What is Palliative Psychiatry with Dr. Daniel Buchman

[Music] Today's episode is a little different from our usual conversations. We're still talking about mental health treatment, but this conversation leans more into the underlying philosophies of what we do the most. So it feels a little less like,"Here's a clinical technique that you can use on Tuesday, and a little more like, how should we think about the hardest corners of care that is very much by design?" What do clinicians do when treatment is technically available, but it's not helping the person in front of us? My guest works in bioethics, and we spend the first half of this conversation building toward a topic that's uncomfortable, clinically important, and easy to misunderstand. Palliative, psychiatry. This is not a conversation about giving up on people. It's a conversation about suffering, quality of life, the limits of medicine, and how clinicians might think more carefully when the usual treatment framework is not working. Today's episode, we talk about how my guest got into bioethics, the role of clinical ethicists in hospitals, how palliative care principles might apply to serious and persistent mental illness, and why the word futility carries so much weight in mental health care. But first, if you're new here, I'm your host, Dr. Dan Cox, a professor of counseling psychology at the University of British Columbia. This is psychotherapy and applied psychology, where I talk with leading researchers about what matters in practice, what's behind the findings, and what they wish clinicians new sooner. And if you enjoy the show, please subscribe when your podcast player or on YouTube, like and subscribe. That small click makes a surprisingly big difference. This episode begins with the story of how my guest found his way into bioethics, including a powerful early experience that brought together memory, trauma, suffering, and the question of what medicine is for. So without further ado, here's my conversation with Dr. Daniel Buckman.[MUSIC] I've long been interested in ethical and social issues that arise in healthcare. I think when our around the dinner table growing up, I have a parent who's a healthcare professional. And so hearing things such as bowel movements or blood or things that are happening with the human body, or things that are just happening in the healthcare system generally, was something that was very much part of my environment growing up. And kind of just sort of had a language that we sort of talked about this every day. You know, my father who's a healthcare professional also very committed to issues around social justice, and other sort of values in healthcare. And so I think that was very much as part of our like, again, dinner time or everyday conversation as well. So it was very much absorbed into me and my family growing up. And then when I was in undergraduate, I was an undergraduate student. I was in a program called Social Studies of Medicine. And within social studies of medicine, we took a range of classes, medical history, medical anthropology, medical sociology, and bioethics. And the bioethics class absolutely blew me away. We were talking about issues that were coming up in research, in practice, these like really thorny dilemmas. I was like, this is a thing. Like you can actually think about these things and study these things. We learned about scandals like the Tuskegee syphilis study or the Willow Brook study or the Nazi medical experiments. And aside from being a completely sort of appalled of what human beings are capable of, in the name of science, in the name of medicine, I was sort of just fascinated that this was sort of an area of exploration. And sort of around that time, I was taking a class in neuroscience. I think it was more in like behavioral neuroscience. And the professor I had, Dr. Kreeb-Nader actually, he was doing some really interesting work on condition place preference. And also sort of this like this condition, this conditioning experiments where he'd put two rats in a cage. And or he put a rat in a cage and he would pair a light with an electric shock. And then, you know, the follow-up would be, and he would measure like the the startle response in the in the rat or on their paws. And then he would show, if I've got these experiments correct, a light. And now that's paired with the shock. And so the rat would still exhibit a startle response, but not be actually be shocked, right? So there's a classic design, experimental design, in condition. And what he was interested in is if there was a way to erase or even eliminate or dampen the emotional impact of these rats' fear memories. So he, I believe, gave these rats per per analogue, which is a beta blocker. And actually found when he then presented these rats who had been shocked with the light, before the light and then paired with the shock, just the light, who were given per per analogue, they showed a diminished fear response. And I was like, this is fascinating. This has so many sort of ethical, like, considerations like, you know, this was done in rats, which has its own sort of set of issues, but with animals, but human beings. And so as I was sort of bitten by this bioethics bug, as an undergraduate, I was very fortunate to get a summer research job through the joints and for bioethics at the University of Toronto. And part of that was being paired with a clinical ethicist, so an ethicist who works in a hospital. And follow them around and do some, do like a project for the summer and ethics as an undergraduate student. So I was, I was placed at Baycrest Center for Geriatric Care in Toronto. And this at the time, I don't know if it's still the case, but at the time they had the sort of largest concentration of Holocaust survivors anywhere in the world, I think, outside of New York maybe. And I was following Dr. Marcia Sokolowski, who was the bioethicist there at the time. And we were on one of the units and we walked past this room of some room of a of a patient, an older, an older person, an older woman who had advanced stages of dementia and was having flashbacks. And she was having flashbacks to her time in the concentration camps. Terrible, horrible traumatic flashbacks. I was startled. And I couldn't believe what was happening. And there was something sort of within me being like, well, what can we do for this person? And it was sort of at that moment where I started to link this, what was going on in my behavioral neuroscience class at university and the experience of this person having a traumatic flashback. What if we, you know, were able to apply, gave her this person for Pranolol and dampen her traumatic memories. So she doesn't suffer. You know, I had been learning about sort of the goals in the ends of medicine and, you know, the duty to relieve suffering, to promote welfare, to relieve suffering, has been core values in healthcare and in medicine. Well, wouldn't relieving suffering in this person be something that we ought to do? And that's an ethics question. However, I was also learning concurrently around, you know, issues around post-traumatic growth or things around narrative identity. There are people, you know, in the world throughout history who had gone through unimaginable atrocities and have provided testimony about it, have been able to bear, you know, bear witness, been able to tell the world about how these horrible things based on their experiences. If we did that, if we were able to erase or even emotionally dampen the impact of the traumatic memory, might we also be impacting the ability to provide testimony about these atrocities? So these are fundamental ethics questions. What I focused on in my summer, from my summer research position. And so I continued to maintain interest of this, you know, I had wanted, you know, it's like, how do I do this? How do I become like a clinical ethicist? This was so fascinating to me. And I ended up doing a Master's in Social Work. I was also very interested in mental health and substance use. And I was also then became sort of very interested in ethics and social work. And I sort of trained to be an addictions counselor worked in areas such as first episode psychosis. And, you know, I had been so fascinated again by ethics. I started sort of see ethics everywhere. Ethics not just in like the big issues, but the everyday issues. The micro moments of working with someone who's experiencing severe and persistent mental illness. And we're meeting them, for example, maybe in their shelter or meeting them wherever they're happening to live, which may not necessarily be a house or an apartment, right? Some people were street involved or experiencing homelessness or inconsistently housed. And it's like there were questions, you know, that came up there too about should we force someone to take medication? Or maybe not force them, but how do we strongly persuade someone to do that who doesn't want to take it? But maybe it's because of the symptoms they're experiencing. Right? What are the trade-offs of, you know, medication or not or other options? What are the roles of the social determinants of health? So this also started to sort of build into my sort of overall interest in the everyday issues that came up in in healthcare and practice, but also broad more broadly, sort of in a systemic way. From there, I ended up taking a job out at West, at UBC, doing research in a neuroethics research group and was able to explore some of these ideas further. I then decided to stay on and do a PhD in bioethics where I got to explore ethical issues related to trust and chronic pain and substance use, working with some incredible mentors who I was just like, how do I get to be you one day? Like not like actually like, you know, take your job from you, but you know, how do I, how can I create that job for myself someday? Because I knew that they're, you know, in Canada, you know, and it's which is still the case, there are not many academic positions in bioethics that are available at these tenure track positions. There's, you know, a lot of clinical ethics roles and major sort of teaching hospitals, but not really many that combine the two. And so that's sort of what I had, I had never really had like a five year plan or really knew exactly what I wanted to do, sort of, but I knew that this was something that I was really excited about. This was a field that I wanted to be able to contribute to both from a clinical perspective in terms of supporting healthcare teams, patients, families, others in making really, really challenging decisions, but also explore some of these really tough thorny questions from a scholarly perspective and be able to contribute that way. So you said that you were working with a ethicist or bioethicist in a hospital. And that, so are there do lots of hospitals have experts on ethics on staff. And then to the follow up to that is like outside of academic academic academic research, where do bioethics folks work? Like what do they do? In Canada, to be accredited from a accreditation Canada, you have to have access to ethics resources or an ethics framework. And usually that means for a hospital to be accredited. A hospital to be accredited in Canada. The US also has certain accreditation standards with regard to ethics services within healthcare. I mean, there's really interesting histories there too of how this all came about, which we can get into if you'd like, but at the, but there is, in Canada, you have there are accreditation requirements. So an ethics is part of that accreditation requirement. So what you have in Canada is most teaching hospitals, academic hospitals, will have at least one ethicist or maybe a part-time ethicist. Some hospitals, some of the bigger ones will have teams of ethicists who might serve a wide range of hospitals or institutions that the organization has. So these are people who are, you know, they don't make ethical decisions for you, but their purpose is to support ethical decision-making process and enhance ethics capacity within organization. And that may be at clinical, so clinical level. So for example, a big part of what clinical ethicists do are what's called ethics consultation or healthcare ethics consultation. Right. And so if there's an ethical issue that comes up in patient care, let's say, you know, competing values between the patient and their family and the healthcare team, or maybe the healthcare team has a different values-based perspective than the patient, which has a completely different perspective than the family, but these are values-based disagreements. Let's say around things around clinical benefit or even harm, or terms like quality of life. And they're out of him pass. An ethicist can come in and work with all of these people who are sort of relevant to making the decision and supporting a decision-making. An ethicist might also work in what's called organizational ethics. And so that is helping to contribute to hospital policy, either drafting it or reviewing it and developing it as well. Not all hospital policies, but many hospital policies that might have sort of a moral dimension to it. That's important to consider, such even around like privacy and security matters, or, you know, in mental health institutions, such as covert administration of medication. So that's an important one that an ethicist may be involved in because issues of autonomy, of deception, of agency, all those things may come up. The ethicist is often also involved in education. So this may be for education for the organization to help build ethics capacity and knowledge, or they might work directly with clinical teams or groups. So let's say there's a really challenging issue coming up around discharging people and living at risk. So for example, that might mean a situation where a patient wants to go home from the hospital after a procedure, but the healthcare team feels that their environment is not, you know, quote unquote, safe for them and are worried about them going home. But the patient wants to go home. So you might have a conflict there between, you know, patient's autonomy and healthcare providers sort of duty to not cause harm, right? And so an ethicist can help sort of negotiate that and maybe provide some education around issues around those things or consent capacity and so forth. And also many ethicists are involved in research, not maybe as of their primary duties, but that's also something that they definitely contribute to. Right. Right. So your area, they're one of your areas of research that we're going to, there are an expertise that we're going to talk about today is palliative psychiatry. So how did you get into palliative psychiatry and then as part of that, what is it? So I've long been interested in ethics and mental health and this was something that I had come across through introduction from my colleague Dr. Sarah Leavitt, who is a psychiatrist and works on what's called an AC team in Toronto and AC stands for a sort of community treatment. And so these are people who likely experience severe and persistent mental illness, but also have sort of a lot of intersecting structural vulnerabilities as well. So they may also be experiencing homelessness, some of them, not all. People may also be disadvantaged due to gender, other sort of other structural determinants. And they're often people whose symptoms are very, very severe. They may also have what's called a community treatment order. So that's a very specific piece of legislation from the province that I'm in, where someone is essentially considered involuntary with respect to treatment, but instead of keeping them in the hospital, they're discharged to the community, but with sort of the idea that if anything sort of happens within the confines of the CTO, they can be brought back into the hospital involuntarily. This is part of the broader deinstitutionalization movement. So that's been happening sort of in North America since the '60s and '70s. So anyhow, so I was introduced to this through my colleague, but was also, I was noticing as I was also at the time I was working as an ethicist in an academic psychiatric hospital. And I was sort of struck by the fact that there were a lot of people who were very, very, very unwell. And they were really earnest and good attempts by the healthcare teams on helping to treat them, helping to do what they could. Some people had been in and out of care and involuntary admissions, you know, had tried every possible treatment, and was not necessarily experiencing any clinical benefits from all of those interventions over 20, 30 years. In some cases, it may have actually even been experiencing increasing harms from them. Also knowing some data that about 30% of people with diagnosed major depression have what's called treatment-resistant depression, or issues around what's so-called treatment-resistant schizophrenia. And seeing healthcare teams sort of being, you know, what we don't know what to do, we've been trying everything, this is really hard, patients sort of feeling very frustrated, families being really frustrated, being like, isn't there another way then sort of continue doing what we're doing, which is not helping with quality of life, suffering is not helping, and even sort of outcomes that, you know, we find that we, deep important, or that matter to us, we're not able to achieve, and we've been trying this for so, so long. And so I learned about this concept called palliative psychiatry, which is applying principles of palliative care that we might think of in physical medicine to serious and persistent mental illness. And so, you know, I was very intrigued by this as someone who was working within the healthcare system, but also as an ethicist, and it's not, can we apply these principles, which I don't know if we can, maybe we can, that's sort of a part of my research is trying to figure out, but also should we, and can, you know, should we transfer some of these principles to a psychiatric context? What might that look like? If so, what are some of the reasons why we might consider that? What are the reasons why we might not want to do that? Why that might not be a good idea? Is there, is that a neat transfer, or does it actually look like something else? And also, is this already happening in many places, like in the community, like people have been doing this for many years, and there's maybe things that we can learn from. Of course, while I was sort of getting into all of this, the major discussion that was happening, particularly in Canada, was around medical systems dying, in particularly medical school assistance in dying for people with mental illnesses, is so underlying medical condition. And so, that was very much in, in the background of all of this. And I want to say, like casting a shadow over it, but it was, it was part of the water we were swimming in. And some of the questions that I had, we're also coming up in that context, but I wasn't sort of, as I wanted to pursue this area, not necessarily thinking that this is part of that of medical assistance in dying, but actually, could this be a potentially another way? Could this be another sort of, another philosophy, like another philosophical approach, or philosophical approach to care, that's not quite treatment as usual, which is not providing any sort of benefit to people clinically or otherwise as they define it or made? So, just because I think that this is, because a lot of folks, just like I wasn't really, aren't going to be familiar with what palliative psychiatry is. Could you give sort of the easy to understand pithy definition of what palliative psychiatry, yeah, for listeners? For sure. So, it's, so I would say it's a working definition at this point. And part of my research is trying to figure out exactly what this might be. But essentially, it's applying sort of the holistic principles of palliative care to mental illness. It's looking at increasing quality of life. It looks at reducing suffering. It looks at sort of taking a very holistic understanding of the person's situation and working with them to help them live life in a way that they find most meaningful. It's life-affirming, so it's focused on how can people best live in this current situation that they find themselves in? And it works with symptoms as opposed to trying to eliminate them, although that could be part of a goal. It doesn't mean that curative approaches are off the table. So just like palliative care and physical health, people can have curative interventions alongside more comfort oriented or quality of life interventions. But the treatment philosophy has changed. So, what does this actually look like? That is to be determined. There are some groups that are starting to do this and starting to look at it and apply it. But it's still very early days and part of some of my work on more of the health services end is trying to figure this out. So what do you think the problem is that palliative psychiatry is trying to address that traditional, if that's the right word, that traditional psychiatry typically isn't focused on? So I think what palliative psychiatry does, at least for me and how I'm sort of conceiving of it or what I've been learning along the way from people with lived experience, from healthcare professionals, family members and others, really is that it raises a very uncomfortable question or idea about the limits of medicine. It raises issues around the potential limits of psychiatry. It doesn't mean that healthcare professionals are not trying their best or healthcare professionals aren't doing the best they can or doing whatever they can in order to meet the client's goals or improve their quality of life. But that there may actually be limits. And sometimes it can help raise questions about what are we doing and why are we doing it? Which I think is important in any area of healthcare, as really. But I've sort of found and what I've been learning is that sometimes those questions aren't always asked in mental health context. And there's very reasons why. There's various reasons that may be the case, right? Sort of the nature of various mental health issues, you know, issues around prognosis. These terms that have been coming off in the last number of years, which are like these very fuzzy terms, like erimedia ability, you know, we don't really, we don't have very good at prognosis. All of these ideas, it's like, so there may be sort of some, you know, some concern about some of that. But it really is, is what we're doing consistent with the client's goals of care? Is this going to help the person, the client or the patient's goals of care? Is this going to, is what we're doing, helping going to help the person live, you know, in a way that they find most meaningful? Is it going to help reduce their suffering? And is it going to help enhance their quality of life? And so I think that's what palliative side-ciatry, at least in this initial working definition, is trying to really get at. Yeah, I think that, you know, when we were talking a couple of weeks ago, so we're talking about this, it kind of hit me that it's just, it's a different framing, you know, like I have a, by training says a psychologist, but there's a lot of similarities there in certain ways. Just general mental health training is, right, what's the problem? How can we get rid of the problem? Right, like that's typically the focus and that, you know, oftentimes there are getting rid of the problem can include some uncomfortable, unpleasant processes, right? So like, whether it's side effects or medications or the difficulties of, you know, certain types of exposure or behavioral experiments or whatever those types of things are. But so, but the focus to orientation is on getting rid of the problem or reducing, shrinking the problem, which is just a different perspective than reducing suffering, right? And so like, if we take, if in certain cases, we focus on reducing suffering, that just naturally, what we're going to do is going to change clinically. Right. Yeah, so it is, I agree with you. It's that reorientation to the situation. It's trying to take a different treatment approach or philosophy to what's going on. Yeah, which is, I just think it sort of like clicked in that like, oh, this is an opening for like a new way of thinking about what we're, what our goal is with our clients and that you can see that in certain situations where one might determine and that we're about to get into this, that what they're suffering, that sort of, if there's some futility in trying to make this thing go away, that perhaps a different type of orientation would best help the client, would be the appropriate thing to do. So let's sort of get into that a little bit. So can you, can you sort of this term futility, you've done a lot of work on it and sort of this idea of what futility means in psychiatry? Could you just give us sort of the 30,000 foot of that to start with? Yeah, for sure. So I like to refer to futility as the F word because nobody really likes to say it and talk about it and it has a lot of baggage and a lot of meaning behind it. So futility, you know, at its core, what we understand from like physical health care is something that doesn't work, right? It doesn't work and there could be different reasons for why it doesn't work. So in there's a huge literature on futility in medicine, from physical medicine. And this largely started to come up in like the, you know, in the 60s and 70s as they were new advances in life-sustaining technologies for health care, where people were sort of being able to be kept alive or live longer with conditions that were previously sort of untreatable. And so these were these, so typically in the literature we think of futility in three different ways, although this is sort of at the basic level of what we might think about it, but there are other. So the first one is a quantitative futility. And the idea of quantitative futility is that, you know, something will not work, you know, in the last sort of 100 cases that a clinician may have seen or in the literature, it didn't work in, you know, in achieving its goals or objectives. In this case, that might be something that doesn't, it's not going to work. It's quantitatively futile. Another example might be something called physiological futility. So the easiest way I think to think about that is something that will have almost certainly no physiological effect if you, at treatment, if you give it. So, you know, if you give antibiotics for a viral infection, that is physiologically futile. Or if you give orange juice for to treat a heart attack, that's also going to be physiologically futile. It's not going to work from a physiological perspective. Then there's this idea of qualitative futility. And qualitative futility is more of a subjective interpretation from the person. So the person might think that, well, this treatment is not helping me contribute to a quality of life that I find reasonable or meaningful, or I'm, it's not allowing me to achieve certain goals. So it may be, it may not be quantitatively futile and it may not be physiologically futile. But from what my goals are, my goals of care are there's things maybe, it may be qualitatively futile. So, so an example of this may be in some like end of life contexts in hospitals where someone might be on life support or on respiration. And it's not going to cure their underlying condition. It's more or less going to keep them alive sort of for a very, very long time. So someone may say, well, actually that is, that is futile intervention in this case. But the person may say, well, actually, I want to have it because my family members coming in from out of town, I want to be able to say goodbye to them before I die. And so they may want to sort of continue with that particular intervention. So for them, that may not be something that's futile in that sense. So the question also that has come up and similarly with the questions that I've had around college psychiatry is, you know, can we and should we invoke futility in psychiatry? So if futility in psychiatry is something that is not talked about as much in the literature at all in comparison to medicine. And I'm not to say it's been sorted in physical medicine either. There's still tons of controversy around it, which is why I call it the F word, like when you bring it up and people sort of roll their eyes and go, like, you know, are they? But so the question I had is, you know, are people, you know, can you can't be and should we do this? And again, I was also noticing that maybe people were referring to futility in mental health, but not using the F word. They were saying things like treatment resistance or treatment refractory, which again, I'm going to just acknowledge that those are two also very contested terms. They're very much part of the broader sort of discourse around this, but there are very contested for various reasons, like exactly what it means or even the definition of those. You know, or people saying, oh, that person is a non-responder. Are we actually implying futility here? We're just not using that language because maybe there's too much sort of baggage associated with it. I don't know. But so I started to notice these things as well, where we've seen in the literature in mental health is in around futilities around anorexia nervosa, the most of it anyway. And I think that's largely because of the strong physiological component of the condition, where, you know, some treatments may be considered, you know, futile and whatever sense because of sort of the physiological sequelae that can come from the from the condition itself. So people have talked about it really in that context. For example, like continued tube feeding in someone with severe and enduring anorexia nervosa, right? You know, the person pulls it out or all the time, right? And there's risk associated with that. Or, you know, they're not even doing this for decades or for very many years. And it's not, you know, they're not able to gain any weight, right? So that's what we've seen in literature around anorexia nervosa. But I started to also wonder, you know, what does this, what might this look like in a mental health context are some treatments potentially futile for, for, and we're talking about situations of, you know, severe and persistent mental illness here. We're not, we're not like, I'm not talking about someone who may, you know, have a diagnosis of, you know, general anxiety disorder or depression, who's at sort of minor to moderate levels, of that. We're talking people who, you know, have severe mental illness and may, and may be considered sort of treatment refractory. However, that's sort of typically defined. You know, or, you know, the sort of this cold standard treatment, for example, for treatment resistance, schizophrenia, clasipine, right? So some people have what might be called clasipine resistance schizophrenia. And, and so that's really sort of what I was, I have been and my colleagues have been thinking about when it applies here to, to, to, to potential futility. And so, you know, because it's not spoken about a lot and people, you know, don't know what it means. It's sort of also, we're sort of trying to figure out, okay, does this exist and what might this look like? And if so, how should we approach it in a mental health context? You know, what benefit might it have and what drawbacks does it have? It was, so you and some colleagues, I don't know, it's in between like a dozen and 20 folks got together somewhere in the middle of Europe and you guys had like a two and a half day conference or two and a half day meeting. And you can correct me if I'm saying anything incorrect about this. And then it seems like there were several articles that sort of came out, but one of them that you sent me was an article by, I think the person who put the conference together or the meeting together, perhaps I should say, and there was really a trying to hit the highlights and the different perspectives that people, you know, had about these different aspects of futility. And in reading it, so one, I'll link it in the show notes, and I forget the author, you can, you can let folks know that. But the, in reading it, I had a couple of experiences, one of which was, wow, this person did a really good job of communicating some really complicated things in some relatively straightforward ways. So, I think it's very readable. Another was, and it was, it seems like this author is doing a good job of representing all of the voices. I don't know what your experience was being at the meeting, but that was what my experience was reading it. But then there was also a boy, I bet this was fun. Like, I bet there were some, there were some arguments that people felt pretty strongly on different camps about things. So I was just, as I was reading it, it's kind of a, you're kind of a fly on the wall, but not really. Because it's more just a generic reporting, and the author goes to lengths to, you can tell, to not disclose or not have any indication of who said what, right? So I was just curious, what your experience was being at that meeting, what that was like. Well, I, yeah, first, I first will say, like, yeah, kudos to Brent Kios and, and, and many of my colleagues who were tasked with putting together the, putting together the manuscript as a summary from that meeting because, yeah, it was with such diverse perspectives that was no easy task. So that was a very diplomatic way to say it, such diverse perspectives. That was good. It was very different. And understandably so, right? It's, this is a very controversial topic. People have a lot of strong moral intuitions about what futility is or isn't or whether or not it should or should not be applied in a mental health context. And so we, we expected that we had people, we had healthcare professionals, we had ethicists, we had philosophers, we had patient advocates, we had activists, and we really wanted that those diverse perspectives. So I was part of the planning group that that invited people to brought them together. And we really, we, we wanted people who we knew were sort of in favor of this concept. We also wanted people who were not in favor of this concept. And people who maybe were not sure yet. And I think that was also contribute to a really rich discussion. So what was my experience like? Well, it was incredible for various reasons. One is so we were very fortunate we applied for funding from the Roche Foundation in Geneva, Switzerland, which funds a lot of bioethics research. And we were sort of very fortunate to be able to be awarded funding to hold the meeting at their location at on Lake Geneva, which is just absolutely stunning. And I like cannot recommend it enough to anyone who has a chance to go is by the border of France. Like you just it's just the absolute privilege, you know, of a lifetime to be able to do that. And to get and get funding to go. So we were able to invite folks from all over the world. And it was really, you know, the discussions were difficult. They were really, really challenging, but that's so great. And it's just so rewarding. And we, you know, we didn't really come to a consensus, really, it's called a consensus statement, but it's very clear that we did not come to a consensus. And that's okay. But I think what was some of the benefit of that discussion is that we brought people together and to really start this conversation and ask these hard questions. So I'm a bioethicist. I don't dwell in easy areas or easy issues as I dwell in the gray. My job is to ask hard questions and to like explore them and also find ways to work with people who disagree and sort of try to figure out at this thorny or wicked problem together. And so that's what it really was our goal. And so it was incredibly rewarding on that respect. One thing we did discuss in the meeting, which it was a, it's a Delphi study that we have that we're doing right now that's under review at the moment. And so a Delphi study for those who may not be familiar is sort of a systematic approach. It's a research approach that attempts achieve consensus on a particular topic or issue. And so we did an international edelphi study to try to get some consensus on this concept of futility. And so we delphis involve multiple rounds and you ask a bunch of questions and people rate on like a one to five or one to set like a liquid scale. And there's, I'm not going to go into the details of the methodology, but there's ways that we after rating and you try to get a certain level agreement on each item and then you can modify the item based on the level of agreement. And then you include it in the next round. And people we also have open text boxes that people can write and elaborate on the responses. So all of that is sort of taken to consideration. And we, so what we've come up with is a bit of an algorithm, well not in like the AI algorithm sense, but more of like a decision tree algorithm to help support conversations around futility in mental health care. So and this is what's coming up from the findings of the Delphi and some of the discussions also that came from the meeting in Geneva. And really, you know, what I think futility, you know, means here at least my interpretation of it is that it's a signpost or an immoral intuition that something needs to change. Something's not working. And I think it provides a window or an door or whatever sort of analogy you want to use into of having a conversation about goals of care. And so goals of care is something that you know, again, borrowed from physical medicine, you know, typically discussed with people around end of life discussions, right? Like what are your goals, what are your values? Do this proposed treatment fit with that, right? We don't really do that well in mental health. I think goals of care discussion with people. And I'm not talking about people who are at the end of life because I think you can have goals of care discussion, no matter your stage of health or illness. It's like what matters to you? And as this particular intervention or treatment, meeting that goal, right, or your values. And so it's an opening for a conversation. So this is what this decision algorithm attempts to to highlight and open the space for shared decision making between the person who might be experiencing mental health symptoms and their health care professional, obviously bringing in family and others, you know, as they as they wish. And saying, look, you know, we've been on this, like for example, we've been on this treatment or set of treatments or combinations of treatments for X amount of time. Do you feel that it's helping your quality of life or meeting these outcomes that we've identified together that matter to you? And yes, maybe no, right? Or, hmm, you know, or we're, you've been asking to, like I've been providing this particular treatment. And, you know, I don't think it's helping. What do you think? Or here's the markers that it's not helping. So maybe, so what actually, so I use the word, it's not helping grandentially. So the lead author of that paper, my colleague, Brent Kayaus also had a really interesting paper that came out a couple of years ago where essentially he did a study of US psychiatrist on the issue of psychiatric futility. And there were two case vignettes. I believe someone with a diagnosis of borderline personality disorder and someone with a diagnosis of major depression. Anyway, he, the team asked a bunch of questions and one of the questions was, would you essentially provide any of these new treatments, like neuro stimulation, additional psychotherapy, other treatments? If you didn't think it would be helpful. And a not small percentage of psychiatrists reported that they would continue to provide these treatments or additional treatments that they did not think would be helpful. And that was, so they didn't use the term futility, probably very intentionally. But this was a sort of situation where it's like, oh, so why are people providing something that they don't think would be helpful? And I was like, is this, do they think it's going to be harmful? And what other area of health care would you say, well, I'm going to continue to provide a treatment that I don't think is going to help you because you want it. You know, is this sort of this perverse interpretation of autonomy or respect for autonomy? You know, what is it? Is it that we lack available tools for people or good evidence-based ones? I don't know, but that sort of struck me. And so I think this, so futility might be the signpost that can open an opportunity for conversation. Because if you, you know, what we looked at, like these sort of three definitions, or these three aspects of futility, like quantitative physiological, right? We don't have the same mechanism understanding of many psychiatric treatments, you know, that we do in physical medicine for why it may or may not work work. You know, I'm using work in here in quotations just because what does it mean for something to work? I think it's also a really important question of this conversation. You know, something may have a physiological response, but may not be symptomally beating, right? Or anyway, but so this is something that is sort of very still very underdeveloped in in psychiatry or in mental health care broadly. So anyhow, so the idea is that, yeah, so there's, so there this it may represent something for conversation, but it has a lot of baggage associated with it. So I don't know if that's the the best way to talk about it or think about it, but I think there's a there may be an opportunity there for to have these types of goals of care conversations. Well, one of the things there are a couple things that stood out in reading about psychiatric futility, but you know, one of them is sort of what you just said, which is the mechanisms of action in psychiatry aren't as clear as they are in some other areas of medicine. So to say, oh, that, you know, this drug won't work for like we do. There's just so much less clarity in terms of like why certain medications or treatments work that there it's difficult in many cases to say nothing's going to work because there's just so much more ambiguity there. You know, even in reading one of the papers that you sent me before this one of the things that they were talking about is like, okay, so a person even went into some sort of psychotherapy and that didn't work. And then immediately from my psychotherapy mind, it was, well, sure, but it could be that, you know, that could be for all sorts of reasons that doesn't mean that no psychotherapy would work for that patient, right? So it could be the psychotherapist. It could be this specific approach, you know, that when we're talking about somebody with, you know, schizophrenia or other psychoses, there's lots of different treatments, right? Psychotherapeutic treatments. And I had on the podcast, Mahesh Manan, they're doing all this really cool stuff with these like virtual reality stuff to represent voices and all these sorts of things, right? And so there's all these other like innovations that are happening. That to mention the patient is a human who's having a dynamic life experience. So the same thing, you know, something that didn't work today might be extremely effective 18 months from now, right? So there's like all this additional, these additional challenges in the psychiatric context that aren't always there in the more physical medical context that you guys are struggling with and trying to figure out within the context of utility. Yeah, and I think that's absolutely right. And that's part of the challenges that we're trying to sort of work through is like, well, what does it mean to say that we've exhausted all evidence-based treatments? You know, have we tried all of the psychotherapies, right? Should someone have even have to try all of everything, right? And is that even sort of possible? What's that? I guess that's a separate question. But yeah, what does it mean to sort of try everything? You know, there are new things coming down the pipeline. And so a question is, okay, so should we wait for some of these novel treatments to come out, which can take years? Maybe, maybe so. I'm not saying like either way. So that is part of that is a part of the question. And you know, we really hope that there are new treatments and effective treatments for people that come through so people can be helped. But you know, so I think part of this, the challenge of the futility discussion is sort of thinking of that trade-off. It's like, okay, so we can think of this in a sort of dynamic way, right? So this person being sort of best served right now. And it doesn't mean that it's like an irreversible thing where it's like we stop and then or whatever the decision is and then you can't go back or modify at all or it's like an all or nothing thing. It's fluid. It's dynamic. It's it's thinking of this, hey, like maybe this, you know, you've been doing X, Y, or Z for how many, you know, ABC years and, you know, this combination or set of combinations have clearly not achieved the outcomes that, you know, you've wanted or we've wanted together. You know, what's our, what are our alternatives and pathways here, right? Is this, do we, should we have these, anyway, should we stop, should we deep-rescribe, should we add something else, right? So I think it opens that conversation, sort of talking about what's what's working, but you're right. It's like someone may be on, you know, a medication that's not working right now and then it could potentially work 10 years from now. So it's so is that a, and I guess it's just a little gimmick question. It's like, is that a reason that we should continue to wait for someone where they're suffering right now is that should we say, well, let's wait another decade or another five to seven years or ever, or just see and continue doing what we're doing, but the person continues to suffer, the person continues to report that their quality of life is very, very poor. And so, you know, as a health care professional and again, as a question is like, should we ask someone to wait? Or should we, or maybe it's an opportunity to revisit the treatment philosophy and potentially return to it at another time and try again? So these are, again, the questions that we're, that we're thinking about. And I think this is such an important point to hit on, which is, and correct me where I'm wrong here, that, or if I misspeak, that, you know, I think that culturally we think, when we think of palliative, we think of end of life. That's a wrap on the first part of our conversation. 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