The Case of the Depressed Patient
When
seriously ill patients ask to discontinue life-sustaining treatment,
depression may be impairing their ability to make decisions. In this
case study, a geriatrician discusses how a physician might work
through the ethics of this situation. At
80, R.L. lives with his wife in a retirement community. He has
always valued his independence, but recently he has been having
trouble caring for himself. He is having difficulty walking and
managing his medications for diabetes, heart disease, and kidney
problems. His
doctor diagnoses depression after noting that R.L. has lost interest
in the things he used to enjoy. Lethargic and sleepless, R.L. has
difficulty maintaining his weight and talks about killing himself
with a loaded handgun. He agrees to try medication for the mood
disorder. Two
weeks later, before the effect of the medicine can be seen, R.L. is
hospitalized for a heart attack. The heart is damaged so severely it
can't pump enough blood to keep the kidneys working. Renal
dialysis is necessary to keep R.L. alive, at least until it's clear
whether the heart and kidneys will recover. This involves moving him
three times a week to the dialysis unit, where needles are inserted
into a large artery and a vein to connect him to a machine for three
to four hours. After
the second treatment, R.L. demands that dialysis be stopped and asks
to be allowed to die. You
are R.L.'s physician. What should you
do? R.L.'s
was an actual case that presented his physicians with a common
dilemma in treating patients with serious illnesses: Had depression
rendered him incapable of making a legitimate life-and-death
decision? When
patients agree to undergo or refuse medical treatment, they are
supposed to reach the decision by a process called informed consent.
The doctor discloses information about the medical condition,
treatment options, possible complications, and expected outcomes
with or without treatment. To
give informed consent or refusal, the patient must be acting
voluntarily and must have the capacity to make the decision. That
means the patient must be able to understand the information,
appreciate its personal implications, weigh the options based on
personal values and life goals, and communicate a decision. From an
ethical point of view, informed consent is based on the
philosophical principles of autonomy and beneficence. In R.L.'s
case, these two principles are in conflict. First, R.L.'s prognosis
is unclear, and the physician does not know if the benefits of
dialysis will outweigh the burdens. Under normal circumstances, this
decision would be made by R.L., but the physician suspects the
patient's capacity for autonomous decision making is impaired by
depression. Depression
is a mood disorder that can profoundly affect a person's ability to
think positively, experience pleasure, or imagine a brighter future.
Depressed people frequently have little energy, poor appetites, and
disturbed sleep. They may have difficulty concentrating, or they may
be troubled by feelings of guilt and hopelessness. Preoccupation
with death is common and, in some cases, may include contemplating
suicide. Because
R.L. was suicidal before his heart attack, no one was sure whether
his refusal of dialysis represented an authentic exercise of his
right to stop life-saving treatment or a convenient means to
passively end his life. On the other hand, if the doctor continued
dialysis, he would be denying R.L. the same right to refuse
treatment that another patient who was not depressed would have. When
patients ask to have life-sustaining treatment withheld, doctors
have been taught to consider whether depression is driving the
request, because the condition lifts in two-thirds of those who are
treated with anti-depressant medications. The presumption is that
once the problem has cleared, the patient will look at treatment
decisions differently. Recent
research has challenged that presumption by showing depressed
patients don't necessarily choose to hasten death in the first place
and they often make the same decisions after they recover from
depression. Thus,
depressed patients may be able to give informed consent, but doctors
and loved ones must consider whether the decision to refuse medical
treatment is logical, internally consistent, and conforms with past
life choices and values. In
R.L.'s case, the doctor, in consultation with a psychiatrist,
decided to continue the course of anti depressant medication to see
if, when it began to take effect, R.L. would change his mind about
treatment. In the meantime, his dialysis was continued. After
five weeks, R.L. showed no improvement, and he began to refuse
medications and food. His wife was asked to give consent for a
feeding tube. On
conferring with the rest of the family, R.L.'s wife denied the
doctor's request. Her husband's repeated refusal of dialysis had
convinced the family R.L. really did want to die. In addition,
R.L.'s unchanged physical condition indicated that, if he survived
to discharge, he would probably need nursing home care, a fate he
had resisted even before his depression. Ultimately,
the physician shared the family's assessment that R.L.'s consistent
refusals indicated an authentic wish to halt treatment. He was taken
off dialysis and put on comfort measures. Six days later, he died. How
would you sort through the ethics of this situation? |