Palliative Electroconvulsive Therapy in Serious Illness: A Narrative Review and Conceptual Framework.

CONTEXT: Severe depression, catatonia, psychosis, and agitation can become major sources of suffering in serious illness, impairing communication, decision-making, and quality of life (QOL). Although electroconvulsive therapy (ECT) may offer rapid relief of these syndromes, its role as a palliative intervention remains poorly defined. OBJECTIVES: To review the literature relevant to palliative electroconvulsive therapy (PECT), clarify how the term has been conceptualized, and examine the clinical contexts in which ECT may serve palliative goals in serious illness care. METHODS: We conducted a narrative review of literature relevant to ECT in serious illness and palliative contexts using PubMed and PsycINFO through February 2026. English-language case reports, case series, reviews, and observational studies were screened for relevance. Findings were synthesized using a deductive, theory-driven approach guided by a previously proposed four-domain conceptual framework for PECT. RESULTS: Thirty-four studies met inclusion criteria, consisting primarily of case reports and case series. No randomized controlled trials or standardized PECT protocols were identified. Literature clustered across four overlapping evidence areas: ECT in explicit palliative or end-of-life settings; ECT for psychiatric syndromes complicating serious illness; ECT for severe behavioral and psychological symptoms of dementia; and ECT used with palliative intent in treatment-refractory psychiatric illness. Across contexts, reports described rapid improvement in severe neuropsychiatric symptoms, restoration of communication or decision-making capacity, reduction of behavioral distress, and improved participation in goal-concordant care. CONCLUSION: PECT is a promising but underutilized intervention in serious illness. Greater conceptual clarity, interdisciplinary collaboration, and structured clinical pathways may help expand appropriate access to PECT.