Ethics, Psychiatry, and End-of-Life Issues
Ethics, Psychiatry, and End-of-Life Issues
At the end of life, psychiatrists are often asked to assess a patient’s capacity to refuse treatment, but the role of the psychiatrist in this situation is much broader. Even when a person’s mental capacity is not at issue, subtle and not-so-subtle psychological forces can weigh heavily on life-and-death decisions that may be elucidated with a psychiatric assessment.1,2 In an ideal world envisaged by supporters of physician-assisted death, patients ask for assistance to die because they have weighed the pros and cons of continued existence; finding the option of prolonging life unsatisfactory, they opt for death at a time of their own choosing—an exit with dignity and grace. Although this scenario may happen, it is far from universal. Often, a request for physician-assisted dying or for withdrawal of life-sustaining treatment results more from a fear of the unknown, a need to maintain control, or a misunderstanding of what the future may bring.
Most nonpsychiatric physicians should be able to make competency assessments. However, when a patient appears to be choosing death and when proposed treatment cannot be regarded as futile, an expert in capacity—a psychiatrist—should be involved.3
Ms P was a 44-year-old woman with advanced multiple sclerosis. She was entirely restricted to her bed and needed help with her meals and toileting. Her major activity was to watch daytime television. She was admitted to the hospital because of a urinary tract infection. When the treating team approached her with an intravenous cannula for antibiotics, she batted them away. Her brother, who was her full-time caregiver, told her doc-tors that this reaction was not surprising. She had often told him that if things “got bad” she would not want extraordinary treatment. As the hospital consultation-liaison psychiatrist, I was consulted to ensure that it was reasonable and ethical to withhold treatment.
I have a long interest in end-of-life issues and am a staunch advocate of a patient’s right to refuse treatment or even (when legally permitted) to request physician-assisted dying. The referring physician, therefore, had little doubt that I would agree with his opinion that the antibiotics should be withheld.3,4 When I saw Ms P, however, she exhibited an obvious delirium that the treating team had missed. Her delirium had robbed her of any ability to attend or concentrate. She could not retain or understand information about her treatment options, and it was clear she was not competent to refuse treatment. Moreover, although her brother seemed to genuinely believe that Ms P would not have wanted treatment, he had no evidence for this except a vague recollection of a few casual remarks. I recommended that antibiotics be given to Ms P.
When her delirium cleared, I talked with Ms P again to find out what she would like done in a similar situation. Her speech was dysarthric but clear. Would she want antibiotics again if she found herself in the same situation in the future? “Of course I would,” she said, “I only wouldn’t want treatment if things got really bad !”
Delirium is easily missed, but unlike nonpsychiatric physicians, psychiatrists are trained to recognize it. Because of this training, a psychiatrist probably would not have missed Ms P’s delirium. However, the fact that Ms P’s treating physician missed it is not surprising. Numerous studies have demonstrated that nonpsychiatric physicians routinely overlook delirium.5-8 This is extremely concerning when it comes to evaluating capacity for end-of-life decisions. We know that delirium is likely to rob a person of his or her capacity; that it is common in patients with serious, chronic, and terminal illness; and that frequently it is reversible.9-13
Patients with delirium will almost certainly lack the capacity to make important decisions.14 If a patient lacks capacity, any apparent request to refuse treatment should be ignored, and unless there is a clear advance directive to the contrary, the patient should be treated according to his best interests. Unless treatment can be reasonably regarded as futile, treatment according to best interests means that the underlying cause of the patient’s delirium is addressed and the patient’s mental state restored to normal, if possible. Once capacity has been regained, the patient can be asked directly about treatment preferences.
Capacity concerns in end-of-life decisions are not limited to patients with delirium. The diagnosis of delirium is relatively straightforward in the chronically or terminally ill patient compared with the diagnosis of clinical depression. The overlap in the symptoms of depression and the symptoms of many physical diseases and the similarity between clinical depression and understandable distress combine to make the diagnosis of depression in this population frequently challenging, even for experienced psychiatrists.1,15 It is completely understandable that nonpsychiatric doctors routinely miss clinical depression in patients who are chronically and terminally ill, despite its high prevalence in this population.15-21