Even when a depressed patient demonstrates the 4 elements of DMC, providers might be concerned that the patient’s preferences are skewed by the negative emotions associated with depression.11-13 In such a case, the patient’s expressed wishes might not be consistent with views and priorities that were expressed during an earlier, euthymic period.
Rather than focusing on whether cognitive elements of DMC are impaired, some experts advocate for assessing how depression might lead to “unbalanced” decision-making that is impaired by a patient’s tendency to undervalue positive outcomes and overvalue negative ones.14 Some depressed patients will decide to forego additional medical interventions because they do not see the potential benefits of treatment, view events through a negative lens, and lack hope for the future; however, studies indicate this is not typically the case.15-17
In a study of >2,500 patients age >65 with chronic medical conditions, Garrett et al15 found that those who were depressed communicated a desire for more treatment compared with non-depressed patients. Another study of patients’ wishes for life-sustaining treatment among those who had mild or moderate depression found that most patients did not express a greater desire for life-sustaining medical interventions after their depressive episode remitted. An increased desire for life-sustaining medical interventions occurred only among the most severely depressed patients.16 Similarly, Lee and Ganzini17 found that treatment preferences among patients with mild or moderate depression and serious physical illness were unchanged after the mood disorder was treated.
These findings demonstrate that a clinician charged with assessing DMC must evaluate the severity of a patient’s depression and carefully consider how mood is influencing his (her) perspective and cognitive abilities. It is important to observe how the depressed patient perceives feelings of sadness or hopelessness in the context of decision-making, and how he (she) integrates these feelings when assigning relative value to potential outcomes and alternative treatment options. Because the intensity of depression could vary over time, assessment of the depressed patient’s decision-making abilities must be viewed as a dynamic process.
Clinical application
Recent studies indicate that, although the in-hospital mortality rate for critically ill patients who develop acute renal failure is high, it is variable, ranging from 28% to 90%.18 In one study, patients who required more interventions over the course of a hospital stay (eg, mechanical ventilation, vasopressors) had an in-hospital mortality rate closer to 60% after initiating RRT.19 In a similar trial,20,21 mean survival for critically ill patients with acute renal failure was 32 days from initiation of dialysis; only 27% of these patients were alive 6 months later.21
Given his complicated hospital course, the medical team estimates that Mr. M has a reasonable chance of surviving to discharge, although his longer-term prognosis is poor.
EVALUATION Conflicting preferences
Mr. M expresses reasonable understanding of the medical indications for temporary RRT, respiratory therapy, and enteral tube feedings, and the consequences of withdrawing these interventions. He understands that the primary team recommended ongoing but temporary use of life-sustaining interventions, anticipating that he would recover from his acute medical conditions. Mr. M clearly articulates that he wants to terminate RRT knowing that this would cause a buildup of urea and other toxins, to resume eating by mouth despite the risk of aspiration, and to be allowed to die “naturally.”
Mr. M declines to speak with a clergy member, explaining that he preferred direct contact with God and had reconciled himself to the “consequences” of his actions. He reports having “nothing left to live for” and “nothing left to do.” He says that he is “tired of being a burden” to his wife and son, regrets the way he treated them in the past, and believes they would be better off without him.
Although Mr. M’s abilities to understand, reason, and express a preference are intact, the psychiatry team is concerned that depression could be influencing his perspective, thereby compromising his appreciation for the personal relevance of his request to withdraw life-sustaining treatments. The psychiatrist shares this concern with Mr. M, who voices an understanding that undertreated depression could lead him to make irreversible decisions about his medical treatment that he might not make if he were not depressed; nevertheless, he continues to state that he is “ready” to die. With his permission, the team seeks additional information from Mr. M’s family.
Mr. M’s wife recalls a conversation with her husband 5 years ago in which he said that, were he to become seriously ill, “he would want everything done.” However, she also reports that Mr. M has been expressing a passive death wish “for years,” as he was struggling with chronic medical conditions that led to recurrent hospital admissions.