Title : Depression as a terminal illness – Is there a place for palliative care?
Abstract:
Background: Melanie is a 38-year-old female, who has suffered 3 episodes of severe, treatment-resistant depression over the past 18 years, each time requiring hospitalisation under section 3 of the MHA and a prolonged course of electroconvulsive therapy. This is her fourth episode. But this time, something is different. During remission, whilst she was well with full mental capacity, Melanie created a legally-binding advanced directive, stating that should she ever relapse again, she wishes for no active treatment– she does not wish to have ECT, medications or hospitalisation. Instead, her wishes are for her to remain at home where she feels safest and most comfortable and to allow the disease to run its course, even if this ends in suicide. As the caregivers, how do we approach this situation? What is ethically the right thing to do? How do we balance autonomy, beneficence, non-maleficence and justice in such cases? What can we do to really listen to our patients? How do we advocate and care for Melanie, taking her wishes into account whilst respecting the limits of law and ethical boundaries? What can we learn from Melanie’s story?
Implications for practice: Suicide is often viewed as a symptom of severe depression, but I challenge us to ask ourselves: what if we considered death as part of the disease process itself? Consequently, could we consider depression in some patients as a form of terminal illness? Since without treatment, the condition would likely lead to death? Accordingly, could there be a place for palliative care in a small minority of suicidally depressed patients? This would mean that instead of placing the focus on prevention of deaths and prolonging of lifespan (sometimes requiring highly restrictive and traumatising measures), we would instead focus on making the patient as comfortable as possible, maintaining their dignity, and promoting autonomy. This would surely allow patients to have more say, more rights and more options pertaining to their care and ultimately, their own lives? Patients with psychiatric conditions are generally not given the same rights to make decisions regarding their mental health and treatment, particularly if they wish to decline treatment. The rationale for this is that psychiatric patients do not have capacity to make such decisions in the acute setting, due to the direct effects of the unwell mind on their decision-making processes and cognitive faculties. Whilst this may be true in some cases, what happens in cases like Melanie’s, where she created an advanced directive whilst she was mentally well, with full capacity to maker her decision? In this case, the circumstances in which the statement was made would be entirely valid– the patient at that moment has capacity, is not under coercion, is able to articulate logical thought processes, and their reasoning would not be affected by a concurrent psychiatric pathology. Furthermore, they are able to demonstrate that suicide is not an impulsive decision and have considered the consequences of suicide on themselves and others. If the patient is able to demonstrate all of the above, what would the ethical grounds be for refusing this advanced directive? Is it fair to confiscate one’s right to decline treatment, solely because they suffer from a mental illness, as opposed to a physical one? Numerous studies have demonstrated clear structural, neurological, and neurochemical changes in suicidal depression. This is evidence that such a condition encompasses a clear physical property. Other conditions, such as dementia and chronic pain have previously been accepted for euthanasia in certain countries. Pain is a subjective experience of nociceptive and neurochemical signalling. In the same way, depression is a subjective experience involving aberrant neurochemical signalling. Like distinct forms of physical pain, suicidal depression creates a different form of pain, but it is pain nonetheless. Is it therefore fair for suicidally depressed patients to be given lesser rights than those suffering from physical illnesses in determining their fate?
Conclusion: In a rapidly-evolving, dynamic world, where our understanding of treatments, their prognoses and beliefs are constantly changing, we must be open to considering alternative approaches and this is why it is important that we break down the stigma and open these conversations for healthcare providers, patients and society.
Audience Take Away Notes:
- I hope that this case will help raise awareness, provoke internal reflection and arouse open discussions and debate into these immensely important and meaningful topics of ethics and law, since this is a rising topic, which so far has rarely been openly discussed.
- I hope that discussing Melanie’s case will help healthcare professionals when facing similar situations with complex ethical/legal/clinical/professional conflicts in their own professional practice in the future.
