Understanding and Addressing Mental Health Disparities and Stigma in Serious Illness and Palliative Care

Abstract

Patients receiving palliative care experience stigma associated with their illness, personal identity, and healthcare utilization. These stigmas can occur at any stage of the disease process. Varying stigmas combine to cause palliative care patients to feel misunderstood, contribute to treatment barriers, and further negative stereotypes held by clinicians. Stigma surrounding palliative care patients stems from complex intersections of varied access to resources, familial and physical environment, socioeconomic status, mental health and disorders, and identity characteristics. This article examines the relationship between mental health stigma and palliative care through three pathways: stigma and barriers existing within healthcare, the tendency of this stigma to undermine social support, and the deferral of treatment-seeking in response to stigma. Recommendations to address and diminish stigmatization are presented, including advocacy, increased research and assessment, and contextual and intersectional awareness. Clinicians are also encouraged to turn to their colleagues for peer support and team-based care.

Palliative care refers to noncurative treatments that ease the pain, physical symptoms, and distress in patients with serious illnesses such as cancer, dementia, cardiopulmonary diseases, and organ failure. An illness is considered to be serious when it carries a heightened risk of death, causes extended pain or suffering, and often requires sustained support from family and other caregivers. Although many healthcare providers can play a role in easing pain, supporting coping, and facilitating healthcare decision-making, patients with serious illnesses can be referred to inpatient or outpatient palliative care specialists. Specialized treatment regimens and other targeted supports are needed for pain, symptom, and distress management. Palliative care teams may include physicians, nurses, and advanced practice providers, along with social workers, chaplains, and psychologists. These professionals often work as teams to provide multidisciplinary care driven by patients’ preferences and values. The World Health Organization estimates that 56.8 million people could benefit from palliative care on a yearly basis (World Health Organization, 2020). Unfortunately, many people cannot access palliative care, or may not utilize it because of stigma. The objectives of this paper are to discuss how mental health stigma may deter some patients from using palliative care services and to identify strategies that palliative care professionals may use to overcome mental health stigma.

Up to half of the U.S. qualifies for a mental health diagnosis such as a mood, anxiety, or substance use disorder during their lifetime (Kessler et al., 2005). Furthermore, six percent of the U.S. population experiences severe and persistent mental illnesses, which may be overrepresented in people with serious illnesses (Terpstra & Terpstra, 2012). Mental health concerns may appear comorbid with serious illness when they precede the physical illness, share overlapping risk factors, participate in the etiology of disease, occur in response to the serious illness, or when subthreshold mental health concerns are exacerbated by illness-related stressors. Thus, chronic stress and adversity can trigger downward spirals of health risk, mental health concerns, and loss of coping resources while contributing heightened risk of premature mortality (Andersen et al., 2022; Pinquart & Duberstein, 2010).

Public mental health stigmas perpetuate negative evaluations of psychiatric concerns by blaming patients and stoking judgment, fear, and intolerance in others. Public mental health stigma also facilitates injustices such as abuse, segregation, and discrimination. People with living mental illness are more likely to be subjected to violence and are vulnerable to housing and occupational discrimination. Histories of loss, trauma, mental health concerns, and stigma also affect how patients interact with the healthcare system and undermine medical treatment advances and palliative care’s potential benefits to patients’ and their loved ones’ quality of life (Perry et al., 2022)Click or tap here to enter text.. Stigma, disparity, and loss are intersectional and synergistic such that disadvantages synthesize into new problems that emerge qualitatively distinct from their components (Layne, Briggs, et al., 2014; Layne, Greeson, et al., 2014). As statuses and identities intersect and beget one another (e.g., racist economic structures foster poverty that contributes to mental illness), some individuals become enveloped by complex systems of discrimination that are nonlinear and non-reductionistic so that rectification of one status or stigma (e.g., racism, or poverty, or mental illness) does not imply escape from individuals and systems that perpetuate stigma and discrimination (Akrami et al., 2011).

Despite significant deleterious effects on patient outcomes and high need, mental health stigma research in palliative care is all but non-existent. With important exceptions (e.g., Chou et al., 2016; Grassi & Riba, 2020; Irwin et al., 2014), there has been little research and intervention focused specifically on addressing mental health needs in palliative care, especially when concerns include persistent and severe mental illness (Kozlov et al., 2018; Sultana et al., 2021). To aid this research and inform clinical practice, palliative care needs to apply a conceptual framework that can encompass the multilevel sources of mental health stigma and its effects.

Before proceeding, it helps to survey why social problems like stigma persist how they related to healthcare. Stigma and discrimination serve as a resource accrual and conservation strategy called “Stigma Power.” Exerting Stigma Power allows people to gain or sustain status, domination over others, and control of capital. Healthcare is a critical, but costly resource and target of political control in the United States. Growth of the U.S. National Health Expenditure is outpacing that of the average Gross Domestic Product. The Centers for Medicaid Services estimate that health expenditures will account for one-fifth of the GDP by 2031. Serious illness is also costly with the bulk of healthcare spending concentrated near the end of life. The economic implications are that these expenditures can be managed by reducing unnecessary or unwanted treatments, but also can be a source of profit by limiting access to care. In a recent expose’ by ProPublica and the New Yorker, Jean Stone, a former employee of the Centers for Medicare and Medicaid Service discussed how the stigma of discussing death may deter effective oversight of Hospice business practices. Marginalized patients have been targets of erroneous and fraudulent Hospice enrollment and billing. Beyond financial fraud, these practices result in the premature or unnecessary termination of curative treatments for some patients.

Mental health concerns are another leading driver of healthcare costs. Mental health complaints are implicated in as much as 90 percent of primary care visits. Stigmatizing psychiatric concerns by attributing them to a deficient moral character or poor choices of an individual shifts the burden of responsibility for care away from society and its social safety nets.

The financial and economic context of these stigma is consistent with broader ecological models of resource allocation, stress, and health such as Conservation of Resources Theory (COR), Coyne’s Interpersonal Model of Depression. Much of human life involves activities of resource accrual and conservation, and people rely on family relationships, communities and culture to stockpile and exchange resources that may be needed in times of illness and other crises (Figure 1). Inherent to some definitions of serious illness is that people begin to tap into these resources as they and their families and other caregivers work to manage the disease. As serious illnesses like cancer or dementia often take a chronic course, there is a risk of exhausting finances, social supports, and safety nets (Goodman et al., 2009; Hobfoll et al., 2016; Layne, Briggs, et al., 2014; Layne, Greeson, et al., 2014).

Figure. 1.

Individuals, stigma, and disparities are nested in social structures.

The sharing of resources within relationships and larger social units allows for wealth, and status to become concentrated among some and scarce among others (Hobfoll, 1998). In a resource-rich environment, a person with a serious illness may have family, friends, and neighbors to rely on. Earlier academic support and achievement may have allowed for occupational success, savings, health and disability insurance, and reliable transportation to medical centers and community-based organizations. They may have an established relationship with a therapist who knew them well before the illness. Even as physical and cognitive abilities decline they may maintain a sense of meaning derived from prior accomplishments. Thus, those resources and others to help them may appear more resilient in the midst of illness and stress.

By contrast, people living in resource-depleted and isolating environments may encounter conflict and tension within their support system, may reside in substandard housing or homelessness due to discrimination, and encounter financial and geographic barriers to healthcare access. The lower half of Figure 1 highlights the layering stigmatization. At the family level, a patient with cancer and mental health concerns may be blamed for their illness because they smoked or had a sedentary lifestyle. Shame and victim-blaming could diminish the patienťs hope and deter them from seeking emotional and instrumental support from loved ones. Moving further out to the community level, local attitudes regarding mental health treatment for the “crazy,” may deter them from seeking psychotherapy. At the cultural level, victim- blame for psychiatric concerns, poverty, and illness allows for governments and political groups to divert tax dollars away from accessible healthcare and other social safety nets. The common function across levels is that stigma provides a justification for withdrawing support and isolationg the person with illness. This withdrawal from the person living with serious illness and psychiatric concerns places the burden of coping on them. As resources become depleted people appear to behave defensively, become emotionally distant, and disengage from treatment regimens. In turn, this loneliness and isolation may accelerate myriad health problems and the process of mortality.

Stressful events that threaten mental health and the conservation of essential resources such as health, finances, social connection, and status are ubiquitous in palliative care because they can precipitate, accompany, and follow life-threatening illness (Hobfoll et al., 2016; Kübler-Ross, 1972). Simply seeking palliative care requires a great investment of money and time that some patients and families may not have readily available. Furthermore, physical complaints and psychiatric symptoms exhibited by palliative care patients may be comorbid because of overlapping etiologies in biopsychosocially toxic environments where those lacking resources are not protected from pollution, infectious disease, mistreatment, and stress. Once initiated, these somatic and psychiatric symptoms can enter reciprocal relationships creating self-sustaining systems and downward spirals of pain, distress, and loss. These loss spirals are compounded when individuals with disabilities encounter healthcare structures that are biased against them.

Poverty, mental health, chronic illness, and access to palliative care are interdependent across levels of social organization. At the individual level patients with cancer and financial strain report higher levels of depression (Barbaret et al., 2017; (Perry et al., 2019). Low socioeconomic status is associated with a lower life expectancy and higher rates of disease co-morbidity (Richards, 2022). Among people living in multidimensional poverty (defined as monetary, educational, and infrastructural poverty), 75% live with a chronic health condition and 26% live with depression and mood disorders (Callander et al., 2013). Patients with lengthy histories of mental health diagnoses may struggle securing and sustaining adequate work and fair housing. Others may have been discouraged from work to avoid occupational stress that may exacerbate underlying symptoms. Socioeconomic status also impacts palliative care access, as people living in low or middle-income countries have much more limited opportunities to receive palliative care, including access to pain medications (Callander et al., 2013; Poudel et al., 2019).

Charting Pathways from Mental Health Stigma to Palliative Care Disparities

Based on the previous multilevel analysis of loss and stigma, we outline three pathways whereby mental health stigma may translate to disparities in palliative care (see Figure 1). The first pathway applies to stigma in the realm of culture and communities where discrimination is codified into social structures, policies, and social norms. The second pathway applies to stigma manifesting in close relationships that individuals could turn to for support during serious illness. The third and final pathway applies to the life of the individual where internalized stigma may deter a person seeking support and services for their serious illness and mental health needs.

Pathway 1: Stigmatization Presents Barriers within Healthcare and Other Systems

Healthcare implicitly and explicitly promulgates bias, stigma, and disparity against individuals with disabilities including psychiatric, developmental, and cognitive concerns (Lagu et al., 2022). Structural discrimination that codifies bias into healthcare warrants analysis and intervention. Such structural discrimination is evident in the racial segregation of healthcare, where black, indigenous and persons of color receive care separately from more affluent white patients. Emphasis on service reimbursement and profit derived from an ideal payer mix may function as a marker that allows for systems to decline and discharge patients with a range of stigmatized statuses including their need for mental health services (Shippee et al., 2022).

Given that stigma is a process of dehumanizing people with labels, the assignment of mental health diagnoses may be impacted by processes of stereotyping, and discrimination due to race, age, gender identity, and sexuality. Ageist perspectives, including negative attitudes towards older people, stereotypes about the aging process, and discrimination and mistreatment of older adults, can result in age-biased healthcare decision-making. Diagnoses may be missed or conflated (e.g., mistaking depression for dementia) because older adult patients may not always present in a typical way. If somatic symptoms are the foci of attention, core symptoms of depression, anxiety, or dementia may not be addressed. African Americans are disproportionately diagnosed with psychotic-spectrum disorders (Schwartz & Blankenship, 2014). In a study measuring implicit racial associations in medical students and psychiatrists, over one third of participants associated Black faces with psychotic disorders and non-compliance, compared to less than 10% for white faces, suggesting significant implicit racial bias within the mental health care system (Londono Tobon et al., 2021). LGBTQ+ populations report more difficulties with mental health and more barriers accessing treatment (Williams et al., 2022) which is especially harmful as LGBTQ+ patients are more likely to both experience a mental health condition and die by suicide.

In addition to the misapplication of the psychiatric nosology, this nosology is vulnerable to codifying stigma and bias into healthcare practice. Mental health stigmas originated in a cultural and historical backdrop of Western and dualistic philosophy that often evaluates certain modes of thinking, feeling, and behaving as being unacceptable or dangerous, especially if they deviate from social norms. Dualistic philosophies emerged in part to balance spiritual-religious conceptualizations of freewill with the scientific assumptions of determinism. The implications are that our discourse around mental health concerns often vacillates between compassion and victim-blaming. Some psychiatric labels have connoted such judgement and stigma. Homosexuality was diagnosed as “Sexual Orientation Disturbance” in the psychiatric nomenclature until publication of the DSM-III in 1980 (American Psychiatric Association, 1980; Spitzer, 2006). Though psychiatry and psychological science has made strides to correct its treatment of LGBTQ+ populations, the historical legacy of the association of queerness with deviance and illness remains and has important implications. Conversion therapy continues to be used in attempts to alter sexuality (Independent Forensic Group et al., 2020). Gender affirming care of those considered “gender dysphoric” is a frequent target of politically polarized legislation (Hughes et al., 2021; Park et al., 2021). Codification of stigma is also salient with personality disorders. The diagnostic language around these relatively stable disruptions in the sense of self and interpersonal function imply that negative attributions of one’s essential personhood are disordered. In the case of borderline personality disorder, one of the most stigmatized mental health diagnoses, there is considerable debate as to whether symptoms should be considered problematic aspects of one’s personality (Tyrer, 2009; Zandersen et al., 2019).

Beyond the codified mental health nosology, patients with mental illness are also branded “difficult patients” in their medical records. The use of the term “difficult patient,” its associations, and connotations often promulgate stigma and other misconceptions throughout healthcare settings, including among mental health specialists (Pinfold et al., 2005; Thornicroft et al., 2007). Although the term may have fallen out of favor, rates of academic publications featuring the term appear to be increasing: A PubMed search revealed that approximately 11 articles with “difficult patient” in the title/abstract were written each year between 1983 and 2002, and this increased to 27 articles per year in the period of 2003 to 2022 (p<.000001). These patients may never be contacted for scheduling, are subject to increased scrutiny and criticism and may be referred elsewhere for services.

Physicians discuss their own explicit biases toward people with disabilities. Physicians have reported that accommodating patient disabilities can be burdensome and have denied care or discharged patients with disabilities (Lagu et al., 2022). Black, Latino, Asian, and Indigenous Americans are not likely to receive outpatient mental health care when they need it, and the care that they do receive is less likely to adhere to quality guidelines (Snowden, 2003). Patients living with chronic illness who experience poverty may feel that they are unfairly treated by social safety net services (Whittle et al., 2017).

Pathway 2: Stigmatization Undermines Family and other Informal Support

COR Theory with its emphasis on nesting predicts that problems of serious illness, mental health concerns, and other major life events cascade with the family system and other support networks for several reasons (Hobfoll, 1998; Lane & Hobfoll, 1992). Broadly defined, families share resources in terms of caregiver support, housing, insurance benefits, and transfers of wealth via gifts, loans, and inheritances, and these are codified through legal, economic, and political systems (e.g., power of attorney, inheritance taxes, corporate health benefits). By extension, families are also vulnerable to shared loss of resources. Taking family medical leave to support a family member with a serious illness who is also on medical leave can rapidly create strain on the family finances (Liu et al., 2019). Family members share further vulnerability to physical and mental illness through common exposure to toxic environments, in the case of genetic kin through heritable risks for illness, and via behavioral modeling and emotional contagion. Given the segregation of housing and healthcare, patients from marginalized groups often come to rely on others of marginalized status who face their own loss, stress, and frustration.

In addition to being co-vulnerable via heredity and structural discrimination, families may transfer intergenerational trauma and stigma to one another (Siegel, 2013). Family members may perpetuate the invalidation of children who are more emotionally labile or blame members for their exposure to violence and trauma thus setting the stage for later emotional dysregulation. Patients with psychiatric symptoms and physical complaints may also elicit complaints and criticism from loved ones. Patients prone to chronic worry and low self-efficacy may exhaust caregivers through excessive reassurance seeking. Caregivers may begin by offering patients support, affection, and encouragement before becoming frustrated when patients' chronic mental health needs do not change. To coerce change, they may criticize patients in ways that elicit more distress and sustain negative beliefs about themselves. In the case of persistent and severe psychopathology, these critical interactions can precipitate psychosis and rehospitalization. Individuals are more likely to be discriminated against when their behavior is deemed to be within their control, dangerous, or unfamiliar (Corrigan et al., 2003; Corrigan & Nieweglowski, 2019). Negative attributions of patient pain behaviors as controllable or aimed at secondary gain tend to increase the likelihood that caregivers will respond with criticism and hostility (Burns et al., 2018). In summary, the family system can operate as a lens that concentrates and focuses culturally borne stigmas on individuals with serious and chronic physical and mental health concerns.

Pathway 3: Stigmatization Deters Help Seeking

When individuals are publicly stigmatized and discriminated against, they often develop self-stigma and shame due to internalizing others’ judgments of them. These negative evaluations of their behavior (e.g., “My speech is confusing”) become fused with their global sense of self (e.g., “I am crazy”) and their expectations for the future (e.g., “I deserve the ways I am treated because I am crazy”). Shame and stigma may culminate in efforts to suppress their emotional experiences. Shame can become so pervasive that patients may fail to focus on the positive outcomes of the activities, events, and beliefs that they personally value. In the short-term, these avoidant behaviors are reinforced by momentary escape from discomfort, dissonance, or emotional contrast, and the hostile treatment of others. Though efforts to avoid upsetting emotions may provide short-term relief from distress, these responses may feedback to erode a patient’s quality of communication and social relationships. Rigid attempts to avoid discomfort tend to interact with prior experiences and fears to predict a range of maladaptive interpersonal styles that could disrupt quality of care (Gerhart et al., 2014). For some patients, the chronic patterns of behavior such as cynicism, substance misuse, and anger that are adopted to avoid feelings of shame and abandonment often become part of a vicious cycle that increases the likelihood that criticism, rejection, and other negative social interactions will occur (Schoenleber & Berenbaum, 2012).

Stigmatization of mental disorders (including associations with violence, criminality, and laziness) is extensive and reduces health utilization of supportive services (Cipollina & Sanchez, 2019; Parcesepe & Cabassa, 2013). Internal stigmas such as the fear of expressing emotions help to explain why individuals with depression are more reticent toward palliative care despite needing it more (Gerhart et al., 2020). A need for palliative care itself is associated with a number of misconceptions and stigmas, most notably that the patient is frail and nearing death (Cherny, 2009) or that the term “palliative care” is often associated with care that is worse in quality compared to curative treatments (Collins et al., 2017; Zimmermann et al., 2016). Among patients with metastatic cancer, women were found to be three times more likely than men to consider palliative care to manage their diagnosis (Saeed et al., 2018). Furthermore, unmanaged depression and anxiety in metastatic cancer could increase the likelihood of utilizing potentially avoidable, costly, and burdensome end-of-life care such as late-line chemotherapy, ED visits, and inpatient or ICU admissions (Mossman et al., 2021). These healthcare experiences may further exacerbate financial strain, death anxiety, stigma, mental health symptoms, and underutilization of palliative care.

Recommendations to Mitigate Stigma in Palliative Care

Blame, shame, and stigma are undermined when clinicians gain increased personal familiarity with previously stigmatized groups and when they commit to identifying contextual and environmental factors to help explain problematic patient behavior (Corrigan et al., 2003; Corrigan & Nieweglowski, 2019). Open-mindedness, psychological flexibility, and humility may help ameliorate the impact of some stigmatizing attitudes (Jacobsen & Andrykowski, 2015).

1. Advocate

Healthcare providers hold status, privilege, and power through our professional roles, and our advocacy is needed in the training, community, and political arenas to combat structures that reinforce the stigmatization and de-medicalization of patients with mental health concerns (Peisah et al., 2020). Federal and state-level advocacy is needed as existing reimbursement structures present barriers to care including delays in consultation, referral, and availability of integrated care.

2. Build the Evidence-Base

Stigma being driven by stereotypes is undermined by awareness, knowledge, and exposure. Effects of palliative care on quality-of-life outcomes in advanced cancer tend to be small in magnitude (Hoerger et al., 2018). The small effects may be due to common symptom assessments capturing heterogeneous symptoms not pertinent to each patient. As such, it is possible that many patients show significant improvement in symptoms that require treatment, but these improvements are masked by extraneous symptoms. Another major challenge is that the treatment outcome studies needed to establish therapeutic efficacy are often costly and difficult to conduct with patients with comorbid physical and mental health conditions. An alternative is to administer psychological interventions with an evidence-base to individual patients and to carefully track their response to treatment (Gerhart et al., 2019).

3. Adopt a Contextual, Humanistic, and Intersectional Viewpoint

Psychology is a science of the individual in relation to our broader humanity. It aims to explain the core and common features of humanity, how some of us are more or less alike, and how each individual is unique (McAdams & Pals, 2006). The psychopathology literature supports the existence of very few diagnostic taxa, epidemiology suggests mental illness is relatively normative during the lifespan, and stress-based disorders are often reactions to extreme environmental events in the human narrative (Haslam et al., 2012; Kessler et al., 2005b). Dimensional, contextual, and evolutionary-based systems of psychopathology are reformulating our understanding of mental health diagnoses. Mental health is a difference of degree rather than category. Understanding the meaning or function of a behavior in one’s earlier development, specific life domains, genetic history or culture tends to foster more compassionate attitudes and suggest new avenues for change.

4. Discuss, Normalize and Destigmatize Patient Mental Health Concerns

If concerns such as psychological distress, impulsivity, difficulties with decision-making, and even bizarre psychological experiences fall along continua and are rather common, these concerns can be labeled, normalized, and accepted as part of the human condition. Patients can be encouraged to internalize compassion and understanding from palliative care providers, and direct their attention toward harnessing social supports, dignity, and other resources to manage their illness (Funk et al., 2006).

5. Inoculate and Empower Patients and Families Against Stigma

Patients can be encouraged to internalize compassion and understanding from palliative care providers, and direct their attention toward harnessing social supports, dignity, and other resources to manage their illness. Patients and families should be empowered to advocate for themselves with assertive communication strategies and through modes of communication including patient advocates, navigators, and community advocacy groups (Funk et al., 2006).

6. Provide Interdisciplinary Team-Based Care

Teams gather and leverage each other’s professional expertise, but also bring an array of personality traits, backgrounds, and identities. Certain members may be more effective in forging alliances with specific patients, addressing certain emotions such as anger, or responding appropriately and assertively to aggressive behaviors. These working relationships offer enhanced opportunities to successfully manage family meetings, navigate difficult dialogues relates to prognosis and death, as well as offer person and family-centered care.

7. Incorporate Behavioral Health

Despite a consistent call for increased integration of mental health services into primary and specialty care (Kessler et al., 2005), challenges remain, one of which is the consideration of which mental health services should be included within an integrated model. Access to specialty mental health providers including clinical psychologists, school psychologists for school-aged patients, and psychiatrists may be facilitated through telehealth services.

8. Constrain Human Bias with Valid Assessment and Evidence-Based Treatments

A tremendous amount of data is collected from patients including routine psychological distress, but this information fails provide a comprehensive view of the patient and the meaning of their behaviors. Tools such as the Minnesota Multiphasic Personality Inventory – 3rd Edition provide a comprehensive summary of an individual’s overall personality and psychological health, and contain validity scales to detect if self-reports are biased or misconstrued (Siafaka et al., 2008; Sobel & Worden, 1979). The use of personality testing is standard practice in other areas of specialty health care including bariatrics and organ transplant (Hintz et al., 2022; Marek et al., 2021; Pona et al., 2022).

9. Use Peer Support, Supervision and Mentorship

Self-reflection is also encouraged through supervision with mentors and peers who have an external perspective on case conceptualization. In the context of palliative care, case conferences, peer support, and resilience training may be essential for maintaining a healthy workforce (Back et al., 2016a). Patient-centeredness is particularly important during case conferences and other interactions where clinicians may be inclined to “vent” about difficult encounters. The perceived cathartic effects of such venting are short-lived and increase the risk of propagating shame, stigma, and anger. A suggestion is that venting can be reframed so that providers can discuss the emotional impact of their work while respecting the dignity and diversity of their patients, their complex needs, and the difficult circumstances they are facing (Gerhart et al., 2017).

10. Seek Psychotherapy

The COVID-19 pandemic accelerated long-standing concerns with burnout, and secondary trauma in palliative care (Back et al., 2016b; Kamal et al., 2019; O’Mahony et al., 2017). Healthcare careers may be a vulnerability to mental health concerns. Provider mental health supports empathy and occupational performance (Barrett & Stewart, 2021; Ghawadra et al., 2019; Yoo, 2022), and engagement in behavioral health services can provide an important perspective on the experiences of patients.

Conclusion

Although many people around the world could stand to benefit from palliative care services, stigma and discrimination foster disparities in access and quality of care. In some cases, the marginalization of people with serious illnesses means that they are unnecessarily enrolled in end-of-life care when they could still benefit from curative treatments. One potential but understudied source of disparity in palliative care is mental health stigma. Mental health stigma dehumanizes people with serious illnesses and may prevent them from seeking care. It is critical that clinicians and healthcare providers do their best to mitigate this stigma and improve palliative care through advocacy, support, and empowerment.