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?
Melinda Lee, M.D. (Santa Clara University '69), is associate professor of medicine at Oregon Health Sciences University and a geriatrician with Providence ElderPlace in Portland.
Winter 1997