Depression, decisions and the desire to die

All patients who request withdrawal of non-futile life-sustaining treatment should first undergo psychiatric assessment

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Major depression is far more than a disorder of emotion; its effects on reason and the intellect may be just as profound. As it takes hold, it steadily infiltrates and infects its victim's every thought. Everything comes to be seen through a veil of despondency and despair. As time passes, sadness turns to emptiness and emptiness turns to pain. Increasingly, there seem fewer and fewer options. Often, toward the end, the patient can see no way out of the blackness and all hope is lost. Ten percent commit suicide.

Some seriously ill people, like those with end-stage renal failure or potentially terminal cancer, require medical treatments to continue to live. In Australia, there is a legal right to refuse such treatment. The laws that bestow this right are based upon the principle of maximising autonomy, which asserts that competent adults should be allowed to make their own choices about their own lives, provided these choices do not cause harm to others. This principle assumes that the choices are not influenced by mental illness. However, one would expect that a patient with major depression might be more likely to refuse life-sustaining treatment, because of the cognitive effects of the depression.

In this issue of the Journal, Hooper and colleagues (page 416) provide empirical evidence that depression does influence choice about life-sustaining treatment. They asked a cohort of elderly, depressed people to imagine which life-sustaining treatments they would reject in two hypothetical situations. They found that, on average, people rejected more life-sustaining treatments when they were depressed than when they had later recovered. Major depression is eminently treatable. If it can influence the seriously ill to refuse treatment, then some of those who do refuse treatment might be depressed and might change their minds if the depression were treated.

Other recent studies have also shown a link between depression and a desire to die. Chochinov et al. found that 47% of terminally ill people who expressed a serious desire for death suffered from major depression.⁵ Emanuel et al. found that oncology patients who seriously considered and prepared for euthanasia or physician-assisted suicide were significantly more likely to be depressed.⁶ Taken together, these studies underline the importance of recognising and treating major depression before meeting a request to withdraw life-sustaining treatment.

Unfortunately, the diagnosis of major depression in the gravely ill is very difficult. Low spirits are to be expected in serious illness, and many of the other features of major depression (such as weight loss and sleep disturbance) are also common in physical illnesses. The difficulty of diagnosis is reflected in studies that reveal that non-psychiatrically trained doctors miss up to half of cases of major depression in the medically ill.^7-9

Life-sustaining treatments are often withdrawn in situations where their continuation would provide no tangible benefit to the patient. The decision to withhold these futile treatments will be based upon many factors besides patient preference. However, when a treatment is not futile, patient refusal is usually central to a decision to stop. A doctor caring for a patient in this situation has a duty to ensure that the refusal is not motivated by a major depression. Given the difficulties of accurate diagnosis, this duty is best fulfilled by asking a psychiatrist to review the patient.

Advance directives ("living wills") are documents that allow their users to specify in advance which life-sustaining treatments they would accept if needed in the future. If an advance directive is made while a patient is depressed, it is unlikely to be a valid indication of that patient's future preferences. The same arguments outlined above apply. Advance directives made in the context of a serious illness should only be completed after psychiatric review. Without this review, doctors should be cautious about complying with the directive.

The Northern Territory legislation that permits active voluntary euthanasia demands a psychiatric review before a patient can be assisted to die.^10,11 This provision was included to provide patients with the best protection against the possibility of meeting a request driven by a treatable depression. Our duty to protect those with a desire to die extends far beyond those who request active euthanasia. Any patient who refuses life-sustaining treatment, and for whom such treatment would not be futile, should receive psychiatric review before that request is met.

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11. Northern Territory Rights of the Terminally Ill Act. Legislative Assembly of the Northern Territory (Act No. 12 of 1995).

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