Primary Mental Health Competencies for Hospice and Palliative Medicine Physicians: A Delphi Study

Abstract

Context.

Psychiatric and psychological care in serious illness is a core domain of hospice and palliative medicine (HPM), encompassing both normative psychosocial responses and mental health comorbidities. While social workers serve as psychosocial leaders on HPM interdisciplinary teams, commitment to supporting whole-person care remains the responsibility of the entire team. However, training and scope of practice for HPM physicians in the mental health domain are poorly standardized.

Objectives.

To establish and prioritize “primary mental health competencies” for specialist hospice and palliative medicine physicians using expert consensus methods.

Methods.

We convened a panel of eight physicians, one social worker, two psychologists, and one nurse practitioner with expertise at the intersection of palliative care and mental health. Using group meetings and 1:1 interviews with the project leads, the expert panel generated initial competencies. A purposive voting panel of 36 palliative care physicians representing a range of practice settings and areas of career focus finalized high-priority competencies using a two-phase modified Delphi approach.

Results.

The expert panel proposed 68 competencies divided into: (A) psychological foundations of serious illness care, (B) diagnosis and management of mental health disorders in serious illness, and (C) systems-based practice. After first-round voting, 23 competencies were recirculated for a second vote. Following second-round voting, 32 competencies were included in the final list: seven from part A, 20 from part B, and five from part C.

Conclusions.

This consensus-based, expert-led process successfully generated and prioritized essential competencies in the psychological and psychiatric aspects of palliative care for specialist physicians.

Introduction

Palliative care addresses the holistic needs of individuals with serious illnesses and their caregivers across physical, spiritual, social, and emotional dimensions. Psychiatric and psychological serious illness care is recognized as a core component of hospice and palliative medicine (HPM) by major scope-of-practice guidelines, practicing clinicians, and patients.^1–3 The psychiatric and psychological components of HPM include understanding normative psychological reactions to serious illness, applying psychological concepts to guide serious illness communication, diagnosing and treating common psychiatric comorbidities, and promoting equity for individuals with mental health and substance use disorders.⁴

The ubiquity of psychiatric and psychological issues in palliative care practice underscores the need for interprofessional expertise in this domain of care. Mental health comorbidities like depression and anxiety are highly prevalent among individuals receiving palliative care—in fact, they often predict or prompt referral to palliative care services.^1,5 Mental health comorbidities among individuals receiving palliative care are associated with poor outcomes, including lower quality of life, higher symptom burden, and poorer functional status.⁶ Beyond the treatment of mental health symptoms or disorders, an understanding of psychological and psychotherapeutic principles is an important component of skillful and sustainable serious illness care.^7,8 Finally, palliative care teams can play a critical role in addressing serious illness care disparities experienced by individuals with serious mental illness or substance use disorders.^9–12 While most hospice and palliative medicine physicians are not mental health specialists, meeting the aim of supporting the quality of life of patients with serious illness does require primary mental health knowledge and skills.

The essential nature of interprofessional work is a core value in HPM and social workers are rightfully recognized as frontline psychosocial experts on the palliative care interdisciplinary team (IDT)^.3 In our efforts to support patients and families as whole people, the psychological and psychiatric components of palliative care also remain the responsibility of the entire team.^13–15 For instance, HPM physicians routinely diagnose and manage common psychiatric comorbidities of serious illness, including depression, anxiety, and delirium.² In addition, all members of the team interact with patients during periods of intense emotional distress.¹³ Delivering optimal mental healthcare sustainably within the IDT requires interprofessional collaboration and expertise. Social workers provide specialized expertise in psychosocial assessment, social determinants of health, and behavioral interventions; other team members may offer expertise at the intersection of mental and spiritual health (e.g., chaplains) or in the management of mental health conditions (e. g., psychologists, physicians, advanced practice providers). Ultimately, all team members can help support each other’s skill development and sustainable practice.¹⁶

Unfortunately, current workforce paradigms fail to adequately prepare the full palliative care team to address psychological and psychiatric components of serious illness care. In particular, physician training in these topics is highly variable and often insufficient. Only 15% of U.S. HPM fellowships include a required mental health clinical rotation; many programs lack comprehensive didactic content on core topics such as depression, anxiety, psychotherapy, or serious mental illness.^17,18 These gaps extend beyond training programs: in a survey of >600 practicing palliative care physicians, respondents were dissatisfied with opportunities for ongoing training in mental health despite reporting they frequently manage one or more mental health disorders.² Perhaps as a result, screening and management of mental health comorbidities in palliative care settings is suboptimal and over 80% of respondents reported that mental health comorbidities reduce their comfort in delivering palliative care.^2,19–23

The absence of focused guidelines defining the scope of practice for palliative care clinicians in psychological and psychiatric care compounds these challenges. Though scholarly work has been done on defining palliative care competencies for social workers,^24,25 no clear and specific educational competencies exist for HPM physicians in this domain, despite the fact that physician fellowship guidelines include psychosocial assessment and management of psychosocial distress and nonpain symptoms like depression and anxiety in the AAHPM Entrustable Professional Activities (EPAs 2 and 11) and ACGME Professional Milestones (Patient Care 1 and Patient Care 2).^14,15 Some psychological and psychiatric content is implied in other elements of these guidelines (e.g., in EPA 7 on managing conflict, in EPA 13 on self-care and resilience), but without clear identification of the principles that inform this. This lack of granularity and clarity contributes to the variability in education and practice described above and creates barriers to implementing consistent, high-quality care for patients with serious illness.

Operationally defining core competencies and scope of practice in the psychological and psychiatric components of palliative care is a key step in improving training, supporting clinicians, and enhancing patient outcomes. When training objectives are clear, educators are empowered to create scalable, standardized curricula. Consensus on core competencies also provides national organizations (e.g., the American Academy of Hospice and Palliative Medicine) a framework to curate and disseminate highest-yield educational content. Clinicians in practice can use clear objectives to self-assess their own mental health competence and guide ongoing professional development, including optimizing learning and collaboration within the IDT. This manuscript describes the development of a core set of HPM physician competencies in the psychiatric and psychological components of palliative care, using an adapted Delphi methodology to achieve consensus on highest-priority items.

Methods

We utilized a modified open Delphi technique with a purposively-assembled interdisciplinary panel of content experts at the intersection of mental health and palliative care (N = 12) developing the initial set of competencies and then a separate panel of purposively-sampled practicing physicians (N = 36) participating in two voting rounds to select the final set of competencies. The Delphi method is widely recognized for developing expert consensus, particularly in health education.^26,27 Our approach was tailored to balance expert input and diverse clinician perspectives while maintaining methodological rigor.

Developing the Competencies

Expert Panel:

A purposive sampling strategy was used to assemble an expert panel with diverse expertise in mental health and palliative care. The panel included experts in geriatric psychiatry (ML), psycho-oncology (WP, NG), addiction medicine (BT), palliative care psychiatry (KB, DC, DS), bereavement (SM), and psychologically-informed serious illness communication (LP, LR). Interprofessional perspectives were represented through members specializing in palliative care social work (BS), psychology (NG, SM), and advanced practice nursing (LW). Though we recognize that this work intersects with related fields such as spiritual care and ethics, the panel chose to focus on psychological and psychiatric elements specifically, consistent with how this content is delineated in the EPAs.¹⁵

Competency Development:

Competencies were developed through a structured, iterative process, integrating input from all expert panelists. First, an initial group meeting established the organizational structure and preliminary content of the competencies by consensus. Second, two project leads (LP and DS) conducted 2:1 meetings with each panel member to review, revise, and expand the competencies. Finally, LP and DR edited the competencies and circulated them to the expert panel for final input.

Prioritizing the Competencies and Defining Scope of Practice

Voting Group:

A separate purposive sampling strategy was employed to assemble a diverse voting group of palliative care physicians. The voting group was designed to specifically address scope-of-practice questions, recognizing that scope varies across different roles within the IDT. Inclusion criteria ensured representation across practice settings (academic, hospice and community, as well as geographic and institutional distribution nationally), senior/founding members of the field, educational roles, and subspecialty expertise. This strategy also employed an open invitation to AAHPM’s Psychosocial and Mental Health SIG for volunteers to be on the voting panel to maximize inclusivity. In considering potential voting panel members, we ensured that at ≥5 members were invited from a list of specified categories (educators, senior leadership, community practice, hospice, and palliative care-trained psychiatrists), with weighting towards educators and senior leaders in the field. We also ensured that no more than 20% of participants were psychiatrists practicing palliative care to prioritize the perspectives of non-mental-health-specialist HPM physicians regarding scope of practice. Selected individuals were sent information and recruited by email with a requested commitment to participate in two rounds of voting, as is typical of Delphi and modified Delphi approaches.

Voting Process:

The competency prioritization process involved two rounds of voting. In both rounds, competencies were presented in an online RedCap survey using a modified RAND appropriateness method scale.²⁸ Participants rated each competency from 1 (low priority) to 9 (high priority). Open text boxes captured qualitative feedback on specific competencies. The first-round survey also included demographic data on the voting group (see Table 1).

Table 1.

Voting Group Composition

Respondent Clinical and Demographic Characteristicsa		N (%)
Gender	Female	26 (74%)
	Male	9 (26%)
Race/ethnicityb	Asian	1 (3%)
	Black or African American	1 (3%)
	Latine/o/a/x or Spanish origin	2 (6%)
	White	32 (91%)
	Other	3 (8.6%)
Specialties/subspecialtiesb	Hospice and palliative medicine	34 (97%)
	Internal medicine	23 (66%)
	Family medicine	2 (6%)
	Pediatrics	3 (8%)
	Psychiatry	7 (20%)
	Hematology and oncology	3 (8.6%)
	Geriatrics	2 (6%)
	Other	2 (6%)
Years of experience	<1 year	1 (3%)
	1–5 years	3 (9%)
	6–10 years	8 (23%)
	11–15 years	10 (29%)
	15–20 years	6 (17%)
	>21 years	7 (20%)
Institution typeb	Academic medical center	27 (77%)
	Community-based health system	11 (31%)
	Veteran’s Health Administration	2 (6%)
	Other	2 (6%)
Clinical setting(s)b	Ambulatory palliative care	20 (57%)
	Home-based palliative care	4 (11%)
	Inpatient palliative care	28 (80%)
	Nursing home or long-term care facility palliative care	2 (6%)
	Hospice	8 (23%)
	Other	1 (3%)
Nonclinical role(s)b	Administration/leadership	18 (51%)
	Fellowship program director	13 (37%)
	Other educational role	16 (46%)
	Research	7 (20%)
	Other	2 (6%)
Geographic region (N = 34)	Northeast	13 (37%)
	Southeast	3 (9%)
	Southwest	3 (9%)
	West	6 (17%)
	Midwest	9 (26%)
Geographic setting(s)	Urban	23 (66%)
	Suburban	4 (11%)
	Rural	3 (9%)
	Other or mixed	5 (14%)

^aOne respondent did not fill out demographic information.

^bRespondents could select more than one category, so percentages may exceed 100.

The first survey was sent to the members of the voting group in May 2024. Following completion of the first round of voting, competencies were either included, excluded, or deferred to a second vote. Competencies that received high priority scores (defined as ≥7/9) from ≥75% of the voting panel were included in the final list of high-priority competencies. Competencies were deferred for a second-round of voting if they (1) received high priority scores from 65% to 75% of the voting panel, (2) had an interquartile spread of at least 4 points between the 1st and 3rd quartile scores with a 1st quartile score being ≥7/9, or (3) had substantive qualitative comments suggesting the need for adjustment in phrasing/content of the specific item. Competencies that did not meet criteria for inclusion or deferral were excluded.

The expert panel reviewed all qualitative comments from the first-round survey and adjudicated them by consensus. Subsequently, the second survey was sent to the voting group in July 2024. Only deferred competencies were included in the second survey (along with a reference list of competencies that had met inclusion criteria in the first round). Competencies were added to the final competencies list if they received high priority scores from ≥75% of the voting panel in second-round voting.

Data Analysis

Quantitative data were analyzed using descriptive statistics in Microsoft Excel and Stata (v18). Qualitative comments were reviewed and summarized for the expert panel to inform competency revisions between survey rounds. Incomplete surveys were included in the analysis if the participant had rated at least one competency.

Results

Through a structured, iterative process involving a panel of experts and a diverse group of palliative care clinicians, we developed and prioritized a core set of physician competencies in the psychiatric and psychological components of palliative care. The final set of competencies includes 36 competencies across three broad categories.

Initial Competencies

Following the group and individual meetings with the expert panel, 68 initial competencies were developed within three broad categories: (A) psychological foundations of serious illness care (17 competencies), (B) psychiatric disorders in serious illness (43 competencies), and (C) systems-based practice (8 competencies). During the iterative competency drafting process, the expert panel decided to include specific psychological terminology in parentheses alongside relevant competencies to facilitate further learning (see Table 2 for examples). Refer to Tables 2–4 for the final list of high-priority mental health competencies. For the full set of initial competencies, see Supplemental Table 1.

Table 2.

Final Consensus Competencies in the Category of Psychological Foundations of Serious Illness^a

Competency	Psychological Concept(s)c
A. Psychological foundations of serious illness care:
1. Demonstrate the ability to recognize and attend to a broad range of normative emotional reactions to serious illness (e.g., sadness, worry, anger, ambivalence, anticipatory grief, gratitude, sense of meaning, existential distress)	Attunement Accompaniment
2. Foundational principles in serious illness care: Principles from psychology and psychotherapy that are important in describing and optimizing the therapeutic relationship.b  a. Develop a dynamic conceptualization of each patient as an individual whose feelings, thoughts, and behaviors are informed by prior life experiences, coping strategies, elements of identity, culture, spirituality, social context, and illness experience.  b. Notice and manage how our own reactions to patients and families can influence clinical decision making, including recognizing our own implicit biases  c. Create a therapeutic environment that allows for the exploration and containment of strong emotional reactions among patients, families, and teams  d. Remain nonjudgmental when navigating medical decisions with patients and caregivers  e. Recognize the role of cultural context in influencing individual’s psychological reactions to serious illness 3. Demonstrate self-awareness of one’s own knowledge and skills and set limits appropriately (e.g. advocate for an additional consult or refer a patient to a mental health specialist).	Formulation, Clinical Attunement, Coping Countertransference Holding environment, Therapeutic accompaniment, Therapeutic alliance Mindfulness, Technical neutrality, Unconditional positive regard Cultural Formulation

^aThis category represents concepts and skills that play a role in adaptive coping with the stress of living with serious illness. All palliative care physicians should be able to recognize and support these typical patient responses and behaviors.

^bOrganizational headings are indicated in italics.

^cNote: we have listed psychological concepts as a key term to direct physicians’ further reading/learning, not as an indication that the concept is fully captured in this competency.

Table 4.

Final Consensus Competencies in the Category of System-Based Practice^a

C. Systems-Based Practice:
1. Navigating care:b
a. Effectively use resources for patients’ mental health services within the palliative care interdisciplinary team.
b. Facilitate referral to specialty mental health services outside of the palliative care interdisciplinary team when warranted.
c. Recognize the impact of social determinants of health (e.g., racism, socioeconomic status, housing) on mental health.
2. Sustainable Work Environment:
a. Appropriately seek consultation with peers or supervisors for challenging cases. (Psychological concept: Supervision)c
b. Identify signs and symptoms of clinician mental health needs such as burnout.d

^aThis category includes systems-level knowledge and skills that empower palliative care clinicians to provide high quality serious illness care to patients with varying mental health needs and to attend to their own wellbeing in doing so.

^bOrganizational headings are indicated in italics.

^cNote: we have listed psychological concepts as a key term to direct physicians’ further reading/learning, not as an indication that the concept is fully captured in this competency.

^dIncluded in final competencies with 74% of initial votes in the 7–9/9 range, erroneously not submitted for a second-round vote.

Voting

The voting group consisted of 36 members (see Table 1 for voting group composition), identified from a total of 55 email invitations extended. All physicians who accepted the invitation participated in the first-round survey. Of 68 initial competencies, 25 received ≥75% votes in the high-priority scoring range (≥7/9) and were included in the final list following the first round, 23 were deferred to a second vote based on meeting one of the a priori criteria, and 20 were excluded following the first voting round.

In the second-round survey, 32/36 (89%) of the voting group participated. Of the 23 competencies deferred to a second-round vote, seven received sufficient high-priority votes for inclusion in the final list. One item that nearly met criteria for inclusion after first round voting was accidentally not submitted in the second-round survey; when this error was detected, decision was made to include this item in the finalized list. The overall number of included competencies after two rounds of voting was 32 competencies (seven in category A, 20 in category B, and five in category C). For the numerical outcomes of the Delphi surveys, see Supplemental Tables 2–4.

Discussion

Despite the well-documented burden of psychological and psychiatric comorbidities in patients with serious illness, mental health training for HPM physicians remains inconsistent and underdeveloped.^17,18,29,30 This study represents the first systematic effort to define and prioritize key psychiatric and psychological competencies for palliative care physicians using an expert consensus approach. In the broader medical education literature, competency-based training has been widely implemented to ensure that learners consistently and measurably acquire essential skills. This study contributes to that effort by providing a structured, consensus-driven roadmap for integrating psychological and psychiatric competencies into HPM physician training programs.

Through iterative expert engagement, we developed and refined a structured set of competencies encompassing three categories: (1) psychological foundations of serious illness care, (2) psychiatric disorders in serious illness, and (3) systems-based practice. The prioritization process highlighted several key themes. First, foundational psychological knowledge—such as the ability to recognize and respond to normative emotional reactions to serious illness—was ranked as highly essential, reinforcing previous research on the role of emotionally-attuned communication and psychosocial care in serious illness.³¹ Some of this content overlaps with competencies in palliative care social work, which serves as a reminder of the strength of the IDT in deepening patient care and supporting ongoing skill development in practice.^16,25 This finding underscores the importance of mental health literacy as a fundamental component of general palliative care practice.

Second, competencies related to the diagnosis and management of psychiatric conditions were prioritized, particularly those addressing depression, anxiety, and delirium. This is consistent with prior research indicating that these conditions are among the most frequently-encountered mental health concerns in palliative care settings. However, certain aspects of psychiatric care, such as the management of serious mental illness and substance use disorders, showed greater variability in priority ratings. This variability may reflect the wide variation in resource-availability across practice settings; while some clinicians practicing in large academic medical centers may have access to specialized clinics,³² other clinicians may practice in settings without specialty mental health support, necessitating a stronger generalist skillset.² This presents an ongoing challenge for the field in delineating primary versus specialist mental health competencies.

Third, multiple competencies related to interprofessional collaboration and systems-level knowledge were highly prioritized. This reflects the complexity of addressing mental health in the context of serious illness and the frequent fragmentation of care under the current paradigm. Achieving competence in this systems-level category involves knowing local mental health resources, which can differ substantially by practice site; in this area in particular, the IDT is an indispensable source of knowledge, and collaboration with social workers is crucial for physician learning.

Our findings align with existing literature highlighting the contrast between the substantial role that palliative care teams play in supporting the mental health of people with serious illness and the limited mental health resources and training available for many members of these teams. These findings are particularly striking when compared to the existing educational offerings provided by HPM fellowships; even the mental health topics most highly prioritized, including general psychological knowledge and management of common psychiatric disorders, are not consistently included in fellowship programs.

This study has a number of strengths. First, both our initial competency creation and the prioritization process reflect the diversity of HPM practice. In our competency development phase, we drew on interprofessional and multidisciplinary expertise. The iterative individual meetings with each member of this team allowed us to draft competencies with a high degree of nuance and breadth. In the prioritization phase, we engaged HPM physicians across diverse practice settings and career trajectories, enabling us to refine scope and priority. Second, we utilized an a priori process to guide the inclusion and exclusion of competencies, allowing us to leverage our collective expertise and reduce the risk of individual biases. Finally, we wrote the competencies to optimize accessibility and utility, with a minimum of mental-health-specific technical language in the core competency descriptions and then specialty terminology in parenthesis to guide future learning.

Though an important step towards codifying scope of practice in psychiatric and psychological components of palliative care for physicians, our study has several limitations. Our purposive sampling approach allowed us to capture expert perspectives, but had the potential to introduce bias by over-representing individuals with particular interest in this topic. To mitigate this risk, we limited the proportion of psychiatry-trained physicians in the voting panel and oversampled senior/founding members of HPM, who we expect to have the experience to view this topic within the context of the field as a whole. Future studies might address this by validating these competencies using a broader and more representative sampling. Our study intentionally focused on physicians, but integration of these competencies into physician training depends on more formally identifying roles and training paradigms in this domain of care for every member of the interprofessional team. Furthermore, aligning the prioritized competencies in our study with priorities of other stakeholders, including patients and care partners, can help ensure that these competencies reflect the concerns of individuals with serious illness themselves.

Finally, competency definition is just the first step. The next step is to focus on curriculum development, implementation, and evaluation to ensure these competencies lead to meaningful improvements in HPM training and patient care. Given the variability in formal mental health training for HPM physicians, it is our hope that many practicing clinicians will recognize in these competencies areas of existing knowledge and skill that they aquired in practice, with this document offering mental health terminology to promote validation, deepening of expertise, and transmission of this content to trainees. Collaboration with IDT members will be key in this ongoing process of skill enhancement and dissemination. We also hope that future updates in HPM fellowship Milestones and EPAs will consider the content presented here. By prioritizing mental health literacy and skills within palliative medicine, this work supports the field’s broader mission: sustainably delivering whole-person, psychologically-attuned care for patients facing serious illness.

Conclusion

This consensus-based, expert-led, systematic process successfully generated and prioritized essential competencies in the psychological and psychiatric aspects of palliative care for specialist HPM physicians. These competencies can guide ongoing efforts to improve the consistency and quality of primary mental health training for specialist HPM physicians, in the service of sustainably supporting the whole-person quality of life of people with serious illness and their families.

Table 3.

Final Consensus Competencies in the Category of Psychiatric Disorders in Serious Illness^a

B. Psychiatric Disorders in Serious Illness:
1. Principles of assessment and diagnosis:b
a. Transdiagnostic concepts and skills
i. Assess capacity to make medical decisions using the set criteria of a patient’s ability to: 1) communicate a consistent choice, 2) understand the information relevant to the decision, 3) appreciate the consequences of the decision, and 4) manipulate the information and involved consequences to arrive at their choice, even if not in the way others might.
ii. Identify psychiatric emergencies such as acute suicidality and agitation/aggression and partner appropriately with mental health specialists in management.
iii. Use universal precautions for opioid use disorder in opioid prescribing (e.g., routinely checking the state prescription drug monitoring program, using pain agreements, and obtaining periodic urine drug screens).
iv. Implement strategies to minimize negative consequences of substance-use among patients on controlled substances and/or with substance use disorders (Concepts: harm reduction and risk mitigation).c
v. Provide high quality palliative care to people with serious medical illness who also have serious mental illness, personality disorders, substance use disorders, and/or neurodivergence, in collaboration with mental health specialists
b. Psychiatric disorders:
i. Diagnose and provide first-line management for uncomplicated presentations of the following psychiatric conditions among patients with serious illness, as appropriate in your practice setting:
a. Major depressive disorder
b. Generalized anxiety disorder
c. Adjustment disorders
d. Delirium
e. Opioid use disorder
ii. Recognize and refer to mental health specialty care
a. Complex or treatment-resistant forms of the above conditions
b. Nonopioid substance use disorders
c. Prolonged grief disorder
2. Interventions:
a. Psychopharmacology:
i. Select psychopharmacologic agents for patients with serious illness with consideration of medical context (i.e., prognosis, metabolic considerations, potential drug interactions, available routes of administration, pill burden, side-effects), and potential physical symptom benefits (e.g., olanzapine for nausea, mirtazapine for sleep, SNRI for neuropathic pain)
ii. Safely and appropriately use selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and mirtazapine for treatment of depression and anxiety among patients with serious illness and depression and/or anxiety.
iii. Safely and appropriately use benzodiazepines for treatment of anxiety among patients with serious illness.
iv. Safely and appropriately use antipsychotics for the management of agitation in delirium.
b. Psychotherapy
i. Demonstrate the ability to offer therapeutic presence in the setting of distress
ii. Use nonjudgmental, open-ended questions to elicit motivations among patients navigating behavioral change or medical decisions (Psychotherapeutic modality: Motivational Interviewing)c
iii. Tailor palliative care interventions, including serious illness communication, to patients’ and caregivers’ affective state and coping capacity (Psychotherapeutic modality: Trauma-informed care; Concept: Attunement)c

^aThis section is for common situations that extend beyond typical coping. Psychological reactions become psychiatric concerns when they are severe, persistent, and significantly impair a person’s ability to function in daily life. Psychological reactions, like sadness, worry, or stress, are normal responses to life’s challenges and changes. However, when these reactions are intense, last for a prolonged period, and interfere with activities such as work, relationships, or self-care, they may indicate a psychiatric disorder. All palliative care physicians should have competence providing first-line therapeutic interventions on these disorders while also recognizing one’s practice limitations.

Note: All of the concepts and skills noted in section A continue to be relevant when working with patients who are experiencing a mental health disorder.

^bOrganizational headings are indicated in italics.

^cNote: we have listed psychotherapeutic modalities and psychological concepts as key terms to direct physicians’ further reading/learning, not as an indication that the concept is fully captured in this competency.

Key Message.

This study defines and prioritizes core competencies in the psychological and psychiatric aspects of palliative care for hospice and palliative medicine physicians using an expert consensus approach. These competencies provide a framework for standardizing training, enhancing mental health literacy, and optimizing patient care within the palliative care specialty.