Rapid-Response Treatments for Depression and Requests for Physician-Assisted Death: An Ethical Analysis.
The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry November 1, 2022 DOI: 10.1016/j.jagp.2022.07.003 via PubMed
Summary
AI-generated from the abstractDepression is common in terminally ill patients and can influence requests for physician-assisted death (PAD), but clinicians struggle to assess its role. A case series showed that rapid treatment with intranasal ketamine clarified whether depression was driving the PAD request: one patient withdrew her request after realizing it was depression-driven, while others maintained theirs. Other emerging rapid treatments, such as psilocybin with support and transcranial magnetic stimulation, raise ethical issues. These include using such treatments to evaluate decision-making capacity, tensions between legal definitions of irremediability and clinicians' ethical duties, and obstacles to treatment access that may undermine equal respect for patient autonomy.
Study at a glance
| Characteristics | Review Case report Peer reviewed |
|---|---|
| Sample size | 3 |
| Population | Terminally ill patients with comorbid depression who had requested physician-assisted death |
| Intervention | Intranasal ketamine |
| Topics | Depression |
| Keywords | Physician-assisted death Decision-making capacity Ethics |
| Citations | 12 |
| Key finding | Rapid-acting antidepressants like ketamine can help clarify whether depression is driving a terminally ill patient's request for physician-assisted death, but their use raises ethical concerns about decision-making capacity, irremediability, and equitable access. |
Abstract
Depression is common at the end of life, and there is longstanding concern that it may affect terminally ill patients' decisions to request physician-assisted death (PAD). However, it is difficult for clinicians to determine the role of depression in a patient's PAD request. A recent case series described rapid responses to intranasal ketamine in three patients with terminal illness and comorbid depression who had requested PAD. One patient withdrew her request (which, in retrospect, had been driven by her depression) while the others maintained their requests; in all three, the rapid relief clarified the role of depression in the patients' decision-making. In addition to ketamine, there are other emerging rapid-response treatments for depression, including psilocybin with psychological support and functional connectivity-guided transcranial magnetic stimulation. We examine three key ethical implications of such treatments: their role in clarifying the decision-making capacity of depressed patients requesting PAD; the potential tension between the legal definition of irremediability in some jurisdictions and the ethical obligations of clinicians; and the likely obstacles to treatment access and their implications for equal respect for autonomy of patients.