Abstract
Dear Editor:
Before I began medical school, I imagined that most terminally ill patients were elderly, gray-haired grandpas. Over the past few years, however, I have discovered that people of any age, race, or socioeconomic status can be struck down by a fatal disease when they least expect it. I have cared for children with leukemia, young women with amyotrophic lateral sclerosis, and, of course, the pleasant gray-haired grandpas.
Now that I am involved in the field of psychiatry, I have expanded my view of terminally ill patients even further to include individuals with mental illnesses. There is a growing body of evidence that examines the prevalence and treatment of depression, anxiety disorders, dementia, and delirium in chronically ill patients. Psychiatrists are increasingly becoming a part of hospice teams, and hospice and geriatric physicians today almost always screen patients for mental illnesses.
There is one population of patients, however, that has, for the most part, still escaped my attention (and the attention of many practitioners) as individuals in need of end-of-life treatment. Schizophrenic patients have long been undertreated or have avoided medical care, especially at the end of their lives. The data show that among psychiatric illnesses, schizophrenic patients have higher rates of morbidity and mortality compared to the general population, due to the illness itself, the consequences of the chronic use of psychotropic medications, and medical comorbidities (cardiopulmonary, metabolic, gastrointestinal, and other diseases). This population also has increased rates of smoking, high-risk behaviors (alcohol and drug use, sexual practices, etc.), and homelessness.
During my career, I have witnessed the way that schizophrenic patients suffer in all parts of their lives, including personally, socially, physically, and economically. At the end stage of the disease, these patients often frequent emergency departments, only to be discharged back to shelters or linger in the state hospitals. Seldom are they offered such programs as hospice to manage their psychiatric illnesses and their various comorbidities. And even when services are available, many of these individuals do not even want such help.
It is not obvious what can be done to improve care for individuals with schizophrenia, especially at the end of their lives. More awareness and interest in chronically mentally ill patients by clinicians is needed in order to be able to successfully recognize medical conditions in schizophrenic patients, and more efforts should be made to optimize the integration of medical services into their care. Like gray-haired grandpas, they deserve the opportunity to die with dignity and to have their medical and psychiatric needs met.