The World Health Organization defines palliative care as “the active total care of patients whose disease is not responsive to curative treatment” (World Health Organization [WHO] 2024). Although this definition emphasizes comprehensive care, palliative care continues, in many clinical settings, to be interpreted primarily through the lens of physical symptom control. Such a reductionist perspective overlooks the reality that suffering in advanced illness is inherently multidimensional, encompassing biological, psychological, social, spiritual, and existential dimensions that require formal recognition, structured assessment, and targeted clinical interventions (Breitbart and Chochinov Reference Breitbart and Chochinov2023). Within this context, palliative psychiatry, conceived as a biopsychosocial–spiritual–existential approach to care, has become increasingly relevant as an essential component of high-quality palliative and supportive care.

This perspective converges with Cicely Saunders’ concept of “total pain,” which recognizes that physical suffering cannot be separated from emotional distress, social disruption, spiritual suffering, and loss of meaning. Fairman and Irwin (Reference Fairman and Irwin2013) describe palliative care psychiatry as an emerging subspecialty situated at the intersection of psychiatry and palliative medicine, emphasizing its role in delivering comprehensive, person-centered care. More recently, Shalev et al. (Reference Shalev, Brenner and Carlson2024) characterized palliative care psychiatry as a growing field dedicated to improving the mental health and overall well-being of patients with severe medical illnesses and their caregivers. Together, these contributions reinforce the idea that psychiatric expertise should not be viewed as ancillary within palliative care, but rather as a necessary response to the complexity of suffering experienced by patients and families confronting advanced illness and the end of life.

Psychiatrists are fundamental members of interdisciplinary palliative care teams not only because of their expertise in diagnosing and treating mental disorders but also because of their capacity to understand and therapeutically address the subjective experience of suffering associated with illness, progressive dependency, loss of autonomy, and the proximity of death (Fairman and Irwin Reference Fairman and Irwin2013; Shalev et al. Reference Shalev, Brenner and Carlson2024). Emotional and existential symptoms in advanced illness are frequently underrecognized or mistakenly interpreted as inevitable reactions to terminal disease. Conditions such as depression, anxiety, delirium, hopelessness, demoralization, existential distress, and a desire to hasten death can substantially intensify suffering, impair decision-making and treatment adherence, compromise quality of life, and negatively affect both family functioning and professional caregiving (Breitbart and Chochinov Reference Breitbart and Chochinov2023; O’Malley et al. Reference O’Malley, Blakley and Ramos2020).

Within this framework, psychiatry occupies a central role in palliative care by helping differentiate adaptive emotional responses from clinically significant psychopathology, while also distinguishing psychiatric disorders from the physical manifestations of advanced disease and differentiating conditions such as delirium from psychosis (Griffith and Norris Reference Griffith and Norris2012). This diagnostic expertise is particularly important in medically complex patients, in whom cognitive, emotional, and somatic symptoms frequently overlap. Symptoms such as fatigue, anorexia, insomnia, cognitive slowing, or reduced energy may derive from disease progression, medication effects, delirium, depression, or combinations of these factors. Accurate psychiatric assessment may therefore substantially influence clinical management, quality of life, and end-of-life decision-making (Breitbart and Chochinov Reference Breitbart and Chochinov2023; Terçariolli et al. Reference Terçariolli, Rosa and Vieira2024).

The role of psychiatrists in palliative care is consequently broad and multifaceted. Core responsibilities include the assessment and diagnosis of mood, cognitive, and behavioral disturbances in medically ill patients, often in clinical contexts complicated by medications, metabolic abnormalities, neurological involvement, or disease progression. Psychiatrists contribute to psychopharmacological management through the careful use of antidepressants, anxiolytics, antipsychotics, and psychostimulants adapted to medically fragile populations. They also provide psychotherapeutic interventions such as supportive psychotherapy, meaning-centered therapy, and dignity therapy, while playing a central role in delirium management, assessment of decision-making capacity, and ethical deliberation surrounding end-of-life issues, including assisted dying where legally applicable (Shalev et al. Reference Shalev, Brenner and Carlson2024). Beyond direct patient care, psychiatrists support individuals confronting fear, grief, demoralization, and existential suffering, while also assisting families coping with anticipatory grief and caregiving burden. Their contribution further extends to healthcare teams themselves through the prevention and management of burnout, compassion fatigue, and moral distress. In this sense, psychiatrists function not only as mental health specialists but also as integrative clinicians working collaboratively with physicians, nurses, psychologists, social workers, chaplains, and other professionals within multidisciplinary palliative care teams (Shalev et al. Reference Shalev, Brenner and Carlson2024).

At the same time, it is important to distinguish between the complementary roles of psychology and psychiatry in palliative care. O’Malley et al. (Reference O’Malley, Blakley and Ramos2020) emphasize that psychologists and psychiatrists both contribute essential expertise, although their roles are not interchangeable. Psychologists primarily provide psychotherapeutic and psychosocial interventions focused on emotional adaptation, coping strategies, communication, and psychosocial support. Psychiatrists, by contrast, contribute medical expertise in psychiatric diagnosis, psychopharmacological treatment, delirium management, suicide risk assessment, evaluation of decision-making capacity, and the management of complex neuropsychiatric and behavioral conditions in medically ill patients. Both disciplines are indispensable for addressing emotional suffering and improving quality of life, but psychiatry plays a distinctive role in clinically complex situations where biological, psychological, cognitive, pharmacological, and existential factors intersect.

Despite growing recognition of this multidimensional model, psychiatric care remains inconsistently integrated into palliative services in many healthcare systems. Structural barriers include insufficient inclusion of mental health professionals within interdisciplinary teams, inadequate reimbursement models, lack of standardized mental health assessment protocols, and limited training opportunities in palliative care psychiatry (O’Malley et al. Reference O’Malley, Blakley and Ramos2020). These limitations contribute to fragmented or delayed access to psychiatric expertise and to the undertreatment of psychological and existential suffering in advanced illness.

From both clinical and organizational perspectives, effective integration between palliative care and psychiatry is associated with improvements in quality of life, communication, treatment adherence, and alignment of care with patients’ values and preferences (O’Malley et al. Reference O’Malley, Blakley and Ramos2020; WHO 2024). Within this context, consultation–liaison psychiatry is particularly well positioned to function as an effective interface within the biopsychosocial and spiritual model of care because it routinely addresses the complex interactions between physical illness, emotional distress, cognition, ethics, communication, and family systems (SEPSM 2024; Terçariolli et al. Reference Terçariolli, Rosa and Vieira2024).

The report produced by the Working Group on Psychosomatic and Liaison Psychiatry of the SEPSM further reinforces this perspective through its critical analysis of Orden SND/1427/2023, which establishes the framework for Diplomas of Accreditation in Palliative Care. According to the report, although the regulation seeks to standardize competencies in palliative care, it fails to explicitly recognize the role of liaison psychiatry despite its substantial overlap with the competencies required within the accreditation framework (SEPSM 2024). The report argues that competencies such as psychological assessment, management of bioethical dilemmas, interdisciplinary teamwork, communication, and attention to sociocultural and spiritual suffering are already integral to consultation–liaison psychiatric practice. The absence of formal recognition therefore risks marginalizing psychiatric expertise while creating inconsistencies in training and competency recognition within palliative care systems.

Overall, the literature consistently supports a person-centered, integrative, and interdisciplinary model of palliative care in which mental health, and psychiatry in particular, is not regarded as ancillary, but rather as a structural and indispensable component of high-quality care (Fairman and Irwin Reference Fairman and Irwin2013; Griffith and Norris Reference Griffith and Norris2012; O’Malley et al. Reference O’Malley, Blakley and Ramos2020; SEPSM 2024; Terçariolli et al. Reference Terçariolli, Rosa and Vieira2024). Dedicated education and training in palliative care psychiatry are therefore essential to support multidisciplinary teams capable of addressing the full complexity of suffering at the end of life. A truly comprehensive palliative care model must recognize that relief of suffering requires not only control of physical symptoms but also expert attention to the emotional, cognitive, relational, ethical, spiritual, and existential dimensions of human experience.