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

Existential distress—overlapping with spiritual distress, demoralisation and loss of meaning—produces substantial suffering for patients facing life-threatening illness (LTI). Prior research indicates limited effectiveness of conventional pharmacological and psychotherapeutic approaches in this population, and recent Phase II studies of psychedelic-assisted therapies (PAT) such as psilocybin, MDMA and ketamine have shown promising reductions in depression, anxiety and fear of death in patients with cancer, with some trials reporting benefits persisting in 60-80% of survivors at six months. Despite encouraging early efficacy signals, stigma around psychedelics and limited clinician education remain barriers to broader clinical uptake, and how PAT might be integrated into multidisciplinary palliative care practice is underexplored. Niles and colleagues set out to characterise attitudes among palliative care clinicians toward current treatments for existential distress and toward PAT as potential interventions for distress associated with LTI. To do so they conducted a qualitative study using semi-structured interviews of a multidisciplinary US sample, aiming to identify common themes about existing practice, perceived gaps in care, and opportunities or barriers for PAT integration into palliative care.

The investigators used qualitative semi-structured interviews with palliative care clinicians across the United States, recruiting between May 2019 and August 2020 by purposive and snowball sampling. Participants were drawn from multiple disciplines: physicians, advanced practice nurses, chaplains, psychologists and social workers. Recruitment did not select for prior knowledge or positions regarding PAT; informed consent was obtained and participants were not directly compensated (one participant received a post-study gift card by random draw). Recruitment continued until thematic saturation was reached. An interdisciplinary team developed the interview guide, focused on two questions: clinicians' perceived role in identifying and treating existential distress, and their attitudes toward PAT for existential distress in LTI. Interviews, conducted by a single interviewer via phone, Zoom or in person, lasted 32–52 minutes. Audio recordings were transcribed, de-identified, and supplemented by a post-interview online survey capturing basic demographics and clinical background. Analysis used a grounded theory approach with transcripts uploaded to Dedoose software (v8.3). Open coding was performed by two team members to develop initial themes; subsequent interviews were coded iteratively by additional coders with regular meetings to resolve discrepancies and ensure inter-rater agreement. After code grouping and theme finalisation, themes and representative quotations were sent to a subset of five participants for thematic validation, with a criterion of ≥0.78 agreement for each theme and subtheme. Thematic saturation was reported after 19 interviews.

Nineteen clinicians were interviewed: seven physicians, four advanced practice nurses, four chaplains, three social workers and one psychologist. No participant reported prior clinical experience delivering PAT and two reported no prior awareness of PAT. Four major themes and 15 subthemes were identified; all four major themes and 13 subthemes met the study's validation criteria. Theme 1: Existential distress is common and frequently insufficiently treated. Participants described existential distress as arising both in anticipation of dying and earlier in illness when functional or role losses occur, and as distinct from, though related to, psychiatric disorders. Factors linked to refractory distress included late referral to palliative care, pre-existing psychiatric illness or trauma, young age (especially parents of young children), social isolation and limited family or financial resources. Clinicians working in smaller or under-resourced settings reported constrained time, staffing shortages and lack of specialty interventions as barriers to adequate care. Theme 2: Existential distress is primarily framed as a psychosocial–spiritual problem that eludes medicalised approaches. Across disciplines, treatment was described as falling within the palliative remit but enacted through therapeutic interpersonal techniques—active empathic listening, non-judgmental exploration, meaning-centred interventions—and by referral to specialist spiritual care or psychotherapy for complex cases. Respondents noted limited pre-specialisation training in existential distress among physicians and advanced practice nurses and emphasised multidisciplinary roles in management. Theme 3: PAT are perceived to hold promise but clinicians want a stronger evidence base. Many respondents endorsed the potential of PAT to facilitate meaning-making and to serve as a late-line option for refractory cases, and some viewed PAT as preferable to interventions such as palliative sedation or physician aid-in-dying in particular contexts. Reservations were common: a need for larger trials and more education, concerns about stigma toward patients and providers, fears about precipitating relapse in people with substance use histories, and worries about persistent psychological harm from dysphoric experiences. Attitudes varied by agent, with more negative views toward LSD and more positive views toward psilocybin and ketamine. Key safety considerations raised included screening for cardiac disease and histories of mania or psychosis, skilled supervision during psychedelic sessions, and longitudinal psychotherapy-based integration. Theme 4: PAT do not fit current treatment models and multiple implementation barriers remain. Clinicians struggled to define for whom, when and where PAT would be appropriate—questions included whether to offer PAT early or late in disease, inpatient versus hospice settings, and how psychiatric comorbidity should affect eligibility. Respondents suggested geographic and cultural variability in interest (greater interest reported in West Coast and Northeastern settings), expressed concern that PAT may be cost-prohibitive and therefore inaccessible to underserved populations, and noted that some religious or cultural groups might reject PAT. Several participants highlighted a potential narrow ‘‘window’’ of suitability, where patients are sufficiently distressed to need PAT yet medically and psychiatrically stable enough to tolerate the intervention.

Niles and colleagues interpret their findings as indicating that palliative care clinicians view PAT as a promising addition for treating refractory existential distress but that adoption will require stronger evidence, education and careful integration into existing practice. The study emphasises palliative care's interdisciplinary culture and clinicians' preference to broaden roles within the palliative team—particularly by incorporating psychiatric and mental health expertise—rather than outsource existential distress care. Respondents expressed interest in training within palliative departments and in preserving meaning-focused approaches when integrating PAT. The authors suggest targeting research to populations most likely to have refractory distress—such as younger adults and those with trauma histories—or linking referral triggers to specific disease milestones (recurrence, hospice enrollment, transition to phase I trials). They caution that the same characteristics associated with refractory distress may also render patients ineligible or vulnerable during PAT, creating a potentially narrow eligibility window. Integration strategies recommended include pairing PAT with established meaning-oriented psychotherapies and explicitly involving spiritual care providers in preparation and integration sessions. Stigma and misconceptions emerged as important barriers. Although some clinician concerns mirror contemporary trial exclusion criteria (for example cardiac risk or history of psychosis), others—such as fears that PAT will cause substance use relapse or persistent psychological harm—do not align with modern controlled-study safety data. The authors argue that education is needed to correct misconceptions and promote evidence-based understanding of PAT risks and benefits. The investigators acknowledge limitations: convenience and snowball sampling may bias findings toward particular institutional cultures, attitudes may not generalise beyond the US, the sample skewed younger and less experienced (potentially more favourable toward PAT), and racial diversity in the sample was minimal. Strengths include multidisciplinary sampling and grounding discussions of PAT within current standards for treating existential distress. The authors conclude that further clinical trials, educational outreach, clarification of contraindications and attention to equitable access are required before PAT can be widely adopted in palliative care settings.

Palliative care clinicians describe existential distress as a frequent and meaningful source of suffering for patients with life-threatening illness, and they view PAT as a potentially valuable option for refractory cases. Wider adoption will depend on larger trials to define efficacy and contraindications, educational efforts to address stigma and misconceptions, and careful integration that preserves meaning-focused, interdisciplinary care. Ensuring equitable access and including spiritual and mental health providers in research and clinical delivery are highlighted as necessary steps to facilitate responsible integration of PAT into palliative care.