Abstract
Obviously, palliative care practice incorporates a major emphasis on mental health issues—grief, depression, delirium, anxiety, family conflicts, treatment decisions, existential issues, and the like. But existing members of the palliative care team, including physicians, nurses, and nurse practitioners, as well as social workers, bereavement counselors, chaplains, and other mental health professionals, may believe they already sufficiently address the psycho-social-spiritual needs of patients with advanced illness.
Many also find these areas the most personally and professionally gratifying aspects of palliative care. And yet, according to von Gunten's colleague, psychiatrist Scott Irwin, M.D., Ph.D., psychiatric issues in palliative care are “prevalent, unacknowledged, unassessed, under-diagnosed and under-treated.” Palliative care specialists, Irwin says, often do not have the expertise to assess, diagnose, or manage complex psychiatric conditions in their patients.
Von Gunten has a different perspective on the value of psychiatry in palliative care since San Diego Hospice's Institute for Palliative Medicine launched its Palliative Care Psychiatry Program. Perhaps the only full-time–staffed mental health program based at a hospice, it was founded and has been directed by Irwin since 2006. Recently, it was honored with the Gold Achievement Award from the American Psychiatric Association.
The program addresses psychiatric and psychological issues that cause additional distress for seriously ill patients in hospice and palliative care. It includes a research component, clinical innovation, prompt response to identified psychiatric needs, medical training opportunities in collaboration with the University of California-San Diego, and even the use of evidence-based hypnotherapy to relieve suffering.
“Just as not every hospice patient needs to see the hospice physician, not every patient needs to see the psychiatrist,” von Gunten notes. “That is for the challenging patients, the difficult family dynamics, which can completely overwhelm the generalist skill set of hospice and palliative care team members. Palliative care practitioners have learned to do the first-line treatments for some psychiatric symptoms. But up to now, there often wasn't recourse for cases that didn't respond to the first-line treatments.” The presence of a psychiatrist also helps other members of the palliative care team learn psychological assessment skills and interventions and recognize when to call in the psychiatric specialist, he says. “Now our hospice staff couldn't imagine doing without it.”
Varied Approaches to Collaboration
There are a number of ways to promote collaboration between psychiatry and palliative care and to take advantage of their complementary affinities, for the benefit of both specialties. There are believed to be several dozen psychiatrists who have subspecialty board certification in hospice and palliative medicine, including 25 who passed the exam in 2008, the first time it was offered under the auspices of the American Board of Medical Specialties. A number of these psychiatrists lead or sit on palliative care teams.
Susan Block, M.D., chair of Psychosocial Oncology and Palliative Care at Dana Farber Cancer Institute and Brigham and Women's Hospital in Boston, Massachusetts, and professor of psychiatry at Harvard Medical School, says, “We've had integration of psychiatry and palliative medicine since we started in 2001. That was my vision. I have a strong belief that psychiatry is dramatically underutilized in palliative care. Here, psychiatrists are involved in addressing challenging patients and in teaching the team.”
Other palliative care teams have identified psychiatrists within their health systems or local communities who are willing to consult upon request with individual patients and/or attend palliative care team meetings or rounds and contribute to team care planning. A variety of structures are possible, depending on local resources, culture, and institutions, but the first step is for the two specialties to begin to talk about their mutual interests. Block sees a potential synergy between the two specialties, although it needs further development, and says it could significantly enrich practice in both fields.
At Princess Margaret Hospital of the University Health Network in Toronto, Ontario, a different approach has integrated palliative care, psychiatry, psychology, and other mental health, supportive, and psychosocial services together in the Department of Psychosocial Oncology and Palliative Care. “Psychosocial care is an enormous part of palliative care, obviously,” says the department's chair and head, psychiatrist Gary Rodin, FRCPC, M.D.
What's needed is an integrated approach to patient well-being and quality of life, he says. “But I wouldn't limit the integration with palliative care to psychiatry. We are looking at supportive care more broadly, and we have created one-stop shopping for all of the psychosocial and palliative care supportive services. By bringing these groups together, collectively they have a much greater voice within the institution and a critical mass of research and education,” on an equal footing with the medical, surgical, and radiation oncology departments. “Before the integration, we weren't always represented when important decisions were made. When the hospital moved to a new location several years ago, we took advantage of the available space and window of opportunity for bringing all of the supportive services together.”
Thomas Strouse, M.D., since 2007 medical director of the Resnick Neuropsychiatric Hospital at UCLA, became board-certified in hospice and palliative medicine (HPM) the first time it was offered by the American Board of Psychiatry and Neurology (ABPN) in 2008. Strouse, who helped to write the HPM exam, also has ABPN subspecialty certification in pain management and psychosomatic medicine. “Psychiatrists who understand the multidimensional nature of suffering are well suited to do palliative care,” he says.
Before his current position, Strouse led a palliative care service at Cedars-Sinai Medical Center's outpatient cancer center, also in Los Angeles. It was called Psychosocial Services and Cancer Pain Management. The pain management component was established by anesthesiologists, but it evolved into a service led by psychiatrists, he explains. The service is offered 24 hours a day, 7 days a week for scheduled and routine care and for urgent symptom-based care. Strouse continues to attend 6 weeks a year on the palliative care service at UCLA Medical Center. He also supervises psychiatry fellows on palliative medicine rotations.
He says a cancer center, and an outpatient clinic within one, can be optimal settings to practice both palliative care and cancer-focused psychiatric services. The latter are sometimes referred to as consultation-liaison psychiatry (which is focused on the psychological implications of medical illness and treatment), psychosomatic medicine, or psycho-oncology. “The service at Cedars is so successful because it is under the same roof as oncology and is offered 24/7.”
Challenges and Myths
“The way you get a psychiatrist involved in palliative care is to employ one, even if just to come to treatment rounds one or two hours a week,” and/or have them accept as payment what they are able to bill for their palliative care consultations, Strouse says. Reimbursement can be a struggle for psychiatrists, given low payment rates and carved-out managed care benefits, just as it is for palliative care, which rarely covers its own costs from billing revenues. “But if you want them, pay them,” he says. Or consider avenues such as partnering with an academic institution, developing or participating in fellowship training programs, pursuing research opportunities, or seeking other outside grant funding.
Adds Irwin, “People don't realize that you can bill the Medicare hospice benefit for physician consulting services, including those of psychiatrists. All of our clinically related physician work here at San Diego Hospice is billed fee-for-service.” (See Text Box 1.)
Text Box 1: Physician Billing Issues
There are a number of resources on physician billing for hospice and palliative care at the Center to Advance Palliative Care (www.capc.org), the American Academy of Hospice and Palliative Medicine (www.aahpm.org), and the National Hospice and Palliative Care Organization (www.nhpco.org). In general, psychiatrists in hospice and palliative care bill under the same guidelines, using the same Current Procedural Terminology (CPT) and International Classifications of Disease (ICD-9) codes, as other physicians. It may be that psychiatric diagnoses are reimbursed at a different rate or proportion than “medical” diagnoses, although in the palliative care arena most often psychiatric symptoms are due to underlying medical issues.
For professional services provided to palliative care patients, the physician submits bills directly to the payer on the usual basis, including to Medicare Part B. If the patient is enrolled on the Medicare Hospice Benefit, then billing is determined by the physician's relationship with the hospice. If the physician is the attending physician and associated with the hospice (even in a volunteer capacity) as medical director, then the physician submits bills to the hospice program, which submits them to Medicare under Part A. If the physician is in the role of attending and is not associated with the hospice, the physician bills Part B. If the physician is a consultant providing requested medical services to a hospice patient, the physician (including psychiatrist) submits his or her bill to the hospice, which submits the bill to Medicare under Part A. The hospice will pay the consultant under the terms of a contract (simple) between the consultant and the hospice. In many of these situations, the hospice will retain 10% of the payment to cover the costs of billing.
The most common barrier to billing for physician services for patients enrolled in hospice care is that the hospice agency is unfamiliar with this process. NHPCO (www.nhpco.org) can help member hospice programs learn how to bill for physician services to hospice patients.
Beyond the need to recognize what psychiatry can contribute to the palliative care team (see Table 1), another challenge is the belief that there are no psychiatrists willing to become involved in this kind of work. “There are psychiatrists interested in seeing these patients,” von Gunten says. They are diffusely spread, but they can be found.
Start by suggesting a meeting to explore shared interests, and perhaps offer an exchange of educational presentations between psychiatry and palliative care departments. “Invite them in for rounds once a week, in the spirit of mutual learning, or discuss developing research collaborations,” Irwin says.
“When I give talks around the country to hospices and palliative care programs, they say, ‘We can't get psychiatrists to see the need,’ or ‘The psychiatrists we've been involved with were completely unhelpful,’” he adds. “The biggest lesson I can impart is that when I came over here, I had to work with the hospice and palliative care teams and learn their language, and they had to get to know me as one more member of the interdisciplinary team. The Center to Advance Palliative Care's model for program development emphasizes showing up, walking on rounds, and using good consultation etiquette,” Irwin says. “You can do this outside of the big academic medical centers.”
“Psychiatry has changed a lot in recent years,” Block says. “There are a lot of frustrated humanists who are getting pushed into just doing psycho-pharmacology, but who really care about the patient's existential issues. Those are the psychiatrists I'd look for. They'll find they can learn new things and grow in every way from their involvement in palliative care.”
Complexities of the Interface
The challenges and opportunities of the psychiatry/palliative care interface might be illustrated by the career path of Joseph Weiner, M.D., Ph.D., Chief of Consultation-Liaison Psychiatry at North Shore University Hospital in Manhasset, New York. As a psychiatric attending in the early 1990s, he found himself working with patients who had Huntington's disease, and then with HIV. “That work, along with some personal experiences, made me think more carefully about the needs of patients with life-limiting illnesses,” Weiner says. “Philosophically, the overlap between palliative medicine and consultation-liaison psychiatry is great, although the patients you are called upon to treat may be different.”
Weiner was recruited to Long Island Jewish Medical Center to run a program that trained clinicians in doctor–patient communication skills. Around the same time, he received a Project on Death in America Faculty Scholar Award. He met the other faculty scholars and utilized the award's protected time to found the first palliative care service at Long Island Jewish.
“As its medical director, my role was to be on service two months a year, but more than that I was the philosophical and academic leader of palliative care. But I felt conflicted with the complexities of being a psychiatrist running a palliative care service—the complexities of who should be the leader. I didn't see myself doing primarily pain medicine, but I was really good at conducting family meetings.” When the Program on the Patient-Doctor Relationship closed, Weiner went to a sister hospital in the North Shore-Long Island Jewish Health System to run its Division of Consultation-Liaison Psychiatry, which he now does full-time.
“I miss doing full-time palliative care a lot, but the service I founded is in wonderful hands. Where I intersect with my hospital's palliative care service now, on the front lines, is when they call a consultation-liaison psychiatrist to deal with ‘more traditional psychiatric issues,’ depression and delirium being the top two. I also encourage the clinical team, physician, patient, and family to consider the role of palliative care when they haven't done that,” he relates.
“I believe psychiatrists lend a certain area of expertise to palliative care, without which treatment often is incomplete or not as effective. There are issues such as understanding how the life narrative of the patient comes into focus when facing a life-limiting illness, and what the illness symbolizes in the person's life, and how family dynamics can be understood and dealt with. These things add a depth of caring that can be gratifying for the psychiatrist to experience and so helpful to the patient and family receiving palliative care.” Collaboration also creates opportunities for palliative care team members to grow as clinicians.
“For me, some of the most touching and profoundly gratifying experiences of my career were in palliative care,” Weiner says. Working with patients who are facing the end of their lives raises issues that are central to being human, and also central to the practice of medicine. “Being in a position to talk with patients about these profound issues made me a better human being, which made me a better psychiatrist.”
Footnotes
Larry Beresford is a freelance medical journalist based in Oakland, California, and a consultant to the Center to Advance Palliative Care.