Palliative care: is it time for health professionals to talk openly about psychedelic therapy?

Existential distress at the end of life, termed 'total pain,' involves psychological and spiritual suffering that often does not respond to strong opioid medications. This distress resembles mental health conditions linked to an overactive default mode network (DMN), which includes the medial prefrontal cortex, medial temporal lobe, and posterior cingulate cortex—brain regions associated with the ego and more developed in humans. Patients facing early mortality may experience a crisis of meaning, leading to uncontrolled pain that opioids fail to alleviate. The text suggests that understanding the neural basis of existential distress could inform more holistic approaches in palliative care.

Study at a glance

Abstract

I’ve always been drawn to specialties where medicine can be practised holistically. It’s one of the reasons I applied for GP training and am currently undertaking a diploma in lifestyle medicine. My last post as a second-year GP trainee was a 6-month placement in palliative medicine at a well-known inner London hospice. While on this rotation, I came across patients who suffered with ‘total pain’, a term which describes the existential, psychological distress that is unique to those facing a terminal diagnosis. These patients were often young, and were understandably struggling to come to terms with their early mortality, leading to a crisis of meaning with thoughts of ‘Why me? Is there any sense to this life, to the universe?’ This distress manifested in uncontrolled pain, for which strong opioid medications would initially be prescribed and uptitrated, often with significant side effects. Yet often their ‘pain’ would not improve. Existential distress at the end of life often bears the hallmarks of other mental health conditions that are associated with an overactive default mode network (DMN). This is the area composed of the medial prefrontal cortex, the medial temporal lobe (amygdala and hippocampus), and the posterior cingulate cortex. These regions in our brains are often associated with the ‘ego’, and are far more developed in humans compared with other species. They are active by …