(PO-031) (PO-031) Disparities in End-of-Life Care for Individuals with Severe Mental Illness

Background
Individuals with severe mental illness (SMI) experience healthcare marginalization due to stigma, poor understanding of their symptomatology, and broader societal discrimination. This can manifest as limited access to palliative care during life-limiting or disabling medical illness.1,2 We describe two cases highlighting common challenges and barriers encountered by individuals with severe psychotic symptomatology.

Cases
LP, a 51-year-old woman under public guardianship for schizoaffective disorder, was admitted for acute-on-chronic encephalopathy and found to have breast cancer with brain metastases. Oncologic treatment was expected to extend survival with preserved quality of life. However, the patient denied having cancer, was paranoid of providers, and declined all treatments. She steadily decompensated while awaiting court approval to initiate cancer treatment. Court petition was revised to pursue comfort care and DNR/DNI, but patient was intubated before code status could be changed. Hospital ethics committee was ultimately convened to pursue compassionate extubation.

LB, a 60-year-old kidney transplant recipient, was admitted for worsening kidney function after discontinuing immunosuppressants due to belief that her graft was healthy and physicians were imposters. The patient became combative when treatment was attempted. Despite expectation of graft recovery with timely intervention and surrogate consent from family, care was delayed due to staff discomfort with treatment over objection and repeated requests for transfer to an acute psychiatric unit. Palliative care was deferred by the primary team; the family thus independently arranged home hospice.

Discussion
These cases demonstrate common themes of disparities in end-of-life care, including decreased access to and quality of palliative care; misattribution of symptoms to psychiatric illness; inadequate engagement of surrogate decision-makers; and limitations to managing severe behavioral symptoms in non-psychiatric settings. While early and aggressive intervention was reasonable given expected alleviation of discomfort, these disparities delayed treatment beyond the point of meaningful recovery in both patients. Advocating for standard of care, unfortunately, did not fully account for the practical realities of treatment over objection. Finally, early involvement of palliative care may have prevented non-beneficial interventions and unnecessary suffering.

Conclusions
Stigma-driven disparities, particularly in end-of-life care, impact all individuals with symptoms of SMI, regardless of etiology, care setting, or legal autonomy. CL psychiatrists have the difficult but rewarding duty to advocate health equity given the field’s unique role in mediating broader medical, legal, and ethical conflicts without losing sight of individual patient needs.

References

1. Relyea et al, Journal of Palliative Care. 34:1(2019).


2. Baruth et al, International Psychogeriatrics. 33:2(2021).