and end-of-life models of care for those who use drugs and/or alcohol. Studies were limited to those published in English, and the search strategy did not include grey literature, which may have yielded unpublished organisational reports providing information about palliative care service offerings to those who use drugs and/or alcohol. Most studies were conducted in North America, perhaps limiting the transferability of results to other cultural contexts.
C-L psychiatrist are often involved in the care of patients with drug or alcohol misuse and who are approaching end-of-life. Focusing on creating a trusting relationship, utilizing a harm-reduction model, and involving different specialties in the care of these patients will help improve outcomes and quality of life.
Palliative care physicians found depression more difficult to assess and treat towards the end of life. Despite the estimated high prevalence of depression in this population, only 40% of respondents indicated that they screen palliative care patients for depression. More specifically, physicians were more likely to defer attempts to screen for and treat depression in patients with poorer prognoses. Lack of training in use of more rapid acting treatments (psychostimulants, ketamine, atypical antipsychotics, etc.) were less likely to attempt to screen or intervene than those with training. Seventy percent of respondents voiced interest in greater collaboration with psychiatry.
Strength and weaknesses:
The study was limited to members of the Australian and New Zealand Society for Palliative Medicine and psychiatry fellows and trainees registered with the Royal Australian and New Zealand College of Psychiatrists, so the sample may not be representative of other medical communities. Response rates were low, and the results may also not even be representative of the group from which they were elicited. Psychiatry response rates were particularly low. A significant strength of the study is that it assesses a critically important segment of life where depression is not well evaluated and treated, leaving a significant gap in care.
C-L psychiatrists are optimally poised to provide teaching, collaboration, and encouragement for better assessment and treatment of depression at the end of life.