(120) When is Psychiatric Care Comfort Care? The Role of the C-L Psychiatrist in Transitioning Patients with Serious Mental Illness to Comfort Care

Location: Griffin Hall

Trainee Involvement: Yes

Presenting Author(s)

AN

Ashley Nieves-Archibald, MD (she/her/hers)

C-L Attending Psychiatrist
Boston Medical Center
Boston, Massachusetts, United States

Co-Author(s)

Damien Miran, MD

Clinical Director, DFCI Inpatient Psychiatry Consult Service
Dana-Farber Cancer Institute
Boston, Massachusetts, United States

Background:
While its definition and scope vary, “comfort care” is generally described as an approach to treatment prioritizing relief of symptoms, especially at end-of-life1. In this framework, curative interventions are typically eschewed in favor of those that maximize comfort and dignity while minimizing distress and suffering. In many situations, what constitutes “comfort care” is readily apparent, however clear-cut distinctions are not always possible and the patient’s unique medical history, cultural values, and goals for end-of-life should be considered when making this transition2. For patients with severe mental illness (SMI), this decision-making is particularly complex. Here we describe a case highlighting the role of the CL psychiatrist in guiding psychiatric medication changes at end-of-life.

Case Presentation:
Ms. P is a 63-year-old woman with a history of metastatic non-small cell lung cancer, COPD on home oxygen, chronic pain, and bipolar disorder managed with quetiapine and lithium. After being diagnosed with lung cancer, she was lost to follow-up prior to initiating systemic treatment. Two months later, she was medically admitted following a flash burn affecting her face, neck, and left hand after lighting a cigarette while wearing oxygen at home. Psychiatry was consulted for assistance with management of delirium. Over the next three months, she experienced numerous complications including cardiopulmonary decline and delirium. Due to her deteriorating clinical status, she was deemed too ill to receive cancer-directed therapy. During goals-of-care discussions, Ms. P and her family expressed a wish to prioritize comfort and she was transitioned to “comfort measures only.” In subsequent weeks, she continued to experience functional decline and confusion which impaired her ability to swallow pills. The psychiatry team tapered her off lithium to decrease pill burden while continuing quetiapine. This was thought to best align with her goal for maximizing comfort by providing better agitation management in the setting of terminal delirium and helping prevent psychiatric decompensation at end-of-life.

Discussion:
When transitioning patients with SMI to “comfort care” in the setting of terminal medical illness, it is important to understand the patient's preferences and personal values. Depending on the patient, proper “comfort care” may require active management of premorbid psychiatric illnesses. Others may prefer to minimize polypharmacy and medication side effects while some may prioritize relief of physical symptoms at the end-of-life. Given Ms. P’s expressed preferences, she was tapered off lithium to decrease her overall pill burden while quetiapine was continued at a reduced dose to permit higher doses of sedating pain medications, manage agitation associated with terminal delirium, and help prevent psychiatric decompensation at end-of-life.

Conclusion/Implications:
For patients with SMI, special attention must be paid to the balance between “comfort care” at end-of-life and management of chronic psychiatric conditions. CL psychiatrists are ideally positioned to manage this balance.

References:
1. Blinderman C. D. (2016). Comfort Care for Patients Dying in the Hospital. The New England journal of medicine, 374(17), 1693. https://doi.org/10.1056/NEJMc1600661
2. Toevs C. C. (2019). Transitioning to Comfort-Focused Care at the End of Life. The Surgical clinics of North America, 99(5), 1019–1027. https://doi.org/10.1016/j.suc.2019.06.014