Abstract
The last decade has seen increasing attention to the psychiatric aspects of palliative care. As stated by Professor Ian Maddocks in his foreword to Sandy Macleod's text, The psychiatry of palliative care: the dying mind, psychiatry is a ‘natural partner’ of palliative medicine. Despite the potential contribution that psychiatry can make to palliative care, this has been a relatively neglected area for psychiatric practice and an underdeveloped aspect of palliative medicine. This contribution of psychiatry includes understanding of the biological and psychological complexity of medical illnesses (including the neuropsychiatric consequences of those illnesses), and the profound psychological issues confronted in the face of life-threatening illness, including the short- and long-term significance of loss. Palliative care has evolved to a discipline in which the skills have been extended from advanced cancer to also include neurological and other progressive severe physical illnesses. Psychiatric symptoms and disorder are frequent clinical complications among people with progressive life-threatening illnesses, and require attention to the breadth of psychological, biological and social changes that occur. These issues frequently present the greatest challenge to palliative care clinicians, and thus a text that can provide helpful background to psychiatry for palliative care clinicians is highly relevant and much needed. Furthermore, it is also an achievement to have a text that equally provides the psychiatrist with a grounding in common clinical dilemmas in the care of a dying patient. The author, Sandy Macleod, is an accomplished and highly experienced clinician in both psychiatry and palliative care. His depth of background in both fields forms the foundation to this text, which is practical, scientifically based and scholarly, addressing a comprehensive set of common and important clinical problems in palliative care.
The author provides an overview of the assessment and treatment of common psychiatric disorders and psychological symptoms in palliative care. There is comprehensive coverage of the application of contemporary treatments to common psychiatric symptoms and disorders (including psychotherapeutic and pharmacological interventions) in palliative care, including depression, anxiety and delirium. It is particularly valuable to have the inclusion of sections addressing psychiatric aspects of management of other symptoms (e.g. anorexia, fatigue, pain), including a review of the role of treatments such as the opiate analgesics. The book is especially valuable in addressing the specific needs of people affected by debilitating and terminal illnesses that affect brain function (e.g. dementias), and the needs of people with chronic mental illness when suffering a terminal physical illness. These chapters add to the uniqueness of the book's contribution.
What clinicians will find especially relevant is that the approach taken by the author demonstrates a sensitive appreciation of how psychiatric interventions need to be adapted for the dying patient or, in many instances, delivered by those working most closely with the patient (i.e. the front-line nurse). The recognition of the valuable role played by the general clinician in addressing the psychological needs is conveyed with practical appreciation of the demands on these clinical staff, reflecting the author's extensive experience in both palliative care and psychiatry. As the author says, ‘potentially the most potent psychotherapist for the dying is the attending nurse’ (p. 67). The text is written in a style that will also engage the non-psychiatrist and recognizes the critical role they play in shaping the psychological ‘tenor’ of care. The author's reference to an historical context with relevant citations and quotes reminds us that the clinical problems faced in the care of the dying have been familiar throughout the history of medical practice
Assessment and treatment of common psychiatric disorders that emerge in the dying patient require an appreciation of the complex interplay of biological and psychological processes, while being mindful of the increasing significance of existential and spiritual concerns for patients, families and clinicians. The author addresses these with clarity and sensitivity, alongside a broad range of clinical psychiatric issues in the care of a dying patient. For some readers the text will provide a valuable introduction to theoretical frameworks underpinning models of psychological adaptation and responses (such as regression) to build an understanding of behaviours encountered.
Although touched upon at different times throughout the text, there is scope for greater attention to working with families (including children and youth), how the psychiatric aspects of bereavement can be addressed in palliative care services, and perhaps some attention to the setting of care, for example the challenges in providing psychiatric care in home-based palliative services. Nevertheless, the issues relevant to the psychiatry of palliative care are expansive, and the author has succeeded in focusing on some of the key clinical challenges facing clinicians in the field.
Unfortunately trainees in psychiatry usually have limited opportunities to work in palliative care services; nevertheless an understanding of the impact of severe life-threatening physical illness, understanding of the psychiatric roles played by other clinicians, and the psychological issues at end-of-life are valuable in whatever field of clinical psychiatry in which they work, The chapters on the care of the person with dementia, and terminal neurological disorders, as well as the section of delirium, treatment of depression and anxiety in severe physical illness will be of broad interest as well to those in many fields of clinical psychiatry. For these reasons the book will be a relevant and important text for the training of psychiatrists, and may even prompt some trainees and psychiatrists to develop a greater interest and clinical role in this important field of medicine and health care.
This book is especially relevant to those working in palliative care services but will also be relevant to all clinicians working with patients with physical illness. This book will do much to improve the confidence and skills of general clinicians to address the psychiatric needs of their patients. The book will doubtlessly be highly valued by palliative care clinicians for its practical and thorough overview of some of the most challenging clinical problems they face. In the preface the author states his hope to ‘better inform medical and nursing practitioners about the psychiatry of relevance to the terminally ill’. This has been ably achieved in this excellent and timely contribution to the field.