Understanding the Influence of Depression on Decision-Making Capacity at End of Life (TH123C)

• Published in: Journal of pain and symptom management Vol. 65; no. 5; pp. e520 - e521
• Main Authors: Robbins-Welty, Gregg A., Strong, Cameron, Briscoe, Joshua
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 01.05.2023
• ISSN: 0885-3924; 1873-6513
• DOI: 10.1016/j.jpainsymman.2023.02.022

1. Describe and apply the basic framework of decision-making capacity in patients with comorbid serious mental and medical illness. 2. Appreciate opportunities for collaboration between palliative care and psychiatric providers to support patient autonomy in the final stages of life. The assessment of decision-making capacity is often requested due to impairment in a patient's cognition. At the end of life, concern for depression might raise concern for loss of decision-making capacity. We present a case where collaboration of the palliative care and psychiatry services allowed for examination of a patient's ability to make decisions at end of life. We present the case of an 83-year-old man with a medical history of chronic gastrointestinal bleeding and a psychiatric history of depression. The patient initially presented with a perforated duodenal ulcer. He underwent emergent exploratory laparotomy, suffering complications including aspiration pneumonia and respiratory failure. The palliative care service was consulted to help establish a surrogate decision maker and to confirm a do-not-resuscitate code status. The palliative care consultant expressed concern about underlying depressive symptoms confounding the patient's ability to make these decisions. A psychiatric consultation affirmed the patient was voicing feelings of hopelessness, but also that he had intact decision-making capacity. His clinical status continued to deteriorate. While the patient was transferred to the intensive care service, he subsequently declined interventions in favor of a comfort-focused approach. A second palliative care consultant expressed reticence to proceed due to apparent depressive symptoms. Subsequent evaluation by psychiatry revealed themes of demoralization with declining health while also supporting intact decision-making capacity. He was subsequently permitted to forgo these interventions and passed away. Engaging in decisions at end of life might be confounded by concurrent alteration in mood. We will discuss the mechanisms by which mood states may influence decision-making capacity as well as describe a psychiatric approach to determining decision-making capacity in patients with psychiatric comorbidities, especially in the setting of concomitant serious illness. Ultimately, thoughtful discussions and interdisciplinary consultation can support patient autonomy in the final chapter of their lives.