Ketamine-assisted psychotherapy in palliative care

1. Introduction

Version followed: the "dissociative-psychedelic" palliative KAP model of Campolina and de Oliveira (Instituto do Câncer do Estado de São Paulo / Hospital Samaritano, São Paulo; Healthcare 2025), which is a condensed palliative adaptation of the Montreal model (Garel, Greenway et al., McGill, 2023). Session-level procedures the São Paulo paper does not spell out are taken from the Montreal model and marked as such. Delivery details from three palliative programmes are added where they differ: University of Rochester Pal-KAP (clinical service), the Northwell KAPtivated protocol (NCT05344625, withdrawn before enrolment) and the Ketamine Research Foundation "Conscious Dying/Conscious Living" trial (NCT05214417), plus the Huntsman Cancer Institute ACT-based study (Utah, reported in the press).

What it is: a short, time-limited psychotherapy course for people with advanced or life-limiting illness and existential distress (loss of meaning, death anxiety, demoralisation, grief, anxiety or depression), in which a small number of medically supervised ketamine sessions are embedded in preparation, concurrent psychotherapy and integration. It is psychological support alongside palliative care, never a treatment of the underlying disease. This is a proposed clinical model, not a validated manual: the São Paulo paper is a narrative review that offers the model for testing [source: Campolina & de Oliveira 2025].

How change is thought to happen (the authors' account): ketamine is framed as a catalyst for psychotherapy rather than only a drug. The altered state is described as an "experiential opportunity", not something required for benefit, so preparation and integration carry the therapeutic weight. The model names two experiential registers: an earlier session framed as acclimatisation to a milder, mainly embodied dissociative state, and a later one aimed at deeper emotional and existential processing of the narrative self (the authors link these to salience-network and default-mode-network effects; that neurobiology is their hypothesis). Change is expected as existential relief, meaning-making, emotional resolution, biographical reconciliation and better quality of life, not long-term symptom remission [source: Campolina & de Oliveira 2025]. The parent Montreal model adds that the drug opens a brief "window of opportunity" in which psychotherapy and value-driven action are easier, with emphasis on how the person relates to the experience (process) rather than its content [source: Garel et al. 2023].

Legal and regulatory status (as of the sources; check locally):

• USA: esketamine (Spravato) is FDA-approved for treatment-resistant depression and for depressive symptoms with acute suicidal ideation in adults, is Schedule III, and may only be given within a REMS programme: REMS-certified treatment settings with a healthcare provider on site to monitor patients; the most recent REMS modification found (April 2026) only added Spanish materials [source: CBH Spravato procedures 2026; FDA letter S-028, 2026]. Esketamine is not approved for palliative existential distress. Racemic ketamine used for psychiatric or existential indications is off-label [source: Garel et al. 2023]; its controlled-drug schedule was not confirmed in a source opened [uncertain].
• UK: ketamine is a Schedule 2 controlled drug; NICE's 2020 draft guidance did not recommend esketamine for treatment-resistant depression, while the Scottish Medicines Consortium accepted it for NHS Scotland [source: Pharmaceutical Journal 2020/2021; NICE news]. NICE's final position and any palliative use were not checked [uncertain].
• Brazil and the EU: the São Paulo authors cite ketamine's legal status as a reason for choosing it and name regulatory hurdles and drug cost as barriers, but give no specific regulatory detail [source: Campolina & de Oliveira 2025]; EU/EMA status [uncertain].
• Clinical implication [synthesis]: the psychotherapist's role is limited to the psychotherapy frame inside a legal, medically supervised service. Prescribing, administration and physiological monitoring belong to the medical team.

2. Framework

The São Paulo model sets three phases plus concurrent psychotherapy, inside a time-limited frame where the ending is discussed from the start [source: Campolina & de Oliveira 2025]:

Other published formats:

• Pal-KAP (Rochester): a preparation session (about 60 minutes) in a calm, art-filled room to build trust, explain the experience and set intentions; medicine sessions (about 3 hours, patient lying back with eyeshade and curated playlist, two trained facilitators present); an integration session (about 60 minutes). The facilitator pool is interdisciplinary: nurses, nurse practitioners, a physician, a physical therapist, a chaplain and a master's-level clinician [source: URMC Pal-KAP page].
• KAPtivated (Northwell, palliative radiotherapy patients): one virtual preparatory session to meet the team and discuss key stressors; post-session discussion with a KAP-trained psychotherapist after each medicine session once acute effects subside; a virtual integration session the day after each medicine session and one about a month after the last; later consolidative psychotherapy [source: NCT05344625].
• Conscious Dying/Conscious Living (Ketamine Research Foundation): manualised preparatory and integration psychotherapy; optional daily therapist phone calls for a week after each medicine session; participants keep their own therapist and psychiatric medicines; a designated caregiver is required; 4–6 week protocol [source: NCT05214417 summary].
• Huntsman (Utah, inoperable GI cancer): 90-minute safety consultation, pairing with one therapist, a short series of medicine sessions with eye mask and music and a mostly internal focus, one integration session, ACT as the therapy model, three-month follow-up [source: Daily Utah Chronicle 2024; secondary].

Criteria for moving between phases:

• Into preparation: referral by a clinician; completed medical and psychological evaluation; no exclusion (Section 4.1); consent capacity [source: URMC; NCT05344625; NCT05214417].
• Into the first medicine session: goals of care agreed; expectations discussed; concurrent therapy started; on the day, psychological readiness and consent confirmed by the clinician and physiological baseline confirmed by medical staff [source: Campolina & de Oliveira 2025; Garel et al. 2023].
• Out of each medicine session: discharge when medical staff judge physiological status normal and the clinician judges the patient psychologically ready, with safety reminders and a contact route [source: Garel et al. 2023].
• Ending: the course is fixed and ends as planned; ending is not made contingent on response, because response-contingent extension produced "termination reactions" in the Montreal service [source: Garel et al. 2023]. Follow-up assessment at 1–4 weeks is proposed [source: Campolina & de Oliveira 2025].
• Stopping early [synthesis]: medical deterioration, delirium, a new exclusion, or the patient's wish; the course is a choice the patient can leave at any point without losing palliative care.

3. Guiding principles

[source: Campolina & de Oliveira 2025 unless marked]

• Psychological safety and patient-centred care: the patient's comfort and sense of safety outrank completing the protocol.
• Autonomy, informed consent and transparency about limits of evidence: tell patients plainly that this is a proposed model with limited evidence, and what side effects to expect.
• Psychological support, not disease treatment: never imply the course will change the course of the illness [job brief; consistent with the authors' existential aims].
• Altered states are opportunities, not requirements: reassure patients that a "weak" or unremarkable session is not a failure; the work continues in integration.
• Psychotherapy-grade frame: consistent structure, clear roles, fixed course and an ending named from the start, to keep the frame safe and prevent regression and existential despair at the end [also Garel et al. 2023].
• Time-limited, flexible, integrated: fit the course to the patient's prognosis and energy, and keep it joined up with palliative and psychiatric care.
• Bridging biomedical and psychedelic paradigms: combine medical safety (screening, monitoring) with psychedelic-informed set and setting, without imposing a rigid metaphysical framework.
• Cultural and spiritual sensitivity: help patients explore meaning within their own belief system; do not introduce yours.
• Process over content: attend to how the patient meets the experience (openness, avoidance, letting go) more than to interpreting images [source: Garel et al. 2023].
• Window of opportunity: use the period around sessions for active steps (goals, conversations, therapy), moving the patient from passive recipient to active participant [source: Garel et al. 2023].
• Non-directive support in session: follow the patient's lead; offer presence and reassurance rather than guidance unless the patient asked for guidance beforehand [also URMC Pal-KAP; Garel et al. 2023].
• Trauma-informed and psychedelic-informed care, with clear emergency procedures: staff are trained for both, and everyone knows who does what if something goes wrong.
• Therapist qualities the authors name: empathetic presence, trust-building, "spiritual intelligence" and ethical integrity: be steady, honest and comfortable with talk of death and meaning.
• Team communication and multidisciplinary consultation: ketamine providers, psychotherapist and palliative team share information and document decisions.
• Role boundaries [synthesis]: the psychotherapist does not prescribe, administer or monitor vital signs; raise any medical concern with the medical team at once.

4. Intervention inventory

Order follows the course. Example language is illustrative wording, not taken from the sources. All drug-related decisions (whether, how much, how, when) and all physiological monitoring are the prescribing and medical team's responsibility and are not described here.

4.1 Referral, eligibility assessment and screening

• Purpose: confirm the patient is likely to benefit and can take part safely; done before any preparation work.
• Steps:
  1. Accept referral from a treating clinician (Pal-KAP takes referrals into its palliative care programme for evaluation) [source: URMC].
  2. Psychological assessment of the target problem: existential distress, death anxiety, demoralisation, grief, anxiety or depression tied to the illness; openness to exploring identity, meaning and values [source: URMC; Campolina & de Oliveira 2025]. CDCL required that the patient and investigator agree the current anxiety is mainly illness-driven [source: NCT05214417].
  3. Psychiatric history covering the exclusions the protocols publish: current or past psychotic disorders (and, in KAPtivated, a first- or second-degree family history of psychosis or bipolar disorder), bipolar disorder (bipolar I excluded in CDCL; KAPtivated left mild cases to investigator discretion), borderline or other personality disorder judged to interfere, dissociative identity disorder, eating disorders, recent or current substance use disorder or heavy alcohol use, and high suicide risk needing immediate treatment [source: NCT05344625; NCT05214417; Campolina & de Oliveira 2025]. The Montreal model notes that acute suicidal ideation alone was not an exclusion there but required careful exploration and safety planning [source: Garel et al. 2023].
  4. Cognitive screen: significant dementia or cognitive impairment, including chemotherapy-related deficits, excluded participation in CDCL [source: NCT05214417].
  5. Medical screening is done by the medical team; protocols list uncontrolled hypertension and significant cardiovascular or cerebrovascular disease, past stroke, brain bleed or seizures, raised intracranial pressure risk, significant liver or kidney disease, poor functional status, pregnancy, and medicines that interact or cannot be adjusted [source: NCT05344625; NCT05214417; Campolina & de Oliveira 2025]. The therapist's job here is to pass on anything relevant they learn, not to judge it.
  6. Practical supports: a designated caregiver or support person who can take the patient home, be reached if the patient becomes unwell or suicidal, and give collateral information (CDCL requirement) [source: NCT05214417].
• Example language (illustrative): "Before we decide anything, I'd like to understand what feels hardest right now. Is it fear about dying, a sense that things have lost meaning, grief, or something else?"
• Watch for: distress that is mainly a long-standing psychiatric disorder rather than illness-related (consider standard care first) [synthesis]; delirium or fluctuating cognition, which in palliative patients can mimic or mask distress [synthesis]; family pressure behind the referral [synthesis].

4.2 Informed consent and expectation-setting

• Purpose: autonomy and an honest frame; heading off the disappointment the Montreal team saw when patients expected dramatic or miraculous results [source: Garel et al. 2023; Campolina & de Oliveira 2025].
• Steps:
  1. Explain that the approach is a proposed or off-label use with limited evidence; name the short-term effects the São Paulo authors list as expected (dissociation, unusual perceptions, transient anxiety) and that medical staff monitor throughout [source: Campolina & de Oliveira 2025].
  2. Present the drug as opening a brief window, not a cure; any relief may be partial or temporary [source: Garel et al. 2023].
  3. Explain that the course has a fixed number of sessions and a set ending, and that this is discussed openly from the start [source: Campolina & de Oliveira 2025; Garel et al. 2023].
  4. Make clear it does not treat the illness and does not replace palliative care [synthesis].
  5. Explain practical rules the protocols use: avoid alcohol and other non-prescribed psychoactive substances around sessions, keep the medical team informed of all medicines, no driving after sessions for a protocol-defined period, and arrange an escort [source: NCT05344625; NCT05214417].
  6. Document consent and multidisciplinary discussion [source: Campolina & de Oliveira 2025].
• Example language (illustrative): "This won't change the illness itself. What it may do is open a short window where some of the heavier feelings are easier to look at. Some people have strong experiences, some don't, and both are fine."
• Watch for: hopes of cure or of a guaranteed mystical experience; consent given mainly to please family or staff; fluctuating capacity [synthesis]. Revisit consent at each session.

4.3 Psychoeducation and orientation to possible altered states

• Purpose: reduce fear of the unknown and prepare the patient to meet whatever comes with openness [source: Campolina & de Oliveira 2025; URMC].
• Steps:
  1. Describe in plain language the range of possible states the authors name: feeling detached from the body, changes in time and space, dream-like imagery, a sense of the self dissolving, feelings of transcendence, revisiting one's life story ("biographical reconciliation") [source: Campolina & de Oliveira 2025].
  2. Say that many people also have little or nothing dramatic, and that this does not mean failure [source: Campolina & de Oliveira 2025].
  3. Explain the stance you will invite: let feelings come, don't fight sensations, notice thoughts without getting caught in them [source: Garel et al. 2023].
  4. Explain what staff will be doing (sitting nearby, quiet, available; medical staff checking vital signs) [source: URMC; Garel et al. 2023].
  5. Agree a simple signal the patient can use if they want contact or reassurance [synthesis].
• Example language (illustrative): "If you feel you're floating or losing track of your body, that's an expected effect. You don't have to steer it. If something frightening comes, try breathing and letting it pass through; I'll be right here."
• Watch for: patients with death anxiety who may read dissolution as "dying"; explore and normalise this in advance [synthesis].

4.4 Goals of care

• Purpose: anchor the course in what matters to the patient; give integration concrete targets [source: Campolina & de Oliveira 2025].
• Steps:
  1. Hold a goals-of-care conversation and agree at least three goals [source: Campolina & de Oliveira 2025].
  2. Palliative examples the authors give: reconnecting with loved ones, meaningful activities, comfort rituals, creative expression, legacy documentation [source: Campolina & de Oliveira 2025].
  3. The Montreal model uses SMART behavioural goals (sleep routine, daily walking) or, for people already functioning well, values-based goals in the style of ACT committed action [source: Garel et al. 2023]. In palliative care, scale goals to energy and prognosis [synthesis].
  4. Write the goals down; revisit them at every check-in and integration session [source: Campolina & de Oliveira 2025; Garel et al. 2023].
• Example language (illustrative): "If the next few weeks went as well as they could, what would you have done, said, or made?"
• Watch for: goals that depend on others (e.g. a reconciliation the other person may refuse); reframe toward what the patient can do [synthesis].

4.5 Concurrent psychotherapy and team coordination

• Purpose: carry the work between and beyond medicine sessions; the authors treat it as part of the model, not optional [source: Campolina & de Oliveira 2025; Garel et al. 2023].
• Steps:
  1. Arrange weekly evidence-based therapy, ideally starting before the first medicine session [source: Campolina & de Oliveira 2025].
  2. Choose a modality to fit the patient: CBT, Meaning-Centered Psychotherapy, Dignity Therapy, existential or narrative therapy, mindfulness-based approaches, or ACT [source: Campolina & de Oliveira 2025; Garel et al. 2023; Utah study].
  3. If the concurrent therapist is external, agree how and when information is shared with the ketamine and palliative teams [source: Garel et al. 2023].
  4. Patients keep their existing therapist where they have one [source: NCT05214417].
• Watch for: split messages between teams; agree one plan [synthesis].

4.6 Music exploration and selection

• Purpose: music is used to deepen the experience and support introspection [source: Campolina & de Oliveira 2025; Utah study].
• Steps:
  1. In preparation, explore the patient's relationship to music: what soothes, what moves, what to avoid (e.g. pieces tied to bereavement) [source: Garel et al. 2023 for exploring the relationship to music; examples are synthesis].
  2. Choose music for the first session together; Pal-KAP uses a curated playlist via headphones [source: URMC; Garel et al. 2023].
  3. Offer the option of no music [source: Garel et al. 2023].
  4. Review the music's effect in the debrief and adjust next time [synthesis].
• Watch for: lyrics in the patient's language pulling attention outward; strong associations with lost people (may be wanted or overwhelming) [synthesis].

4.7 Pre-session check-in and rolling integration

• Purpose: update risk and context and connect each session to the last (the Montreal sequence) [source: Garel et al. 2023].
• Steps:
  1. Review life events, symptoms, medicine changes (refer to medical team), therapy progress and goal progress; check mood and suicidal thoughts [source: Garel et al. 2023].
  2. Discuss the previous session: meaningful content, integration activities, how it relates to daily life [source: Garel et al. 2023].
  3. In the last sessions, discuss the ending explicitly [source: Garel et al. 2023].
  4. In palliative patients, check pain, nausea, fatigue and whether today is a good day to proceed; liaise with medical staff [synthesis].
• Example language (illustrative): "Since last time, what's stayed with you? Did anything shift in how you're spending your days?"

4.8 Setting session intentions and agreeing level of guidance

• Purpose: give the session a direction without forcing content [source: Garel et al. 2023; URMC].
• Steps:
  1. Ask for one or two intentions, linked to goals of care [source: Garel et al. 2023; URMC].
  2. Agree the music (or none) and how much guidance or contact the patient wants during the session [source: Garel et al. 2023].
  3. Confirm psychological readiness and consent; medical staff confirm physiological baseline [source: Garel et al. 2023].
• Example language (illustrative): "What would you like to bring into today, even loosely? And would you like me to check in with you during it, or mostly leave you be?"
• Watch for: intentions that are demands on the experience ("I must see my mother"); soften to openness ("I'd like to be open to what comes about my mother") [synthesis].

4.9 Opening mindfulness exercise

• Purpose: settle attention and model the accepting stance [source: Garel et al. 2023].
• Steps: at the start of the session, guide a brief exercise attending to the mind, breath and bodily sensations [source: Garel et al. 2023]. Keep it short and adapt for breathlessness (attend to contact points or sounds instead of breath) [synthesis].
• Example language (illustrative): "Let your attention rest on whatever you notice: the breath, the weight of your body on the bed, sounds in the room. Nothing to achieve."

4.10 Set and setting

• Purpose: a calm, de-medicalised, comfortable space that supports an inward focus [source: Campolina & de Oliveira 2025; Garel et al. 2023; URMC].
• Steps:
  1. Use a calm, non-clinical-looking room where possible (Pal-KAP describes an art-filled preparation room); in the São Paulo model sessions are inpatient within an oncology hospital [source: URMC; Campolina & de Oliveira 2025].
  2. Offer eyeshades and headphones; the patient lies back [source: URMC; Garel et al. 2023].
  3. Provide comfort measures (pillows, blankets, positioning for pain) and supportive silence [source: Campolina & de Oliveira 2025].
  4. Avoid imposing a metaphysical framework [source: Campolina & de Oliveira 2025].
  5. Minimise interruptions; plan beforehand how medical checks will be done quietly [synthesis].
• Watch for: claustrophobia under eyeshades; offer to remove them [synthesis].

4.11 Non-directive presence during the medicine session

• Purpose: safety and accompaniment without steering [source: Campolina & de Oliveira 2025; URMC; Garel et al. 2023].
• Steps:
  1. Staffing: at least one clinician present throughout (Montreal, São Paulo); Pal-KAP uses two trained facilitators [source: Garel et al. 2023; Campolina & de Oliveira 2025; URMC].
  2. Sit nearby; offer quiet presence and reassurance [source: URMC].
  3. With music playing, keep interaction minimal until the playlist ends; without music, gently encourage openness and acceptance, follow the patient's lead and check in from time to time [source: Garel et al. 2023].
  4. Touch: none of the palliative sources state a touch policy [uncertain]. [synthesis] Agree any supportive touch (e.g. hand-holding) in preparation, in writing, and only offer it with the patient's renewed consent in the moment; never other touch.
  5. Note observations for the debrief [synthesis].
• Example language (illustrative): "I'm here. You're safe. Let it move through."
• Watch for: the urge to interpret or guide; resist unless the patient asked for guidance [source: principle of non-directive support].

4.12 Responding to anxiety and difficult experiences in session

• Purpose: help the patient stay with difficult material rather than fight it, while keeping safety [source: Garel et al. 2023; Campolina & de Oliveira 2025].
• Steps:
  1. Encourage the patient not to suppress emotions or judge sensations, but to feel them without getting tangled in the thoughts that come with them [source: Garel et al. 2023].
  2. Validate the emotion; stay curious about the experience [source: Garel et al. 2023].
  3. Offer reassurance and grounding: your voice, the agreed signal, reminding them where they are and that it will pass [synthesis].
  4. If distress is severe or the patient wants to stop, alert medical staff immediately; follow the service's emergency procedure [source: Campolina & de Oliveira 2025 calls for clear emergency procedures; steps synthesis].
• Example language (illustrative): "It's okay to feel this. You don't have to work out what it means right now. Just feel it, and let the thoughts drift."
• Watch for: panic (the Montreal team saw it lead to early termination of treatment), signs the patient believes they are dying, and any physical symptom, which you report to medical staff at once [source: Garel et al. 2023; reporting synthesis].

4.13 Post-session debrief and discharge

• Purpose: first processing while the experience is fresh; safe handover home [source: Garel et al. 2023; NCT05344625].
• Steps:
  1. When acute effects have passed (or the playlist ends), spend about 20–30 minutes on the experience [source: Garel et al. 2023]. KAPtivated has a KAP-trained psychotherapist lead this discussion [source: NCT05344625].
  2. Sit with and validate strong emotions [source: Garel et al. 2023].
  3. Point out moments where the patient managed, or struggled, to let go [source: Garel et al. 2023].
  4. Revisit the intentions and link to goals; agree next steps [source: Garel et al. 2023].
  5. Discharge only when medical staff judge physical status normal and you judge the patient psychologically ready; give safety reminders and a way to contact the service about adverse reactions or distress [source: Garel et al. 2023]. Hand over to the escort or caregiver [source: NCT05214417].
• Example language (illustrative): "Take your time. What stands out most? ... There was a point you seemed to soften. What happened for you then?"
• Watch for: confusion, unsteadiness or lingering distress (tell medical staff); pressure to make meaning too fast [synthesis].

4.14 Integration sessions

• Purpose: turn the experience into change and closure [source: Campolina & de Oliveira 2025; URMC].
• Steps:
  1. Timing: within 24–72 hours of each medicine session and continuing after the last (São Paulo); KAPtivated used a virtual session the next day plus one about a month later [source: Campolina & de Oliveira 2025; NCT05344625].
  2. Invite a free account of the experience; follow the patient's words [synthesis].
  3. Process unresolved emotional material that came up [source: Campolina & de Oliveira 2025].
  4. Revisit the goals of care [source: Campolina & de Oliveira 2025].
  5. Translate insights into concrete, values-based steps (actionable goals in KAPtivated's wording) [source: Campolina & de Oliveira 2025; NCT05344625].
  6. Identify practices that support self-understanding, self-acceptance and presence (Pal-KAP's stated focus) [source: URMC].
  7. Support existential resolution, legacy work and emotionally significant conversations [source: Campolina & de Oliveira 2025].
  8. Address reactions to the course ending; build closure [source: Campolina & de Oliveira 2025].
• Example language (illustrative): "You said you felt your father beside you. What would you want to do with that, in the time you have?"
• Watch for: whether insights lead to action (calls made, letters written, time spent differently); over-literal readings of imagery that frighten the patient; work within the patient's own beliefs [source: cultural sensitivity principle; specifics synthesis].
• Working signs: lower distress, more engagement with people and activities, more ease talking about death, progress on goals of care [synthesis, aligned with the authors' aims].

4.15 ACT-informed processing: feel, defuse, act on values

• Purpose: the Montreal model's core processing stance; the Utah study used ACT as its therapy model [source: Garel et al. 2023; Utah study].
• Steps:
  1. Feel emotions rather than avoid them: name what was felt and allow it in session [source: Garel et al. 2023].
  2. Defuse from difficult thoughts: notice thoughts as thoughts ("I'm having the thought that...") rather than facts [source: Garel et al. 2023 names defusion; the phrasing is a standard ACT exercise, synthesis].
  3. Take value-driven action: pick a small step toward something that matters [source: Garel et al. 2023].
  4. Work on difficulty letting go gradually across sessions, since each session revisits the last [source: Garel et al. 2023].
• Example language (illustrative): "The thought 'I've wasted my life' showed up a lot. Can we notice it as a thought your mind offers, and then ask what you'd like to do with today?"

4.16 Meaning-centred, dignity and legacy work

• Purpose: the existential aims of the palliative model [source: Campolina & de Oliveira 2025].
• Steps:
  1. Draw on the concurrent modalities the authors name, Meaning-Centered Psychotherapy and Dignity Therapy, in integration and concurrent sessions [source: Campolina & de Oliveira 2025]. Use those approaches as their own manuals describe (not detailed here) [uncertain: protocols].
  2. Support legacy documentation, creative expression, comfort rituals and reconnecting with loved ones as goals emerge [source: Campolina & de Oliveira 2025].
  3. Help plan important conversations (e.g. saying thank you, sorry or goodbye) [source: "emotionally significant conversations", Campolina & de Oliveira 2025; examples synthesis].
  4. Explore spiritual material within the patient's own tradition; offer chaplaincy where wanted (Pal-KAP includes a chaplain among facilitators) [source: URMC; Campolina & de Oliveira 2025].
• Example language (illustrative): "Is there something you'd like the people you love to know or keep from you?"

4.17 Caregiver and support-person involvement

• Purpose: practical safety and collateral information [source: NCT05214417].
• Steps: identify a designated support person who can bring the patient home, be reachable if the patient becomes unwell or suicidal, and give collateral information; agree with the patient what will be shared [source: NCT05214417; consent step synthesis]. Family involvement in sessions is not described in the palliative sources [uncertain].
• Watch for: family conflict or expectations driving the process; family members' own anticipatory grief (offer support or referral) [synthesis].

4.18 Between-session contact

• Purpose: catch delayed distress early [source: NCT05214417].
• Steps: CDCL allowed therapists to phone participants daily for a week after each medicine session if needed; Montreal patients are told to contact the clinic about adverse reactions or distress [source: NCT05214417; Garel et al. 2023]. Agree in advance who answers and out-of-hours cover [synthesis].

4.19 Ending and closure

• Purpose: avoid termination reactions (symptoms returning near the end) and despair at the course ending [source: Garel et al. 2023; Campolina & de Oliveira 2025].
• Steps:
  1. Name the fixed course and its ending in the first session [source: Campolina & de Oliveira 2025; Garel et al. 2023].
  2. Discuss termination explicitly in the last sessions [source: Garel et al. 2023].
  3. Use integration to process reactions to the ending and create closure [source: Campolina & de Oliveira 2025].
  4. Secure continuing support: concurrent therapy and palliative care continue after the course [source: Garel et al. 2023; Campolina & de Oliveira 2025].
  5. In palliative care, the ending can echo the larger ending; name this gently if it fits [synthesis].
• Example language (illustrative): "We're coming to the end of this part. Endings can stir up a lot, especially now. What's it like to think about finishing?"

4.20 Outcome monitoring

• Purpose: track existential and psychological change [source: Campolina & de Oliveira 2025].
• Steps: the São Paulo authors propose the Patient Dignity Inventory, the FACIT-Sp Meaning/Peace subscale, the Distress Scale II or ESAS spiritual domain, and semi-structured qualitative interviews, with follow-up at 1–4 weeks; trials used the Death and Dying Distress Scale, STAI-Trait, GRID-HAM-D17 and HAM-A, and KAPtivated planned the MEQ-30 after sessions [source: Campolina & de Oliveira 2025; NCT05344625; NCT05214417]. Use licensed versions; items not reproduced here.

4.21 Supporting patients who seek ketamine outside a regulated palliative service [synthesis]

• Purpose: harm reduction and integration support, never facilitation.
• Steps: assess why and where (licensed clinic, prescription product, or illicit); discuss in general terms risks the protocols screen for (heart and blood-pressure problems, seizures, psychosis history, interactions with other medicines, alcohol, cognitive impairment); encourage disclosure to the palliative and prescribing teams; make a safety plan (escort, no driving, a contact if distressed); offer integration sessions using 4.14–4.16; refer to a regulated service where available.
• Watch for: illicit supply, frailty and polypharmacy, and patients who feel they "failed" a session; never advise on amounts or how to use.

5. Handling problems

Source-based problems first; the rest is marked [synthesis].

• Termination reactions (symptoms or despair returning as the course ends). Montreal saw this when further sessions were made contingent on response. Response: keep a fixed course, name the ending from the start, discuss it explicitly in the final sessions, process it in integration, keep concurrent therapy and palliative care going [source: Garel et al. 2023; Campolina & de Oliveira 2025].
• Unrealistic expectations and disappointment. Patients who expect dramatic or miraculous results may be discouraged by partial or brief effects; in some, suicidality rose. Response: set expectations in preparation (4.2), restate that the altered state is not essential, check mood and suicidal thoughts at every contact, and follow standard suicide risk assessment and safety planning with the palliative team [source: Garel et al. 2023; Campolina & de Oliveira 2025; risk procedure synthesis].
• Acute panic or distressing dissociation. Distress can range from discomfort to panic and has led to early termination of treatment; distressing experiences framed as meaningful may feel more upsetting. Response: in session, use the accepting, defusing stance (4.12) and alert medical staff; afterwards, validate, avoid insisting the experience was meaningful, and let the patient decide whether to continue [source: Garel et al. 2023; Campolina & de Oliveira 2025; "let the patient decide" synthesis].
• Physical instability or new symptoms during a session. The authors name possible blood-pressure and heart-rate changes and require staff ready to manage them. Response: you do not manage these; stop, call the medical lead and follow the emergency procedure [source: Campolina & de Oliveira 2025; role synthesis].
• Variable or minimal response ("nothing happened"). Response: normalise; explore what was present (calm, boredom, body sensations); keep working on goals in integration and concurrent therapy [source: altered states "not essential", Campolina & de Oliveira 2025; specifics synthesis].
• Reliance on repeated sessions. Montreal notes the costs and drawbacks of open-ended repeat sessions and aims to reduce reliance. Response: keep the course fixed; build the patient's own resources (practices, relationships, therapy) [source: Garel et al. 2023].
• Team coordination failures. Response: one shared plan, named roles, documented multidisciplinary decisions, regular contact between ketamine providers, psychotherapist and palliative team [source: Campolina & de Oliveira 2025].
• Stuck client in integration (intellectualising, "it was just weird") [synthesis]: move from meaning to body and feeling ("Where do you notice that now?"); link back to one goal of care; offer a creative route (writing, a letter, drawing).
• Ambivalence or resistance [synthesis]: explore the fear (losing control, dying, seeing something about one's life); remind them that consent can be withdrawn; offer more preparation or to stop, without loss of palliative care.
• Overwhelm after sessions (flooding of grief, guilt or old trauma) [synthesis]: slow down; stabilise with grounding and concrete support; increase contact (as CDCL's phone-call option allows [source: NCT05214417]); involve psychiatry if distress persists; reconsider further sessions with the team.
• Non-adherence to session rules (alcohol or other substances, undisclosed medicines, no escort, missed integration) [synthesis]: tell the medical team before the next session; explore the reason non-judgementally; reschedule rather than proceed when safety rules are not met.
• Ruptures (feeling abandoned in a session, feeling pushed toward "acceptance" of death, staff disagreement) [synthesis]: name and repair openly; return to the patient's own goals; never press a particular stance on death or meaning.
• Medical deterioration, delirium or loss of capacity mid-course [synthesis]: pause; re-assess capacity with the medical team; shift to supportive or bedside presence and legacy work without medicine sessions; support family.
• Death before the course ends [synthesis]: plan for this in preparation (what matters most to do first); offer bereavement support to family and debrief to staff.
• Spiritual or existential crisis (frightening imagery of death, religious fears) [synthesis]: explore within the patient's beliefs; offer chaplaincy or their own faith leader; avoid offering your own interpretation.
• Trauma resurfacing [synthesis]: the authors call for trauma-informed care [source: Campolina & de Oliveira 2025]; screen for trauma in preparation, agree a plan, and keep integration paced to stabilisation.
• Family pressure or conflict [synthesis]: see the patient alone for consent and goals; offer family support separately.
• Therapist strain (repeated exposure to death and intense sessions) [synthesis]: supervision and team debriefs.

Sources

Sources:

• Unfolding States of Mind: A Dissociative-Psychedelic Model of Ketamine-Assisted Psychotherapy in Palliative Care (Healthcare, MDPI): Campolina AG, de Oliveira MAT, 2025. Primary source for the model.
• The Montreal model: an integrative biomedical-psychedelic approach to ketamine for severe treatment-resistant depression (Frontiers in Psychiatry, full text) and PDF: Garel N, Greenway KT, et al., 2023. Parent model; session sequence.
• Palliative Care Ketamine-Assisted Psychotherapy (Pal-KAP), University of Rochester Medical Center
• Ketamine-Assisted PsychoTherapy ViAbility in Treating Cancer-related Emotional Distress (KAPTIVATED), NCT05344625
• Conscious Dying/Conscious Living: Ketamine-Assisted Psychotherapy, NCT05214417 (registry summary on moreblossom.com; secondary)
• U researchers' ketamine-assisted psychotherapy study is underway (Daily Utah Chronicle, 2024; secondary)
• CBH Procedures: Spravato, June 2026 (US REMS and schedule)
• FDA approval letter, NDA 211243/S-028 (Spravato REMS modification), April 2026
• Scottish Medicines Consortium accepts esketamine for depression after NICE rejection (article title paraphrased) (Pharmaceutical Journal)
• NICE draft guidance: esketamine for treatment-resistant depression not recommended (title paraphrased) (NICE news)

Further reading (not drawn on) [uncertain]: the treatment manuals of Meaning-Centered Psychotherapy and Dignity Therapy; the CDCL trial manual; the Pal-KAP protocol beyond its public page; EU/EMA and Brazilian regulatory documents; the current US schedule of racemic ketamine.

Items still [uncertain]: touch policy (not stated in any palliative source opened); family involvement in sessions; final NICE position; whether Pal-KAP publishes exclusion criteria.