Dilemmas in Cancer Care for Patients with SMI

‘Less aggressive treatment is offered because of ethical issues’

Severe and persistent mental illness with psychotic features as a comorbidity to a cancer diagnosis presents unique challenges to delivery of cancer care. Current literature suggests that there are poorer outcomes and higher mortality in patients with severe mental illness, partly explained by barriers to access of screening services and social vulnerability factors.

However, cancer care is also delivered differently in patients with severe mental illness (SMI), and often less aggressive care is offered.

That is the conclusion of a paper selected for review in the latest edition of Annotations on the ACLP website.

Such health care disparities could be addressed in part by preparing for the ethical issues that can arise during the course of care, say the authors. Cancer care staff may have limited experience and knowledge about treatment of psychiatric symptoms and may feel troubled in scenarios when patients lack capacity and become unwilling to participate in their care.

Conversely, patients may benefit from early involvement of their mental health team for psychiatric optimization and contingency preparation.

“Specifically, pre-emptive planning between the cancer care team and the mental health care team can alleviate distress for the patient and health care teams alike. This is especially important when medical decision-making capacity can fluctuate during treatment.”

It is imperative to acknowledge disparities that exist in this patient population and create a process that will improve care and alleviate distress for the patient and the cancer care team, says the paper.

“Cancer patients with SMI present a unique set of challenges for cancer care. In this patient population, there is a higher case fatality, poorer cancer-specific prognosis, and lower survival time.”

Authors use a clinical case to highlight ethical dilemmas around medical decision-making capacity, treatment over objection, and treatment delivery in a fragmented health care framework. A pre-emptive process is proposed in which patients and the health care team are educated and plan for challenges in care.

A supported decision-making model is proposed in which patients with SMI receive help from trusted others. Another tool proposed is a version of the psychiatric advance directive. Patients are encouraged to pre-emptively identify and engage a health care proxy.

Also within the model is education of the health care team to facilitate cross-specialty problem-solving and reduce SMI stigma. This collaborative care approach would involve a mental health care manager to support the patient, identify triggers, and review safety and restraint protocols and the use of psychiatric medications.

The paper Collaborative Approach to Cancer Care in Patients Who Have Co-Existing Severe Mental Illness with Psychotic Features is here.

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