CASE ‘I’ve had enough’
The psychiatry consultation team is asked to evaluate Mr. M, age 76, for a passive death wish and depression 2 months after he was admitted to the hospital after a traumatic fall.
Mr. M has several chronic medical conditions, including hypertension, type 2 diabetes mellitus, and coronary artery disease. Within 2 weeks of his admission, he developed Proteus mirabilis pneumonia and persistent respiratory failure requiring tracheostomy. Records indicate that Mr. M has told family and his treatment team, “I’m tired, just let me go.” He then developed antibiotic-induced Clostridium difficile colitis and acute renal failure requiring temporary renal replacement therapy (RRT).
Mr. M’s clinical status improves, allowing his transfer to a transitional unit, where he continues to state, “I have had enough. I’m done.” He asks for the tracheostomy tube to be removed and RRT discontinued. He is treated again for persistent C. difficile colitis and, within 2 weeks, develops hypotension, hypoxia, emesis, and abdominal distension, requiring transfer to the ICU for management of ileus.
He is stabilized with vasopressors and artificial nutritional support by nasogastric tube. Renal function improves, RRT is discontinued, and he is transferred to the general medical floor.
After a few days on the general medical floor, Mr. M develops a urinary tract infection and develops antibiotic-induced acute renal failure requiring re-initiation of RRT. A percutaneous endoscopic gastrostomy (PEG) tube is placed for nutrition when he shows little improvement with swallowing exercises. Two days after placing the PEG tube, he develops respiratory failure secondary to a left-sided pneumothorax and is transferred to the ICU for the third time, where he undergoes repeated bronchoscopies and requires pressure support ventilation.
One week later, Mr. M is weaned off the ventilator and transferred to the general medical floor with aggressive respiratory therapy, tube feeding, and RRT. Mr. M’s chart indicates that he expresses an ongoing desire to withdraw RRT, the tracheostomy, and feeding tube.
Which of the following would you consider when assessing Mr. M’s decision-making capacity (DMC)?
a) his ability to understand information relevant to treatment decision-making
b) his ability to appreciate the significance of his diagnoses and treatment options and consequences in the context of his own life circumstances
c) his ability to communicate a preference
d) his ability to reason through the relevant information to weigh the potential costs and benefits of treatment options
e) all of the above
HISTORY Guilt and regret
Mr. M reports a 30-year history of depression that has responded poorly to a variety of medications, outpatient psychotherapy, and electroconvulsive therapy. Before admission, he says, he was adherent to citalopram, 20 mg/d, and buspirone, 30 mg/d. Citalopram is continued throughout his hospitalization, although buspirone was discontinued for unknown reasons during admission.
Mr. M is undergoing hemodialysis during his initial encounter with the psychiatry team. He struggles to communicate clearly because of the tracheostomy but is alert, oriented to person and location, answers questions appropriately, maintains good eye contact, and does not demonstrate any psychomotor abnormalities. He describes his disposition as “tired,” and is on the verge of tears during the interview.
Mr. M denies physical discomfort and states, “I have just had enough. I do not want all of this done.” He clarifies that he is not suicidal and denies a history of suicidal or self-injurious behaviors.
Mr. M describes having low mood, anhedonia, and insomnia to varying degrees throughout his adult life. He also reports feeling guilt and regret about earlier experiences, but does not elaborate. He denies symptoms of panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, mania, or hypomania. He reports an episode of visual hallucinations during an earlier hospitalization, likely a symptom of delirium, but denies any recent visual disturbances.
Mr. M’s thought process is linear and logical, with intact abstract reasoning and no evidence of delusions. Attention and concentration are intact for most of the interview but diminish as he becomes fatigued. Mr. M can describe past treatments in detail and recounts the events leading to this hospitalization.
The authors’ observations
Literature on assessment of DMC recently has centered on the 4-ability model, proposed by Grisso and Appelbaum.1 With this approach, impairment to any of the 4 processes of understanding, appreciation, ability to express a choice, and ability to use reasoning to weigh treatment options could interfere with capacity to make decisions. Few studies have clarified the mechanism and degree to which depression may impair these 4 elements, making capacity assessments in a depressed patient challenging.
Preliminary evidence suggests that depression severity, not the presence of depression, determines the degree to which DMC is impaired, if at all. In several studies, depressed patients did not demonstrate more impaired DMC compared with non-depressed patients based on standardized assessments.2-4 In depressed patients who lack DMC, case reports5-7 and cross-sectional studies8 indicate that appreciation—one’s ability to comprehend the personal relevance of illness and potential consequences of treatments in the context of one’s life—is most often impaired. Other studies suggest that the ability to reason through decision-specific information and weigh the risks and benefits of treatment options is commonly impaired in depressed patients.9,10