APM Resident Education Curriculum Revised 2019 Dustin DeMoss DO Assistant Professor Univ North Texas HSC Anthony Nguyen DO John Peter SmithUniv North Texas HSC Revised 2013 Ryan Kimmel MD ID: 915534
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Slide1
Psycho-Oncology and Palliative Care
APM Resident Education Curriculum
Revised 2019:
Dustin DeMoss, DO
, Assistant Professor, Univ. North Texas HSC
Anthony Nguyen, DO
, John Peter Smith/Univ. North Texas HSC
Revised 2013:
Ryan Kimmel, MD
, Assistant Professor, Univ. of Washington
Revised 2011:
Kristen Brooks, MD
, Assistant Professor, UCSF
Original version:
Bradford D.
Bobrin
, MD
, Medical Director, ACT Program, Division Chief, Psychiatry Consult Service, The Reading Hospital and Medical Center, Reading, PA
Version of March 15, 2019
Slide2Learning ObjectivesReview potential psychiatric comorbidities in the palliative care and psych-oncologic patient population
Become familiar with diagnostic challenges and modalities commonly used in palliative care and in psycho-oncologyReview current evidence based treatment guidelines for those with psychiatric diagnoses in the palliative care and psycho-oncologic patient population
Appropriately identify and screen individuals with risk of substance use disorders
2
Slide3Palliative Care and Psychosomatics
Hospice began in France in 1840s
Involves all stages of life-threatening illness
Includes psychological, social, spiritual, and cultural issues
World Health Organization defines palliative care as:
An approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness through the prevention and relief of suffering.
3
James L Levenson, M.D., 2005.
Slide4Palliative Care and Psychosomatics
Palliative care:
Affirms life and regards dying as a normal process
Neither hastens nor postpones death
Provides relief from pain and other symptoms
Integrates the psychological and spiritual
Offers support system to help patient live as actively as possible
Helps family cope
Utilizes a multidisciplinary approach to address the needs of the patient and their families
Is applicable early in the course of illness in conjecture with other therapies that are intended to prolong life.
4
James L Levenson, M.D., 2005.
Slide5Psychiatry and Palliative Care
Working Together Towards a Common Goal
Palliative care’
s goal is to relieve symptoms and suffering and improve the quality of life for the patient and their families.
Palliative informs psychiatry
Assessment and treatment of pain
Bereavement
Anticipatory loss
Psychiatry informs palliative care
Assessment of psychiatric illness and mental status changes
Evaluation of capacity
Psychiatric treatment
Insight into personality structure and communication issues
Conflict resolution
Patient physician relationship
Recognize the formation of an attachment as a consequence of working towards a common goal
5
JLSpeiss, 2002; Tan et al., 2005, Fairman 2013
Slide6Psychiatric Aspects of Cancer Treatment
Chemotherapy
Drug interactions
Procarbazine is a weak MAOI
Paroxetine , fluoxetine, duloxetine and bupropion are strong 2D6 inhibitors and may decrease the efficacy of tamoxifen due to enzyme inhibition , thus reducing levels of tamoxifen’s active metabolite (
endoxifen
).
Venlafaxine likely the safest antidepressant and can help with tamoxifen induced hot flashes
Citalopram and escitalopram are reasonable as well.
Radiation
Increased fatigue, N/V, and anxiety
Bone Marrow Transplant
Depression and anxiety, N/V, fatigue, adjustment d/o, dependence (dependent needs are associated with poorer survival), neurocognitive deficits due to CNS toxicity
6
James L Levenson, M.D., 2005, SLB Mueller 2005, Desmarais 2010
Slide7Psychiatric Issues Following Cancer Treatment
3-55% get depressed following breast cancer treatment
Cognitive problems include disturbed consciousness, cognitive problems, executive problems. In a study of 8,921 women with breast cancer
Women who got surgery and chemo had increased rates of adjustment d/o and fatigue
Mood disorders were similar in chemo and non-chemo groups
No issues with cognitive disorder
7
JR Sattin 2009, SLB Muller 2005, Takechi 2003
Slide8Common Psychiatric Issues In the Psycho-oncologic and Palliative Care Population
Anxiety
Bereavement and Grief
Depression
Delirium
8
James L Levenson, M.D., 2005, Wyszynski, 2005
Slide9Depression and Cancer
May lead to poor treatment adherence and possibly decreased survival
Increased rates of depression in cancer patients over the general population
25% rate overall
Differs for different cancers
Orophargngeal 22-57%
Pancreatic 33-50%
Breast 1.5-46%
Lung 11-44%
Depression appears to be less common in colon cancer, gynecological malignancies and lymphoma
9
CP van Wilgen 2006, JL Levinson 2005, KM Brintzenhofe 2009
Slide10Depression and Cancer Progression and Mortality
Depression found to be a small but significant predictor of mortality
26% greater mortality with depressive symptoms
39% greater mortality with MDD
Depression may be independent risk factor for mortality
Depression not associated with cancer progression
Chronic inflammation is associated with stress and may underlie depression symptoms.
Biomarkers for pro-inflammatory cytokines are increased in cancer patients
10
JR Satin 2009, Sotelo 2014
Slide11Assessing Depression in the Terminally Ill
Diagnosis often relies more on psychological or cognitive symptoms than physical complaints
Hopelessness that is pervasive with despair and despondency likely indicates depression
Suicidal ideation, even mild or passive, more likely to indicate significant depression
11
James L Levenson, M.D., 2005, Takechi 2003
Slide12Treatment of Depression in Terminally Ill
Prognosis and time frame affect medication choice
SSRIs for person with several months
Low dose stimulants for those with several weeks
Sedatives or narcotic infusions for those with hours to days
Start antidepressants at half the usual starting dose
Methylphenidate 2.5-5mg in morning and noon
Maximum dose is usually less than 30mg/day.
Psychotherapy
Mixture of supportive, CBT and medications.
Newer modalities such as meaning-centered psychotherapy and dignity-conserving care have also been found to be helpful
Music therapy
Shown to reduce pain, decrease anxiety and depression and improve quality of life
12
James L Levenson, M.D., 2005, Wyszynski 2005, Gao 2018,
Slide13Somatic Symptoms and Depression in Cancer
Somatic symptoms of depression in cancer patients
Appetite changes and decreased ability to think coincided with anhedonia
Sleep disturbance and fatigue not significantly associated with non-somatic symptoms
Appetite changes associated with increased severity of depression
13
Takechi 2003, Van Wilgen 2006 Mueller 2005
Slide14Mixed Depression/Anxiety in Cancer Patients
8,265 patients with cancer
Mixed symptoms in 12.4%
Depression in 18.3%
Anxiety in 24%
70% had neither
Mixed symptoms in stomach, pancreatic, head and neck and lung cancers
Lower rates in those with breast cancers
Mixed symptoms in 2/3 of depressed cancer patients
14
KM Brintzenhofe-Szoc 2009
Slide15Suicidal Ideation and Cancer
Passive SI common
Relative risk of suicide was 12.6 within first week of cancer diagnosis
Relative risk is 3.1 within the first year of diagnosis
Risk factors
Regular risk factors for suicide in the general population
Advanced disease and poor prognosis
Delirium
PainPhysical, social, and/or financial exhaustionNeed for control
15
James L Levenson, M.D., 2005, Fang 2012
Slide16Suicide and Suicidal Ideation in Palliative Care
3-20% have pervasive and sincere wish to die.
Risk Factors
All regular risk factors for suicidality are important to consider
Age, race, history of suicide attempts, psychiatric illness, means,
etc
Advanced stages of the disease
Hopelessness
Uncontrolled pain
Confusional
states (delirium)
Loss of control and sense of helplessness
Fatigue of all forms
Physical
Financial
Social supportSuicidal ideation needs to be addressed, but psychiatric hospitalization may not be indicated in some cases16
James L Levenson, M.D., 2005, Wilson 2015
Slide17Desire for Hastened Death
States that allow physician assisted death
Oregon, Washington, Vermont, California, Montana, Colorado, Washington DC, Hawaii
Risks
Depression plays a role in requests for hastened death
Patients with depression were noted to have a 4x higher likelihood of desire for hastened death
Depression and hopelessness are the strongest predictors of desire for hastened death in terminally ill patients
These patients have higher levels of pain and less support
Psychological distress, social factors, spiritual distress and feeling like one is a burden contribute
Management of physical and psychological distress is likely the best treatment
Increasingly legalized but still relatively rare. Primary involves cancer patients.
Main motivations for physician assisted death
Loss of autonomy and dignity, decreased quality of life, Mental distress
17
James L Levenson, M.D., 2005, Emanuel 2016
Slide18Depression and Cancer
SSRI remains the first line treatment
Possibility of inflammation as a cofactor or even etiological reason for depression. SSRIs found to have anti-inflammatory properties on microglia.
SSRIs may even have anti tumor effect. There have been in vitro studies that show SSRIs having apoptotic effects in hepatocellular carcinoma cells
Concurrent depression and cancer related symptoms
Mirtazapine: Helps with insomnia, nausea and anorexia.
Bupropion : Helps with fatigue, poor concentration, or nicotine dependence
Venlafaxine, Duloxetine or low dose TCA: Helps with neuropathic pain
Venlafaxine and SSRI: Helps alleviate hot flashes from hormone therapy
18
SM
Thekadi
2015
Slide19Depression in Palliative Care
Prevalence 13-20%
Loss of meaning and lower spiritual well-being lead to higher levels of depressive symptoms
Pain and functional status also factors in increased rates of depression
Underlying medical conditions may also contribute to depressive symptoms
CNS lesions, metabolic-endocrine complications and paraneoplastic syndromes
Treatment of medical conditions may also induce depressive symptoms
Whole brain radiation, corticosteroids, vincristine, vinblastine, asparaginase, intrathecal methotrexate, interferon, amphotericin
19
James L Levenson, M.D., 2005, Mitchell 2011
Slide20Demoralization vs. Depression
Demoralization
Characterized by
“
various degrees of helplessness, confusion and subjective incompetence
”
to adversity.
Shorter duration than depression Reactive to family and supports
Specific to stressors “
How would you be coping if this went away?
”
20
Slide adapted from Mitch Levy,
Univ
of Washington
Slide21Demoralization
Diagnostic Criteria
1. Patient experiences emotional distress such as hopelessness and losing life’s purpose
2. A general attitude of helplessness, failure pessimism, and lack of worthwhile future
3. Reduced coping to respond differently
4. Social isolation and lack of social support
5. Persistence of the above for
>2 weeks6. Features of major depression are not superseded as primary disorder.
21
Kissane
, 2000
Slide22Treatment Targets for Brief Psychotherapy for Demoralization:
Existential Postures of Vulnerability and Resilience
Vulnerability
• Confusion
• Isolation
• Despair
• Helplessness
• Meaninglessness
• Cowardice
• Resentment
22
Griffith and Gaby,,
Psychosomatics,
2005
Resilience• Coherence• Communion • Hope• Agency• Purpose
• Courage• Gratitude
Slide23Overall Psychological Treatment Goals
Help patients maintain control of their lives
Assist in developing healthy coping strategies
Help control
Anger
Denial
Panic
Despair
Fears of rejection and abandonment
Help establish self-respect by assisting with resolution of guilt, shame and self-blame
Help with communication and the maintenance of support systems
23
James L Levenson, M.D., 2005, JL Speiss, 2002, LW Roberts 2004
Slide24Overall Psychological Treatment Goals
Help maintain interpersonal relationships
Help develop strategies to deal with real and anticipated crises
Help identify and address
“
unfinished business
”
Work with patient to explore meaning of death
Help manage depression and anxiety or other psychiatric symptoms that may result from psychological issues or effects of treatment
24
James L Levenson, M.D., 2005
Slide25Dignity Conserving Treatment
Dignity therapyTreatment is based on strong association with undermined dignity and:
Depression
Anxiety
Desire for death
Hopelessness
Feeling of being a burden on others
Overall poorer quality of life
Some studies even suggest that psychosocial and existential issues may be of greater concern than pain and physical symptoms
Chochinov, H, 2007
Slide26Dignity Conserving Treatment
Dignity therapyPrimary themes of dignity:
Generativity
Life has stood for something
Continuity of self
Maintain one’
s essence is intact
Role preservation
Being able to maintain a sense of identification with roles previously held
Maintenance of pride
Ability to sustain positive self-regard
Chochinov, H, 2007
Slide27Dignity Conserving Treatment
Dignity therapyPrimary themes of dignity (cont.):
Hopefulness
Ability to find and maintain a sense of meaning or purpose
Aftermath concerns
Worries or fears concerning the burden death will impose on others
Care tenor
Attitude and manner with which others interact with the patient either promotes or diminishes dignity
Many of these are also essential to a patient maintaining a sense of control and integrity in any setting
Chochinov, H, 2007
Slide28Dignity Conserving Treatment
Dignity therapy (provider):
Treatment of the provider consists of an A, B, C, D approach to teaching interactions
The hope is to allow care givers, institutions, and families a way to better interact with patients to achieve the desired effect
Our thoughts about an interaction with a patient shape the interaction itself
Engagement Model
Chochinov, H, 2007; Bennington-Davis, M, 2005
Slide29Dignity Conserving Treatment
Dignity therapy (provider):A—Attitudes
How would I feel in this situation?
What leads me to think that way?
Am I aware of how I might be affecting the patient?
Chochinov, H, 2007
Slide30Dignity Conserving Treatment
Dignity therapy (provider):
B—Behaviors
Treat contact with patients as you would any important intervention
Always ask permission to do something
Act in a professional and respectful way at all times
Examples
Knock on the patient’
s door
Use the patient’
s proper name and title unless given permission to do otherwise
Chochinov, H, 2007
Slide31Dignity Conserving Treatment
Dignity therapy (provider):
C—Compassion
Very difficult to
“
train
”
Medical Humanities in school
Considering the personal storiesD—Dialogue
“
What should I now about you as a person to help me take the best care of you that I can?
”
“Who else (or what) will be affected by what
’
s happening?
”Chochinov, H, 2007
Slide32Promoting Resilience
• Assess for prior strengths and life challenges. –What have you overcome previously like this?
–What has helped in the past?
–How do you cope with adversity?
• Engage the family and members of the treatment team.
32
Slide adapted from Mitch Levy,
Univ
of Washington
Slide33Anxiety in Palliative Care
Ranges from 6.8-13.2% and is most often comorbid with depression
Prevalence increases with advanced disease and decline in physical status
Includes fears of clinical course, treatment outcomes, death, social stigma, and/or physical symptoms (such as dyspnea or pain)
Women, more physical impairment and younger patients with advanced cancer were more likely to develop anxiety disorders
A trusting physician-patient relationship is critical to minimize patient shame, humiliation, and power imbalance
33
James L Levenson, M.D., 2005, Wyszynski, 2005, LW Roberts 2004, Spencer 2010, Mitchell 2011
Slide34Causes of Anxiety in Palliative Care
Preexisting anxiety disorder
Anxiety symptoms can be caused by various untreated medical complications
Hypoxia
Pain
Medication side effects
Substance withdrawal
Pulmonary embolism (PE)
Electrolyte imbalance, Dehydration
Fear of isolation and separation of death
34
James L Levenson, M.D., 2005,Wyszynski 2005
Slide35Anxiety Treatment in Palliative Care
Benzodiazepines
Multiple routes of administration (PO, IV, IM or PR)
Neuroleptics may be safest when there is a concern of respiratory depression
Multiple routes of administration (PO, IV, or IM)
Supportive psychotherapy, guided imagery, and hypnosis
SSRIs of limited value in patient when life expectancy is only a few days to weeks
There is lack of evidence for effectiveness of drug therapy in this patient population
35
James L Levenson, M.D., 2005, Salt 2017
Slide36Anxiety and Cancer
Common at start of treatment, recurrence, progression or at follow-up visits
30%
of patients had clinical anxiety after diagnosis of cancer
3-10% PTSD in patients
with breast cancer
Multiple potential medical etiologies of anxiety symptoms
NauseaAkathisia
PEPain
36
MH Antoni 2006, JL Levenson 2005, Cardoso 2015
Slide37Anxiety and Cancer
Treatment
SSRI remains the primary approach to generalized anxiety and prevention of panic attacks
Short term use of Benzodiazepines are well tolerated, safe and effective drugs for anxiety.
Anterograde amnestic properties help to lessen the negative impact of cancer treatment experiences.
Short acting BZD may be used for procedure related anxiety, anticipatory anxiety, or specific phobias
Non-BZD drugs reduce risk of abuse or dependence
Gabapentin, beta blockers, Buspirone and Hydroxyzine found to be helpful for anxiety.
37
SM
Thekadi
2015
Slide38Mania in Cancer
Recurrence of pre-existing illness
Steroids
Infection
Diencephalic tumors
38
JL Levinson, 2005
Slide39Mood Stabilizers
Help with impulsivity, irritability and temper dysregulation.
Also treat neuropathic pain, hot flashes and seizure prophylaxis
Lithium: rarely started in the cancer context
Risk of dehydration, electrolyte abnormalities, renal dysfunction, and drug interactions.
Valproic acid and Carbamazepine: helpful for mood stabilization. Carry risks of hematological suppression and hepatotoxicity
39
SM
Thekadi
2015
Slide40Mood Stabilizers
Gabapentin or Pregabalin:
Helps manage hot flashes, neuropathic pain and postherpetic
neurolgia
Has anxiolytic and sedative effects
No Cyp450 interaction. Cleared renally.
Oxcarbazepine: Recent open label study showed it may be helpful in prevention of oxaliplatin-induced neuropathy.
40
SM
Thekadi
2015
Slide41Psychosis and cancer
Primary psychosis
Delirium
Psychosis due to medical condition
Medication induced psychosis
41
SM
Thekadi
2015
Slide42Antipsychotics
Side effects of select antipsychotics can help target symptoms common to cancer patients. Symptoms include anxiety, nausea, hiccups, loss of appetite, and insomnia.
Haloperidol continues to be gold standard for delirium
New RTC shows that lorazepam + haloperidol provides superior control to agitated delirium in advanced cancer patients
Aripiprazole may uniquely be activating for hypoactive delirium
Recent meta-analysis showed a 50% reduction in postoperative delirium for elderly patient given prophylactic antipsychotics
42
SM
Thekadi
2015
Slide43Antipsychotics
Antipsychotics may be preferred to BZD for acute anxiety. Less risk of AMS and respiratory depression.
Low dose quetiapine or olanzapine may be used for insomnia when sedative hypnotics are deemed too risky.
Haloperidol and chlorpromazine may be used for intractable hiccups
Haloperidol and olanzapine may help with nausea
Olanzapine is efficacious for chemo induced nausea and vomiting
Olanzapine and quetiapine helpful for weight loss and anorexia.
43
SM
Thekadi
2015
Slide44Bereavement and Grief
Bereavement:
Situation in which someone who is close dies
Grief :
Natural response to bereavement
Feelings:
Some may experience shock, sadness, anger, anxiety, disbelief, panic, numbness,.
Physical:
Insomnia, fatigue, loss of appetite, nausea and pain.
Behaviors:
Substance use, less attention to self care, impulsive or harmful behaviors
Stages of Grief:
Denial, Anger, Bargaining, Depression, Acceptance.
44
Slide45Bereavement and Grief
Anticipatory Grief
Draws family closer
Acute Grief
Numbness
D
istress
D
isorganization R
eorganization
R
ecovery and progression
Complicated GriefComplicated by depression, anxiety, and substance use
Chronic Grief
Social withdrawal and isolation along with a fantasy of reunion may lead to suicidal ideation
Traumatic GriefOften complicated by the inability to communicate “good-bye”45
James L Levenson, M.D., 2005, LW Roberts 2004
Slide46Delirium in Palliative Care
Prevalence of
62
-88% especially in the last weeks of life
Rates of cognitive impairment rise just prior to death in up to 62% in cancer patients
Terminal delirium has a 88% prevalence before death
In one study 54% recalled their delirium after recovery
The biggest risk factor for distress during episodes of delirium are the presence of delusions
Delirium may not be reversible in the last 24-48h of life (terminal delirium)
46
JL Levinson 2005, Y.
Alici
2009
Slide47Delirium in Palliative Care
There are 2 subtypes of Delirium to consider
Hyperactive
– Easier and more commonly diagnosed type. Characterized by restlessness, agitation, hypervigilance, hallucinations and delusions.
Hypoactive
– More difficult to diagnose. Characterized by psychomotor retardation, lethargy, and reduced awareness of surrounding. Often misdiagnosed as depression or severe fatigue.
In a hospi
ce setting 29% of 100 acute admissions were found to have delirium, of these 86% of them had hypoactive delirium.
Hypoactive subtype has a higher risk of mortality compared to hyperactive subtype.
47
Y.
Alici
2009
Slide48Delirium
(continued)
Variable rates of resolution
One study showed a 68% improvement rate despite 31% mortality in 30 days
Another study a cause was found in 43% and 1/3 improved
Another study showed that 50% of episodes of delirium in the last week of life were reversible
Potential causes of delirium in the terminally ill often include…
Dehydration
Psychoactive or opioid medications
Hypoxia
Other metabolic derangements
48
JL Levinson 2005
Slide49Substance misuse/use disorders in Oncology and Palliative Care
Opiates are frequently used in these populations.
Screenings for substance misuse and or use disorders are infrequent (less than half according to a recent survey; Tan 2015).
Even fewer palliative care clinics have policies regarding the issue of substance misuse despite the staff reporting to have received training in managing substance misuse or use disorders.
49
Slide50Substance misuse/use disorders in Oncology and Palliative Care
Passik
and
Portenoy
1998 have developed guidelines for the management of patients with aberrant drug taking in terminal and oncologic patients.Primary goals in these guidelines are harm reduction and patient compliance
Some of their recommendations include
Consideration of a written contract between the team and patient
Inclusion of spot urine toxicology screens to assess complianceSet expectations regarding attendance at the clinicManagement of medication supplies
50
Slide51References
1
)
Y.
Alici
& W. Breitbart
,
Delirium in Palliative Care, Primary Psychiatry. 2009, 16:42-48 2)
M.H. Antoni, et., al., Reduction of Cancer Specific Thought Intrusions and Anxiety Symptoms with a Stress Management Intervention Among Women Undergoing Treatment for Breast Cancer
, Am J Psychiatry, 2006, 163(10): 1791-97.
3) KM Brintzenhofe-Szoc, et.al.,
Mixed Anxiety/Depression Symptoms in a Large Cancer Cohort: Prevalence by Cancer Type
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Graca
, J.,
Klut, C., Trancas, B., & Papoila, A. (2015). Depression and anxiety symptoms following cancer diagnosis: A cross-sectional study. Psychology, Health & Medicine, 21(5), 562-570.5) Desmarais, J. E., & Looper, K. J. (2010). Managing menopausal symptoms and depression in tamoxifen users: Implications of drug and medicinal interactions. Maturitas, 67(4), 296-308. 6) Emanuel, E. J., Onwuteaka-Philipsen, B. D., Urwin, J. W., & Cohen, J. (2016). Attitudes and Practices of Euthanasia and Physician-Assisted Suicide in the United States, Canada, and Europe.
Jama, 316(1), 79.
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Slide52References
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Dibaj
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Jama,
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14) S. L.B Muller, et., al.,
Psychiatric Sequele Following Breast Cancer Chemotherapy: A Pilot Study Using Claims Data, Psychosomatics, 2005, 46(6):517-522.15) LW Roberts and AR Dyer, Caring for People at the End of Life in, Concise Guide to Ethics in Mental Health Care, APA Publishing, Washington DC, 2004: 185-9516) Salt, S., Mulvaney, C. A., & Preston, N. J. (2017). Drug therapy for symptoms associated with anxiety in adult palliative care patients. Cochrane Database of Systematic Reviews.17) J.R. Satin et., al.,
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Pirl
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Takechi, et., Al.,: Somatic Symptoms for Diagnosing Major Depressive Disorder in Cancer Patients,
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Antoinette Wyszynski and Bernard Wyszynski,
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Fairman, Nathan; Irwin, Scott. Palliative Care Psychiatry: Update on an Emerging Dimension of Psychiatric Practice. Current Psychiatry Rep.2013 15:374
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Portenoy
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53