Palliative Care for the Psycho-Oncologist

Main ideas, concepts, and lessons

Purpose and audience of the lecture

• The lecture is part of the International Psycho-Oncology Society (IPOS) multilingual core curriculum, supported by the European School of Oncology (ESO).
• It targets oncologists and other physicians/healthcare professionals involved in cancer care.

Why palliative care must include psychiatry (psycho-oncology)

• A key role of the psycho-oncologist is to help guide terminally ill patients through the physical, psychological, and spiritual dimensions of dying.
• Cancer and other life-threatening illnesses carry a large burden of symptoms—depression, anxiety, hopelessness, etc.—often as frequent as or more frequent than pain.
• Therefore, palliative care should expand beyond pain and physical symptom control to include:
  • Psychiatric
  • Psychosocial
  • Existential
  • Spiritual aspects of care.

Global cancer and palliative care need

• Cancer causes a very large and growing global mortality burden, with a disproportionate impact in low- and middle-income countries.
• Palliative care is needed across common cancer types, not only when cure is impossible.
• Barriers include:
  • lack of access,
  • insufficient funding,
  • weak policies,
  • particularly limited access to opioid analgesics for pain control.

Palliative care definitions and “model shift”

• World Health Organization (WHO) definition: active and total care for patients whose disease is not responsive to curative treatment.
  • Palliative care can be provided early, alongside anti-cancer treatment, not just in the last weeks/months.
• Canadian Palliative Care Association: a philosophy of active and compassionate therapy to comfort and support patients and families, addressing physical, psychological, social, spiritual needs while respecting cultural/religious values.
• The lecture contrasts two models:
  • Past model (“cure vs care”): palliative care begins late, after curative options end.
  • Current model: palliative care is delivered from diagnosis onward, with intensity shifting as disease progresses.
• Palliative care also includes continued focus on patient and family bereavement, not only care until death.

WHO-recommended skills and organization of palliative services

• Practitioners (including psychologists/psycho-oncologists) need skills in:
  • communication,
  • aiding decision-making,
  • managing treatment/disease complications,
  • symptom control (physical and psychological),
  • psychological and spiritual care,
  • family care and care of the dying.
• Fully developed services may include:
  • home care,
  • hospital-based consultation,
  • ambulatory/day programs,
  • inpatient palliative beds for complex needs,
  • bereavement programs,
  • training/fellowships,
  • research programs,
  • (sometimes) internet-based services.

Barriers and misconceptions

• Identified barriers to adequate end-of-life care:
  • separation of palliative/hospice from cancer treatment,
  • inadequate professional training,
  • lack of standards/disparities,
  • limited public information,
  • low investment in palliative care research,
  • limited opioid availability due to regulatory barriers.
• A major misconception: that palliative/hospice care hastens death.
  • The lecture counters this with studies suggesting patients may die shortly after hospice transfer due to underlying illness timing, but receiving hospice/palliative symptom relief does not hasten death.

Specific roles of the psycho-oncologist within palliative care

• Symptom relief (including psychological adjuncts to physical symptoms)
  • Supports pain and other symptoms using pharmacologic and non-pharmacologic approaches.
  • Psychotropic medications may be used as adjuncts for symptoms like pain, nausea/vomiting, fatigue, insomnia.
• Assessment and treatment of major psychiatric conditions
  • Addresses anxiety, depression, cognitive impairment/delirium, and risks such as suicidal ideation/desire for death.
  • Helps manage demoralization and other psychiatric complications common in advanced cancer.
• Psychotherapeutic and behavioral interventions
  • Includes both established therapies and newer, cancer-terminal-phase–focused approaches.
  • Emphasizes psychotherapy goals such as reducing distress and supporting meaning and coping.
• Spiritual/existential support and communication
  • Helps overcome barriers to discussing spirituality and meaning.
  • Notes that patients often want physicians—not only chaplains—to address spiritual concerns and the meaning of death.
• Facilitation of communication and advocacy
  • Helps facilitate end-of-life discussions among patients, families, and palliative teams.
  • Supports conflict resolution and improves listening/bad-news communication.
• Culturally sensitive palliative care
  • Incorporates cultural and religious values into evaluation and intervention.
• Bereavement support
  • Provides support after death, monitoring for grief-related psychiatric complications (e.g., depression/anxiety).
  • Offers and coordinates grief interventions (family-focused therapy, interpersonal/cognitive behavioral models).
• Team awareness
  • Recognizes that the palliative team itself experiences grief and bereavement through repeated patient losses.

What can be achieved “beyond good symptom management”

• Symptom management is the first priority, but not the only goal.

• The lecture frames “good death” vs “bad death”:

  • Bad death

    • needless suffering;
    • disregard for patient/family wishes/values;
    • violation of decency norms;
    • neglect/violence;
    • unwanted and senseless care.

  • Good death

    • free from avoidable distress;
    • consistent with wishes/values;
    • aligned with clinical, cultural, ethical standards.

• It also presents “more expansive” aims:

  • reasonable warning,
  • being with loved ones,
  • reconciliation,
  • meaning, peace, and transcendence.
• Clinician tasks include:
  • understanding the patient’s experience,
  • tolerating clinician helplessness,
  • presence/non-abandonment and accompaniment,
  • reverence for the sufferer and transmitting admiration,
  • conveying that the patient won’t be forgotten (patients as teachers).
• Patient tasks include:
  • completion of worldly affairs and relationships,
  • meaning making (life review),
  • love and acceptance of finality,
  • surrender/letting go.

Detailed methodology/list style: therapeutic focus areas and “end-of-life goals”

• Psychotherapy and palliative care may aim at:

  • Life completion / life review
  • Coherent meaning about one’s life
  • Legacy (what is left behind)
  • Peace and equanimity in facing death
  • Acceptance of death and acceptance of the life lived

• “Life completion” elements discussed include attributes such as:

  • being free from pain,
  • being free from shortness of breath,
  • being kept clean,
  • naming someone to make decisions,
  • having treatment preferences written down,
  • knowing what to expect physically,
  • ensuring family readiness,
  • having a doctor who knows them as a person and who can discuss fears,
  • saying goodbye, resolving unfinished business, forgiveness/reconciliation,
  • spending meaningful time with family/friends,
  • expressing faith/meaning,
  • achieving a sense of peace.

Acceptance of death as a key clinical concept

• Acceptance is presented as complex and dynamic, with:
  • cognitive components (awareness/insight into prognosis),
  • emotional components (peace/equanimity, reduced hostility),
  • behavioral components (speech/actions consistent with understanding prognosis).
• Evidence highlighted in the lecture:
  • Greater cognitive/emotional acceptance is linked to better outcomes (e.g., quality of death, reduced depressive symptoms, more advanced care planning).
• The lecture proposes this is a legitimate and potentially “more ambitious” target for psycho-oncologic psychotherapy—approached gently, allowing patients rather than forcing confrontation.

Overall conclusion

• Society should shift from viewing dying solely as suffering to viewing it as a normal part of life that can include:
  • growth,
  • enhanced meaning,
  • completion.
• Psycho-oncology clinicians can help reincorporate the value of dying within the broader “mystery of life” by addressing spiritual and human dimensions alongside symptom management.

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Speakers / sources featured (as named in the subtitles)

• Dr. William Breitbart, MD

  • Chief of the Psychiatry Service and attending psychiatrist of the Pain and Palliative Care Service, Memorial Sloan Kettering Cancer Center (New York, USA)
  • Professor of Psychiatry, Weill Medical College of Cornell University
  • Founding member of IPOS
  • Vice President (as stated)
  • Editor-in-Chief of Palliative and Supportive Care (journal, Cambridge University Press)

• John Stenswart (mentioned re: palliative care philosophy/statements)

• WHO (World Health Organization)
  • definition of palliative care; recommendations on skills/program components
• Canadian Palliative Care Association (definition)
• Institute of Medicine (recommendations and domains of quality end-of-life care)
• Karen Steinhaus (survey referenced about patients wanting spiritual discussion with physicians)
• Irving Yalom (existential concerns; tasks related to end-of-life)
• Victor Frankl (meaning-making/drive for meaning referenced)
• David C. (name partially obscured; “david consain”) (existential concerns and distress framing referenced)
• Ray and P. (name partially obscured; “ray and pergerson”)
  • “peaceful awareness” study referenced
• Kübler-Ross (stage of acceptance as last stage referenced)
• Chan et al. (hospice/survival related studies referenced; “channel and colleagues”)
• Chachnav (insight/prognosis and depressive symptoms study referenced)
• Joshua from this group (part of the Chachnav-related study results referenced)

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Organizations/institutions/platforms referenced

• International Psycho-Oncology Society (IPOS)
• European School of Oncology (ESO)
• EPOS website (mentioned)
• ESO website (mentioned)
• IPOS Online Core Curriculum
• Cambridge University Press
• IPOS Press (pocket handbook mentioned)
• NCI / National Cancer Institute (initiatives referenced)
• American Medical Association (end-of-life training program referenced)
• National Cancer Center Networks (guidelines referenced)
• Institute(s) of Medicine reports (pediatric palliative care and other recommendations referenced)
• Virtual hospital (Canadian example referenced)
• European Association for Palliative Care (as named)
• Multinational Association of Supportive Care and Cancer (as named)
• International Association of Hospice and Palliative Care (as named)