Past, present, and future directions

Theoretical Paper

Practitioner psychologists in palliative care: Past, present, and future directions Nima Golijani-Moghaddam Content & Focus: This article considers the role (and potential roles) of practitioner psychologists in contributing to specialist palliative care in the UK, as developed from modern hospice care. Consideration of psychologist roles is situated within an analysis of the current and historical context of palliative care – permitting some suggestions for future development of roles and broader predictions. The article is structured chronologically and examines three key foci across time. The first of these foci concerns cultural and theoretical conceptualisations of death and dying, which influence caring practices and provide a framework for psychological understanding. The second key focus is the development of palliative care as a specialism – and the provision of psychological support within this specialism. The third key focus is the roles and responsibilities of practitioner psychologists: as potential contributors to theory and practice of palliative care. Conclusions: Despite the centrality of psychological support to the ethos of palliative care, psychologists have historically had little involvement in (or influence on) its delivery. Recent policy guidance in palliative care explicitly recognises the particular competencies of counselling psychologists, and identifies ways in which they can contribute to multidisciplinary palliative care, across all levels of psychological need for the dying and their carers in hospice, hospital and community settings. Keywords: Palliative care; end-of-life care; practitioner psychologist; dying; terminal illness. HE PRESENT ARTICLE considers palliative care as a specialist area of counselling and clinical psychology. Drawing on available conceptualisations, NICE (2004) have defined palliative care as follows: Palliative care is the active holistic care of patients with advanced progressive illness. Management of pain and other symptoms and provision of psychological, social and spiritual support is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families. Many aspects of palliative care are also applicable earlier in the course of the illness in conjunction with other treatments. Although the definition above may serve to orientate the reader to the specialist area of concern in this article, it is important to acknowledge that, over time, and across cultures, there have been numerous definitions of ‘palliative care’ with concomitant variability in specified goals of care and

T

scope of practice. Through discursive analysis of palliative care definitions, Pastrana and colleagues (2008) demonstrated a lack of consensus – reflecting continuing debates within the field – but were nonetheless able to identify some important commonalities. In particular, most definitions agree that palliative care involves a comprehensive, multidisciplinary, patient-centred approach, which specifically aims to relieve suffering and improve quality of life (although these commonalities do not seem sufficient to distinguish palliative care from other forms of care). Notable areas of disagreement or subjectivity in definition pertain to the question of who should receive palliative care (and when they should receive it). Considering the NICE definition above, there is evident ambiguity around identifying the target population of ‘patients with advanced progressive illness’ – and it seems that ‘many aspects of palliative care’ can in any case be applied more broadly. Although

Counselling Psychology Review, Vol. 29, No. 1, March 2014 © The British Psychological Society – ISSN 0269-6975

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Nima Golijani-Moghaddam

palliative care was first defined in the context of terminal illness and care for the imminently dying, the NICE definition reflects a more recent shift towards wider inclusion and earlier introduction of palliative practices (Pastrana et al., 2008). Examination of the role of psychologists in palliative care appears timely: although practitioner psychologists were not involved in the early delivery and development of modern palliative care, their interest and activity in this area has grown in recent years – as evinced by the establishment of the Specialist Palliative Care Research Group of the British Psychological Society (Grant & Kalus, 2010). Policy developments over the past 15 years support a role for psychologists in the delivery and potential leadership of palliative care (Payne & Haines, 2002a). From this position, psychologists may more directly influence future practice. In reviewing palliative care as a specialist area of psychology, three key foci may be identified: 1. Cultural and theoretical conceptualisations of death and dying, which influence care practices and provide a framework for psychological understanding. 2. Palliative care, as a relatively new and rapidly-developing specialism. 3. Psychologist roles in palliative care provision. The present article considers the foci above as they relate to the historical context and continuing development of psychological practice in palliative care. The article is structured chronologically, examining the past, present, and future of this specialist area.

specialism of palliative care has developed, beginning in the 1960s (Hallenbeck, 2003). Walter (1994) characterised the cultural approach to death at this time as having transitioned from a ‘traditional’ response – wherein the dying were cared for ritualistically within their family and community – to a ‘modern’ response involving the medicalisation of dying and unseen deaths in hospitals. This shift also involved a transfer of authority from religion and community to expert doctors (Walter, 2003). Some suggest that these changes have contributed to death-denial and the treatment of death as a taboo subject within Western society, although the reality may be more complex (Sheldon, 1997). Modern death is both ‘hidden’ (in hospitals, in the elderly) and in some ways more public – with management of dying and bereavement by public services and a legal requirement to register deaths. Nonetheless, public surveys conducted since the advent of modern health care have repeatedly found a lack of discussion and openness around issues of death and dying (DH, 2008; Seymour et al., 2010). The general trend described above does not reflect the diversity in responses to death across cultures, faiths, and individuals in the UK but does reflect the broad norms that may have informed service delivery and expectations in the era of modern palliative care (Sheldon, 1997). An implication of this wider context is that it may inhibit understanding and communication around death and dying (between patients, families, and professionals) and limit the development of palliative care (NCPC, 2010).

Past Death and dying It has been argued that familiarity with death has decreased over recent generations in the UK (DH, 2008): increased life expectancies and the relocation of death from family homes to care institutions (although a reversing trend) mean that direct experience of death (e.g. the death of friends and relatives) is typically avoided until mid-life. It is within this context that the modern 30

Palliative care Current practice and principles in palliative care are often traced back to the foundation of St. Christopher’s Hospice by Saunders and colleagues in 1967 (Hallenbeck, 2003). The core principles of the Hospice care model were: (1) control of pain and other symptoms of terminal illness; and (2) psychological, social and spiritual support for both patients and their relatives/carers

Counselling Psychology Review, Vol. 29, No. 1, March 2014

Practitioner psychologists in palliative care: Past, present, and future directions

(Parkes, 2000). This model of care explicitly recognised the importance of psychological support. Saunders had previously been dissatisfied with the psychological support offered to those with terminal illness: which generally focussed on the patient alone (excluding family), did not encompass bereavement support, and lacked sophistication (Parkes, 2000). The core hospice team has traditionally comprised of doctors, nurses, and chaplains: these professionals shared the responsibility for delivering psychological support, with more specialist psychological input delivered by liaison psychiatrists (Alexander, 2004). Over time, social workers have increasingly become core members of teams and assumed some of the responsibilities around psychological support and consultation from liaison psychiatrists (Parkes, 2000). Palliative care largely developed from its hospice-based beginnings through an unregulated organic process (Sheldon, 1997) and professional roles have reflected this: with nursing and medicine at the centre of services as they’ve extended out into hospital and community settings. Although psychological care has been considered integral to palliative care from the outset, psychologists have only recently become involved in multidisciplinary palliative care work (Payne & Haines, 2002a). It has been suggested that professional psychologists showed little interest in the field of palliative care for much of its development (APA, 2000; Parkes, 2000). Although central to its ethos, psychological support has often been identified as a weaker aspect of palliative care provision: inconsistent, unskilled, and poorly rated by patients and families (NICE, 2004; Pessin et al., 2002; Skilbeck & Payne, 2003). Historically, palliative care practitioners have not received mental health training, implementing care on the basis of person-centred care principles (Mannix et al., 2006). Although this approach to support may help to contain transient distress (e.g. at diagnosis) there has been no evidence to show effectiveness when confronting enduring ill

health and consequent anxiety or depression (e.g. Moorey, 1996). If individuals who developed more complex problems were referred to specialist psychological care this may not be problematic; however, specialist palliative care nurses have been found to have negative views about depression and psychological services and to resist referring patients because of concerns about the stigma of mental illness (Payne & Haines, 2002a). These historical problems are reflected in current policy drivers for improving psychological care (NCPRP, 2010; NICE, 2004). Psychologist roles The promotion of the hospice philosophy of palliative care increased awareness of psychological needs, and of a potential role for professional psychology, in end-of-life care (Marwit, 1997; Vandenbos, DeLeon & Pallak, 1982). Palliative care raises a number of issues that reflect psychological in addition to biomedical influences. Marwit (1997) gives examples of such issues, including maintenance of hope and valued living in the context of a terminal prognosis, patient choice and autonomy in end-of-life decisionmaking, and the influence of family support on terminal illness. Furthermore, psychological distress is common and depression (in particular) is frequently presented in palliative care patients and their families (Mannix et al., 2006). However, psychologists have historically been absent from palliative care delivery (as discussed above) and their entry into practice is a recent phenomenon (Payne & Haines, 2002a). Haley and colleagues (2003) reviewed a number of developments that acted as setting conditions to enable this recent change, including: (1) the established participation of psychologists in treatment of chronic illnesses (such as cancer and heart disease); (2) the emergence of the biopsychosocial framework in medicine, which more generally supports a role for psychologists in the delivery of holistic health care; and (3) the recent drive to improve end-oflife care, leading to innovations in care


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provision and recognition of psychological needs as an important (and often neglected) focus for intervention, with specific recognition of psychologist roles (DH, 2000; NICE, 2004). Practice contributions of psychologists will be considered further in the section on present roles. Neimeyer (2005) has observed that, although clinical roles for psychologists were not defined until recently, psychologists have made important scholarly contributions to elucidating human experiences of death since at least the 1950s (i.e. alongside the development of palliative care). Feifel (1955) conducted seminal research into death anxiety as a cause of psychopathology (Neimeyer et al., 2004). This was in the context of then-influential psychoanalytic theory suggesting that death anxiety is secondary to other issues (e.g. separation anxiety). Yalom (1980) saw the omission of death fear (or translation into other concepts) as repressive in itself and symptomatic of a human tendency towards deathdenial. Yalom viewed this tendency as universal, although others have argued that it is provoked (or at least heightened) by modern Western cultural responses to death (discussed above). Much of the psychological research around death attitudes has been described as atheoretical (Neimeyer, 1994), with researchers identifying correlations between variables (e.g. death anxiety and general anxiety; Neimeyer, 1988) or testing hypotheses that are isolated from broader psychological theories (e.g. that religiosity may ameliorate death anxiety; Thorson & Powell, 1990). In contrast to this work, a small body of empirical research has been driven by Terror Management Theory (TMT; Greenberg et al., 1990; Neimeyer et al., 2004). According to TMT, constant awareness of our mortality would be paralysing, preventing us from engaging with our everyday lives. Within this account, it is posited that societies develop cultural frames for understanding life and death as a

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defensive function: to assuage anxiety arising from the profound awareness that life is finite. TMT suggests that people use proximal defences when thoughts of death are salient and explicit (i.e. entering awareness) and distal defences when thoughts are salient but implicit (outside of awareness). Proximal defences are posited to include thought suppression and rationalisation whereas distal defences involve reaffirming or bolstering allegiance to a personally-held belief system (cultural worldview) and distancing from those with contrary beliefs (Harmon-Jones et al., 1997). Observations from practice suggest individual variability: whilst some people are seen to reaffirm their beliefs (particularly religious faith) when close to death, others are observed to challenge or abandon old allegiances (Alexander, 2004). TMT has interesting (contrary) implications for emerging policy initiatives (discussed in the section on future palliative care). However, it is not clear how this model has contributed to professional understandings within palliative care practice, if at all. Although there is a history of academic psychologists examining death and dying, this seems to have been typically independent of clinical practice (Werth et al., 2002). If drawing on theoretical models at all, clinicians have historically applied the stage-based models of death and grief, proposed by psychiatrists Kübler-Ross (1969) and Parkes (1986) respectively. The concept of phases may be too limited to capture the complexities of dying and grief (Sheldon, 1997) but has provided a structure for understanding and beginning to help people through psychologically painful responses to death – recognising experiences that may be present (if not with the order and universality suggested). Unfortunately, these models have sometimes been misused clinically, to categorise and label patients who don’t progress through stages in a predictable way (Corr et al., 2008).



Present Death and dying Each year, approximately 500,000 people will die in England alone: the majority of deaths occur following chronic illness relating to conditions such as cancer, heart failure, neurological diseases, respiratory diseases, and dementia (DH, 2008). People are living for longer (ONS, 2009) but the period of disability prior to death is increasing, suggesting that medically-prolonged living may be at the potential cost of quality of life in later years (Lynn & Adamson, 2003). Most people report that they would prefer a quick death but this is becoming less common (Walter, 2003): Walter has observed that people may now live for months or years with the knowledge of having a life-threatening illness (living with dying). At a societal level there is a (partial) movement away from medical authority over death towards individual autonomy (Pollock et al., 2010; Sheldon, 1997). Personal choice is commonly considered the key determinant of a ‘good death’ at present (Walter, 2003) and this is reflected in current policy priorities for palliative care (DH, 2008). In the early development of palliative care (when modern medical authority was strongest) patients were often not informed about their terminal prognosis (Parkes, 2000). Although this approach to information sharing potentially minimised anticipatory fear and grief, the patient was denied awareness of their condition and had little influence over their care (Cassem, 2000). Currently, informed decision-making is central to palliative care and wider health care policy, but this is a recent (and ongoing) development. It is important to emphasise that, whilst the foregoing characterisation may capture currently-dominant discourses around death and dying, there is considerable variability

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across faiths and cultures within the UK. For example, some cultural and spiritual beliefs may place greater value on principles of relationality and non-maleficence in care of the dying (Carey & Cosgrove, 2006) – challenging common notions of a ‘good death’, which seem to prioritise individual autonomy above other principles. Palliative care A particular priority in current palliative care is enabling people to be cared for in the place of their choosing (DH, 2008). Recent survey data in England found that – of those who expressed a preference – most terminally ill people in England (81 per cent) preferred to die at home but only 49 per cent actually died at home (ONS, 2013). This would suggest that preferences are not currently met, in spite of recent policy and care-pathway developments (Seymour et al., 2007). Psychological distress – in patients, informal carers, and care staff – is associated with end-of-life admissions and inability to cope with home care (Hinton, 1994). For example, around one quarter of calls to rapid-response palliative care teams are from carers in need of psychological support (DH, 2008). Other factors influencing ability to die at home include advance discussions with patients about their preferred place of care (Gomes & Higginson, 2006). Psychologists could contribute to upholding patient preferences (and meeting national policy targets) by supporting patients, families, and staff teams and facilitating better communication at the end-of-life (Werth et al., 2002). If the goal is to promote home-care at the end of life1, psychologists must flexibly adapt their practice (alongside other palliative care professionals) by visiting patients and families at home and providing outpatient clinics.

It is important to assess (and periodically reassess) this and other care priorities on an individual basis, without assuming a preference for home care or attempting to achieve death-at-home as a general target.


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Psychologist roles Recent policy guidance has emphasised the importance of improving psychological support in palliative care (NICE, 2004) and psychologists have been recognised as being able to contribute at all levels of psychological support (including Network-wide leadership; NCPRP, 2010). However, psychologists are not uniquely qualified to take on these roles and psychologists are only beginning to establish practice in palliative care (Nydegger, 2008). NICE Guidance for Supportive and Specialist Palliative Care (2004) identifies four levels of psychological intervention (banded by case severity/complexity). Counselling and clinical psychologists are able to offer support (training/supervision) for staff at levels one to three and are trained in assessment and interventions at levels three and four (BPS, 2008). The only other professionals considered able to practice at level four are consultant psychiatrists (NCPRP, 2010). The staged model of psychological support in palliative care may clarify the contribution that psychologists can make without undermining established palliative care practitioners (Payne & Haines, 2002a). In terms of the specific contributions that psychologists can make, Haley and colleagues (2003) identified roles for practitioner psychologists at different stages of end-of-life care, defining four distinct points of intervention (summarised in Table 1). Haley and colleagues (2003) do not identify contributions that psychologists could make in terms of team supervision, research/evaluation, or service development (Payne & Haines, 2002a). This might reflect a limitation of considering psychologist roles by stages of care: it is difficult to capture continuous contributions that are more broadly focussed at the level of the team/service. Within stages, some important contributions could be explicated more clearly. For example, within advanced

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illness/dying, psychologists can help to manage expectations and reactions of caregivers around terminal restlessness and delirium in the final phases of dying – meeting their particular needs for information, communication, and psychological support at this time (Brajtman, 2003). The psychologist’s role in addressing a patient’s existential distress during this stage should also be emphasised further, particularly given ethical concerns around the use of palliative sedation to alleviate such psychological suffering when perceived to become ‘intractable’ (Cassell & Rich, 2010): skilled psychological intervention may have a preventative function here. It has been recently estimated that there are approximately 50 psychologists working in palliative care in the UK (Junger et al., 2010). Grant and Kalus (2010) conducted a survey of British Psychological Society members registered as working in Specialist Palliative Care. They only received responses from 16 of the 36 registered members (two counselling psychologists and 14 clinical psychologists), but their survey represents the best available data around applied psychologists working in specialist palliative care in the UK. Tellingly, the majority of respondents were the first post-holders for their service and the average length of time in post was six years, reflecting the fact that psychologist roles in palliative care have only recently been developed (Payne & Haines, 2002). Reflecting the way in which UK specialist palliative care services are delivered, most respondents described working across multiple settings (hospital, hospice, and community). Four respondents were employed by charitable hospices and 12 by the NHS. Reported contributions spanned the roles summarised in Table 1 and additionally included contributions to research, supervision, service development, management, and development of national guidelines.



Table 1: Contributions of psychologists to palliative care delivery. Intervention point

Role/contribution of psychologist

1. Prior to life-limiting illness

l l l

2. After diagnosis

l l l

3. During advanced illness/dying

l

4. Bereavement

l

l

l

Health promotion Advance care planning Public awareness and education programming Supporting patients and their families Offering consultation/training for professionals Facilitating patient-professional communication Psychosocial work with patients and their families Interventions addressing: – Anticipatory grief and adjustment reactions – Existential and spiritual issues – Mental disorders – Pain and physical symptom management – Advance care planning – Life review – Unresolved life concerns Identifying bereaved persons at risk Grief therapy

Future This section will consider some of the possible future developments in palliative care, extrapolating within key foci. Death and dying The most confident prediction that can be made is that approaches to death and dying will continue to develop and shift in response to societal changes (Sheldon, 1997). An interesting prediction around how societal responses to death may shift was made by Walter (2003). Walter suggested that people may exercise individual autonomy whilst concurrently seeking out new communities. He posits that – in a society in which people increasingly live alone, sometimes far from their families – patients may deal with protracted terminal illnesses by forming peer networks to share experiences and support (online or through patient groups). Certainly, service-user movements are strengthening and new initiatives are looking to build on this strength (Centre for Policy on Ageing, 2011).

Related to issues of personal autonomy is debate around assisted suicide, euthanasia, and assisted dying. Research to date suggests that a majority of the UK public support assisted dying (Seymour et al., 2010). The House of Lords is currently debating an Assisted Dying Bill which – with certain safeguards around prognosis, capacity, and ongoing informed consent – would enable a person with a diagnosed terminal illness to obtain a prescription for life-ending medication. If passed, it seems that this Bill would be responsive to an apparently popular advocacy for ‘autonomy in death’ (Hendry et al., 2013) but the Bill faces strong opposition (BMA, 2013; LDW, 2013) and concerns that proposed safeguards would be insufficient to protect the most vulnerable from coercion (Noble, 2013). In marked contrast to views of the UK public, most UK doctors oppose assisted dying (Seale, 2009). Consequently, it seems that legalisation of assisted dying would leave many physicians in a conflicted position with respect to their practice and involvement in palliative or end-of-life care.


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A recent initiative by the NCPC (2010) has been introduced to promote future societal openness around death and dying: the rationale for this initiative links to previous discussion of the history of death and dying and the notion that we live in a society that is unusually avoidant about discussing death (to the detriment of palliative care; Seymour et al., 2010). TMT would question the argument that death-denial is largely a product of modern western society (e.g. DH, 2008), seeing this as a universal (and normally functional) defence against death anxiety. TMT would further predict that the initiative will be unsuccessful (or else unhelpful) and may have unanticipated effects. Contrary predictions might be made from psychological models that posit a central role for experiential avoidance in psychological vulnerability (e.g. Hayes et al., 1996). Palliative care Currently, specialist palliative care is not accessed equally. Individuals less likely to access services include those who are: older, unmarried, from an ethnic minority group, in poorer socioeconomic circumstances, without home carers, diagnosed with haematological or brain tumours, or diagnosed with non-cancer disease (Walshe, 2008). There is a clear need to reduce inequalities in palliative care (Coupland et al., 2011), and recent policy has set this as an important target for future practice (DH, 2008). Psychologists could take on an important role in promoting equality, drawing on competencies in research and service development to identify and address local access issues. There is a lack of evidence around appropriate psychotherapeutic approaches in palliative care (BPS, 2008) – reflected in the diverse range of approaches applied by psychologists (Grant & Kalus, 2010) – and this should form a focus of future research.

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Psychologist roles The Department of Health have called for more research into all aspects of palliative care (DH, 2008) and this could be an important contribution for psychologists, applying their competences in applied research to further understanding in the field (Payne & Haines, 2002b) – perhaps most usefully by carrying out more theory-led research or developing theoretical models. Although there are ethical concerns around conducting research with patients at the end of life, there is evidence to suggest that participants often find the opportunity to share their experiences and contribute to future care to be beneficial (Pessin et al., 2008). The researcher role may be especially important if psychologists are to show their value as members of palliative care teams and specialist practitioners. However, there are issues with traditional outcome research in the context of end-of-life care (Sheldon, 1997): it may not be realistic to eliminate negative emotionality and interventions may be carried out in the context of deteriorating health and functioning – capturing quality of life might be most appropriate, and qualitative or mixed-methods research could be helpful in identifying personally meaningful outcomes (Flemming, Adamson & Atkin, 2008). Of note, the majority of NHS formal complaints relate to aspects of end-of-life care (Riley, 2008): these complaints are generally made by family members (although they likely reflect poor experiences for both family members and patients) and suggest that patient and family satisfaction with care should be a target for outcome measurement and improvement. However, ‘satisfaction’ is somewhat nebulous and difficult to measure (Pollock et al., 2010) and there may be dissonance between patient and family notions of satisfactory care. If legislation should change to allow assisted dying in the UK, there would seem to be a clear role for psychologists in undertaking assessment (for example, of mental capacity) and providing support around decision-making (Galbraith & Dobson,



2000) – particularly as most of the reasons given by those requesting assisted death appear fundamentally psychosocial (Cassem, 2000) including beliefs about being burdensome on others. Given the potential psychological stress of assisting others to die – likely to be compounded in some cases by dissonance with personal values or perceived conflicts between ethical imperatives – the psychologist’s role in supporting MDT colleagues may become still more crucial. It has been identified that (in contrast to nurses and physicians) psychologists do not receive specialty post-qualification curricula in palliative care (Jünger et al., 2010). The European Association for Palliative Care (EAPC) Task Force has been set up to develop a core curriculum (and better delineate the roles of psychologists in palliative care) in the near future (Jünger et al., 2010).

Summary and Conclusions Table 2 (overleaf) presents a summary of the key foci of this paper considered across phases (past, present, and future). Since the hospice-based origins of palliative care, psychological support has been considered the responsibility of all professionals working in palliative care. Indeed, psychologists have only recently developed professional roles within palliative care teams. The historical absence of professional psychology within palliative care and the unclear boundaries of knowledge and proficiency in psychological care – a problem not unique to palliative care (Payne & Haines,

2002a) – present potential barriers to the involvement of psychologists in palliative care. Against this context, psychologists have done well to establish professional roles: promoting awareness of their broad competencies and potential contributions. Recent policy guidance has helped to clarify psychologist roles, defining how their contributions can augment multidisciplinary provision. There are a number of ways that psychologists could contribute to the future development of palliative care, particularly as applied researchers, but it is also important that psychologists undertake further training in the field and draw on the knowledge of more established palliative care practitioners.

About the Author Nima Golijani-Moghaddam: I am a Chartered Clinical Psychologist and HCPC-registered Practitioner Psychologist. My interest in and approach to writing this paper (including selection of literature) was informed by experience of undertaking mixed-methods research in palliative care – including work evaluating the NHS End of Life Care Programme from the perspectives of patients, family members, and multidisciplinary professionals – and clinical experience of working with individuals and those who care for them in the context of lifelimiting and terminal illness.

Correspondence Email: [email protected]


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Roles for psychologists

Palliative care

Death and dying in the UK

l

l

l

l

l

l

l

Little clinical involvement Contributions to theoretical understandings of death and dying, but not influential on practice in palliative care

Foundation of hospice movement and modern palliative care Cancer-focussed Psychological support is person-centred and largely untrained

l

l

l

l

l

l

l

Developing clinical roles in palliative care (some resistance from established professions) Policy-based recognition of unique contributions that psychologists can make

National policy-drive to standardise and improve palliative care delivery Broadening focus to non-cancer conditions Recognition of different levels of psychological support and need for specialist training

Transition from medical authority to individual autonomy Deaths (medically) prolonged – living with dying Death returning ‘home’

l

l

Transition from traditional religious and community authority to modern medical authority Increasing life expectancy Death hidden in medical institutions

Present

Past

l

l

l

l

l

l

l

l

Demonstrating contributions to palliative care services – evaluative research? Drawing on theoretical models and carrying out applied research to improve psychological understanding in palliative care? Specialised training

Widening access to palliative care Identifying effective models for psychotherapy and supportive interventions in palliative care?

Seeking shared experiences? From individuals to collectives (peer support networks) Choices in death: euthanasia? Raising public awareness of death and dying

Future

Table 2: Palliative care and practitioner psychologists: summary of foci across phases.




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