Integrating palliative and recovery-oriented perspectives: fostering innovative approaches in end-of life care for people with severe and persistent mental illness

Introduction

This editorial offers a conceptual synthesis of clinical models and ethical perspectives at the intersection of palliative care and psychiatry, rather than an empirical systematic review. Its aim is to explore how emerging approaches can illuminate persistent gaps and new possibilities in end-of-life care for persons with severe and persistent mental illness (SPMI).

End-of-life care for persons with SPMI is profoundly complex, ethically charged, and of increasing clinical importance. It encompasses a broad range of situations. On the one hand, it concerns individuals with SPMI who develop severe somatic comorbidities that progress toward terminal illness, requiring access to high-quality palliative care and advance care planning. On the other hand, end-of-life care also includes self-chosen end-of-life decisions such as suicide or mecal assistance in dying (MAID), including euthanasia and assisted suicide.

In several countries, including Belgium and the Netherlands, legal frameworks regulate these practices, though not without persistent moral, clinical, and societal debate among proponents and critics. Central to these discussions are questions concerning the incurability of mental disorders, the person’s decision-making capacity, and the roles of physicians and multidisciplinary teams in evaluating MAID requests (1). Similar ethical, legal, and clinical tensions continue to unfold internationally, notably in Canada.

This dual reality—palliative care for individuals with life-limiting somatic conditions alongside ethically contested forms of self-chosen death—reveals substantial gaps in both research and clinical practice. Persons with SPMI continue to face multiple barriers to adequate end-of-life support, including limited access to palliative services, insufficient professional training, fragmented care systems, self-stigma, and ongoing challenges in assessing decision-making capacity (2,3).

Addressing these inequities requires ethical reflection as well as innovative, person-centered care models that bridge psychiatry and palliative care. Such approaches must remain attentive to the lived experience of persons with SPMI while navigating the ethical limits of care at the end of life.

Persons with SPMI

Persons living with SPMI experience enduring psychiatric conditions that profoundly affect functioning and quality of life. These conditions typically include schizophrenia, bipolar disorder, major depressive disorder, and severe personality disorders (4). Approximately two to four percent of the population is affected by such disorders, representing a relatively small but highly vulnerable group (4).

The care needs of persons with SPMI are inherently multidimensional, encompassing psychiatric, somatic, social, and existential domains. Comorbid medical conditions such as obesity, diabetes, cardiovascular disease, and chronic pain are common, often related to medication side effects, reduced physical activity, and unhealthy lifestyle patterns. In addition, individuals with SPMI experience disproportionately high rates of social isolation, unemployment, homelessness, and suicide (5).

Over recent decades, integrated models of care—such as assertive community treatment (ACT), peer support, and supported employment—have demonstrated benefits for social inclusion, functional recovery, and quality of life (6). Despite these advances, end-of-life care remains a major blind spot within mental health services. Compared to the general population, persons with SPMI are less likely to receive palliative care, less likely to engage in advance care planning, and more likely to die prematurely (7). These disparities underscore the urgency of developing responsive, inclusive, and ethically grounded end-of-life care systems for this population.

Challenges in end-of-life care

Research has consistently identified several strategies that may improve palliative and end-of-life care for persons with SPMI. First, community-based initiatives can help lower access barriers for individuals who tend to avoid institutional settings (8). Second, strengthening both personal and professional support networks is essential, as many persons with SPMI have limited social ties and often receive fragmented or insufficient care. Third, the implementation of liaison functions between psychiatric and somatic services may help counteract the siloed organization that continues to characterize much of contemporary care delivery (9).

Finally, training initiatives that foster reciprocal competence in both psychiatry and palliative care are crucial. Such initiatives can promote mutual understanding between disciplines and support the delivery of more holistic, compassionate care (10).

In this context, several (Belgian) initiatives have explicitly placed palliative principles at the center of psychiatric care for persons with SPMI. In particular, the Reakiro model, Oyster Care, and the Resource Group (RG) method illustrate how innovative approaches can respond to these challenges by emphasizing quality of life, creativity in care, and person-centered decision-making. Together, these models demonstrate how palliative thinking can be meaningfully integrated into mental health care while remaining attentive to recovery-oriented values and ethical complexity.

Importantly, these approaches also engage directly with ongoing discussions on medical futility, the scope of palliative psychiatry, and the ethical limits of care, echoing perspectives previously articulated in this journal (11,12). They provide concrete examples of how existential, ethical, and relational dimensions of palliative care can inform psychiatric practice, offering alternatives to both therapeutic neglect and therapeutic obstinacy.

Reakiro: a Belgian pilot project for persons with a persistent death wish

Reakiro (www.reakiro.be) is a care and expertise center in Belgium for persons with SPMI who struggle with a persistent death wish or have requested euthanasia due to intolerable mental suffering. Developed between 2017 and 2020 by psychiatrists, psychologists, ethicists, and people with lived experience, Reakiro was founded on the conviction that a society permitting euthanasia for psychiatric suffering has a moral duty to provide specialized care for those who contemplate it.

Established in Leuven in 2020 through collaboration between the Brothers of Charity and KU Leuven University Psychiatric Center, Reakiro expanded in 2022 with a second site in Bruges. From the start, the model was accompanied by empirical research to evaluate outcomes and ethical implications.

The Reakiro model takes the death wish as the starting point of care, integrating existential, recovery-oriented, palliative, and presence-based approaches. It targets individuals facing long-term psychiatric conditions marked by trauma, chronic suffering, social marginalization, and loss of meaning. Many have experienced extensive but ineffective treatment, leading to ambivalence toward further care. Within Reakiro, persons can access information, individual and group counseling, existential therapy, and peer support rooted in palliative psychiatry and meaning-centered care. Core values include autonomy, dignity, connectedness, harm reduction, and shared decision-making.

The goal is not to eliminate the wish to die but to explore its complexity in a safe, nonjudgmental setting. Through dialogue, caregivers remain close to the person’s suffering, helping them navigate ambivalence and rediscover fragile possibilities for life. The multidisciplinary team includes psychiatrists, psychologists, psychotherapists, peer specialists, and volunteers, reflecting a deliberate blending of professional and experiential expertise.

Reakiro collaborates closely with existing treatment teams, palliative services, and euthanasia evaluation committees, employing a dual-track approach: support for continued living while respecting the legal right to euthanasia under Belgian law. The center itself does not perform or evaluate euthanasia but adheres to national guidelines framing it as a last-resort option requiring stringent assessment of medical hopelessness and decision-making capacity.

Recent empirical studies have begun to document outcomes. Quantitative findings show that participants frequently suffer from multiple psychiatric diagnoses—most commonly depressive, personality, and trauma-related disorders—and exhibit high rates of suicidality and existential distress (13,14). Qualitative studies reveal that being able to articulate the death wish within a supportive environment fosters self-understanding, connection, and sometimes a renewed will to live (15,16). Clinicians involved report greater comfort navigating ethical dilemmas and less inclination toward either therapeutic neglect or coercive optimism (17).

Reakiro thus exemplifies how palliative psychiatry can acknowledge unbearable suffering while maintaining an ethical commitment to presence, relationality, and autonomy.

Oyster Care: a palliative approach within psychiatry

Oyster Care, developed in Flanders (Belgium), offers another innovative model bridging palliative and psychiatric care. It emerged from the need to provide meaningful support to patients with treatment-refractory psychiatric disorders for whom traditional recovery-oriented approaches often prove inadequate. Without such models, patients risk falling into either therapeutic neglect—abandonment after failed treatment—or therapeutic obstinacy, where interventions continue despite futility (18).

Oyster Care applies a palliative philosophy to long-term psychiatric care, emphasizing comfort, dignity, and quality of life over cure. The model is explicitly holistic, encompassing four dimensions of care: physical (addressing somatic limitations), psychological (fostering comfort and emotional well-being), social (promoting structure and connection), and existential (cultivating meaning and purpose).

The name “Oyster” symbolizes protection and adaptation: caregivers form an “exoskeleton” around the person, allowing the environment to adapt to the patient rather than forcing the patient to adapt to the environment. This approach prioritizes stability and belonging, tailoring care dynamically to the person’s needs and capacities.

Implementation of Oyster Care has strengthened the identity of long-term psychiatric wards by offering a coherent, value-driven philosophy of care. The Monitor Crustatieve Zorg, a reflective tool developed collaboratively with stakeholders, enables self- and peer evaluation of care quality across dimensions such as somatic well-being, end-of-life care, and team structure.

Ongoing research examines the sustainability and transferability of the model within Belgium and beyond, including its potential applications in geriatric and disability care—sectors characterized by chronic vulnerability and complex comorbidity (19).

RGs

In contemporary mental health care, recovery-oriented practice has become a guiding framework for supporting persons with SPMI. Recovery is understood not as cure, but as the development of meaning, purpose, and self-agency despite the enduring presence of illness. William Anthony defined recovery as “a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and roles...a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness” (20).

Leamy and colleagues (21) later operationalized this concept into the widely adopted CHIME framework, identifying five interrelated processes: connectedness, hope, identity, meaning, and empowerment. These transdiagnostic processes have proven relevant across psychiatric populations (22). Recovery unfolds as a dynamic, relational process that moves individuals from hopelessness toward renewed engagement with life—a trajectory that closely parallels the existential dimensions of palliative care.

Building on this shared foundation, the RG method provides a structured way to operationalize recovery principles within integrated, person-centered care. Originating in Scandinavian and Dutch contexts (23), the RG method rests on three principles: I) patient empowerment; II) systematic involvement of significant others; and III) integrated collaboration across care systems. An RG is a network chosen by the patient—comprising family members, friends, and professionals—that jointly supports the person’s recovery goals. Meetings occur every three months, offering a consistent forum for shared reflection and decision-making.

The distinctive feature of the RG approach lies in its participatory ethos: decisions about care and life direction are made collaboratively among the person and their network, guided by principles of shared decision-making. Professionals, relatives, and peers are all recognized as co-experts, contributing from their respective roles. This structure not only distributes responsibility but also strengthens social inclusion, mutual understanding, and continuity of care (24,25).

Empirical evidence supports the method’s value. Studies have demonstrated improvements in empowerment, quality of life, and functioning among participants (26). Beyond clinical outcomes, RGs cultivate a culture of dialogue and presence—values that resonate deeply with palliative care philosophy. When applied in end-of-life contexts, RGs can facilitate difficult conversations about meaning, values, and preferences, ensuring that care decisions remain aligned with the person’s lived experience and relationships.

In essence, the RG method offers a bridge between recovery-oriented and palliative approaches: both honor the person’s autonomy while grounding care in relationships, dignity, and shared humanity.

Conclusion and recommendations

The Reakiro and Oyster Care models, alongside the RG method, demonstrate how palliative and recovery-oriented frameworks can complement each other in addressing the needs of persons with SPMI. These approaches show that even when cure is unattainable, care can remain deeply meaningful. Both Reakiro and Oyster Care emphasize presence, authenticity, and dignity, while the RG method translates these values into practical, collaborative structures that strengthen continuity and inclusion.

Together, they challenge the dichotomy between psychiatry and palliative care, illustrating that the two can converge toward a shared ethical horizon: alleviating suffering, fostering connection, and supporting existential growth at the end of life. By integrating palliative principles into psychiatric settings, these models open pathways toward more humane, person-centered, and ethically coherent care.

Yet substantial challenges remain. Persons with SPMI continue to face barriers to high-quality end-of-life care, including stigma, fragmented service systems, and limited training among professionals. Addressing these gaps demands concerted action across research, policy, and clinical practice. Future studies should focus on comparative international research that includes the perspectives of all stakeholders—patients, relatives, caregivers, and policymakers.

Such evidence can inform ethically robust, evidence-based strategies that guarantee dignity, continuity, and compassion at life’s end. Beyond the final stage of life, these insights can enrich the broader field of mental health care by affirming that palliative and recovery-oriented approaches are not opposites but allies. As the experiences of Reakiro and Oyster Care suggest, care at the threshold between life and death is also care for the meaning of life itself.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Eva Oldenburger and Johan Menten) for the series “Multidisciplinary and Holistic Palliative Care” published in Annals of Palliative Medicine. The article has undergone external peer review.

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-2025-aw-123/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-2025-aw-123/coif). The series “Multidisciplinary and Holistic Palliative Care” was commissioned by the editorial office without any funding or sponsorship. L.M. has received a grant for his PhD research from BOF KU Leuven. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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