Palliative care provider attitudes toward existential distress and treatment with psychedelic-assisted therapies

This interview study with palliative care providers (n=19) in the US assessed their attitudes toward including psychedelic-assisted therapy (PAT) in palliative care. Common themes included: existential distress is currently insufficiently treated, care providers see existential distress as a psychosocial-spiritual issue, PAT holds promise but does not fit with existing models of care and more evidence is needed.

Abstract

“Background: Existential distress is a significant source of suffering for patients facing life-threatening illnesses. Psychedelic-Assisted Therapies (PAT) are novel treatments that have shown promise in treating existential distress, but openness to providing PAT may be limited by the stigma surrounding psychedelics and the paucity of education regarding their medical use. How PAT might be integrated into existing treatments for existential distress within palliative care remains underexplored.

Methods: The present study aimed to elucidate the attitudes of palliative care clinicians regarding treatments for existential distress, including PAT. We recruited palliative care physicians, advanced practice nurses, and spiritual and psychological care providers from multiple US sites using purposive and snowball sampling methods. Attitudes toward PAT were unknown prior to study involvement. Semi-structured interviews targeted at current approaches to existential distress and attitudes toward PAT were analyzed for thematic content.

Results: Nineteen respondents (seven physicians, four advanced practice nurses, four chaplains, three social workers, and one psychologist) were interviewed. Identified themes were 1) Existential distress is a common experience that is frequently insufficiently treated within the current treatment framework; 2) Palliative care providers ultimately see existential distress as a psychosocial-spiritual problem that evades medicalized approaches; 3) Palliative care providers believe PAT hold promise for treating existential distress but that a stronger evidence base is needed; 4) Because PAT do not currently fit existing models of existential distress treatment, barriers remain.

Conclusions: PAT is seen as a potentially powerful tool to treat refractory existential distress. Larger clinical trials and educational outreach are needed to clarify treatment targets and address safety concerns. Further work to adapt PAT to palliative care settings should emphasize collaboration with spiritual care as well as mental health providers and seek to address unresolved concerns about equitable access.”

Authors: Halsey Niles, Colleen Fogg, Ben Kelmendi & Mark Lazenby

Summary

Existential distress is a significant source of suffering for patients facing life-threatening illness. Psychedelic-Assisted Therapies may be an effective treatment for existential distress.

Background

Existential distress is a significant source of suffering for patients facing life-threatening illness. Pharmacological treatments for depressive symptoms are less effective in patients with LTI than in the general population.

Psychedelic-assisted therapies (PAT) may be potent treatments for patients facing existential distress in the setting of LTI. Pilot studies with ketamine and MDMA suggest similar reductions in distress, but larger confirmatory trials are needed.

A qualitative study of palliative care providers’ attitudes toward PAT was conducted to elicit themes regarding their attitudes toward current treatments for existential distress and the potential of PAT to treat existential distress associated with LTI.

Sample and recruitment

Participants were recruited via email between May 2019 and August 2020 and provided informed consent. One participant received an online gift card after study completion.

Interview guide

An interdisciplinary team of experts developed an interview guide to explore palliative care providers’ attitudes toward PAT as potential treatments for existential distress in LTI.

Data collection

H.N. conducted interviews with participants via phone, Zoom video conferencing software, or in person. The interviews lasted 32 to 52 min and were transcribed using Microsoft Word.

Data analysis

Transcriptions were uploaded to Dedoose software version 8.3 and coded using a grounded theory approach. Themes were developed and updated iteratively following discussion and agreement of team members.

Theme 1: existential distress is a common experience that is frequently insufficiently treated within the current treatment framework

All participants identified existential distress as an important and relevant concept for their clinical palliative care work, and noted a relationship between existential distress and psychiatric illness. They also noted that care of patients’ families was a critical part of their clinical role.

Refractory distress was reported across all types of clinical settings. Barriers to effective treatment included limited time for visits, absence of specialty interventions and insufficient staffing to meet patient needs.

Theme 2: palliative care providers ultimately see existential distress as a psychosocial‑spiritual problem that evades medicalized approaches

Respondents endorsed therapeutic interpersonal techniques as the primary intervention for existential distress, including active empathic listening and nonjudgmental exploration of patients’ distress. Most complicated cases required specialist intervention with providers of spiritual care or psychotherapy.

Theme 3: palliative care providers believe PAT hold promise for treating existential distress but that a stronger evidence base is needed

Respondents identified PAT as a potentially powerful addition to the palliative care “toolkit” and endorsed the use of PAT through compassionate use provisions. However, they cited a need for further PAT research and greater education on PAT within palliative care departments.

Participants expressed concerns about stigma for patients receiving psychedelics, and about stigmatization from other medical providers for providing psychedelics. They expressed confidence in the safety of psychedelics in properly controlled settings.

Theme 4. Because PAT do not currently fit existing models of existential distress treatment, barriers remain

Providers struggled to identify how PAT could fit into the current treatment paradigm, and there was no clear consensus around the relative benefits of delivering PAT to patients early in their course of LTI, later while admitted as inpatients, or even while on hospice.

Discussion

In this study, palliative care professionals perceived that PAT might improve the treatment of existential distress, but further research and outreach are necessary before PAT can be expanded.

Broadening the team

The interviewees emphasized the importance of interdisciplinary collaboration within palliative care, and the language of the subtheme “Physicians and advanced practice nurses have limited roles in the treatment of existential distress” was poorly considered.

PAT would require greater involvement of psychiatrists and other mental health providers in existential distress care, but palliative care providers would prefer to expand the umbrella of palliative care rather than referring cases to outside collaborators.

This study explores current standards of care and attitudes toward PAT in a sample reflective of the interdisciplinary culture of palliative care, and provides a perspective on PAT that is informed by contemporary practice and described gaps in care.

A narrow gap

Expansion of research into PAT in palliative care settings will be facilitated by the clear identification of a target population. Patients with refractory existential distress may benefit most from PAT, and referral to PAT could be triggered by specific shifts in the course of treatment.

PAT may not be appropriate for all patients, and more research is needed to determine which psychiatric comorbidities are contraindications for PAT. Similarly, PAT may not be well-situated to amend the treatment gap for existential distress in less-resourced settings.

Pathways to integration

Respondents in our sample described meaning-enhancing interpersonal interventions as the core of conventional existential distress treatment. They perceived PAT as an intervention with unique capacities to facilitate meaning-making.

Our findings suggest that palliative art therapy (PAT) might be most easily integrated into palliative care practice if delivered in a manner consistent with current first-line meaning-enhancing approaches of psychotherapy and spiritual counseling.

Although psychedelic agents are important sacraments for some spiritual communities, participants suggested that other religious and cultural groups may reject PAT due to concerns of incompatibility with established doctrine. However, participants stressed the importance of maintaining emphasis on PAT’s meaning-enhancing effects.

Stigma and barriers

Positive and stigmatizing views toward PAT were both common, often co-occurring within the same interview. Concerns about potential risks of PAT for patients with cardiac comorbidities echoed the exclusion criteria of recent studies, while concerns about persistent negative psychological effects were unsupported by recent evidence.

These examples highlight the importance of education to dispel longstanding misconceptions regarding carefully monitored psychedelic use and promote data-driven understandings of the risks associated with PAT.

Limitations and strengths

The study was skewed toward younger and less experienced clinicians, and the sample demonstrated minimal racial diversity. Its major strengths are its broad inclusion of palliative care professional disciplines and emphasis on existing treatments for existential distress.

Conclusions

Palliative care providers describe existential distress as a common source of suffering for patients with LTI. PAT is a promising treatment for refractory existential distress, though further research is needed to clarify a target population and address safety concerns.