(116) "I Don't Want to Live Like This Anymore": C-L Psychiatry and Clinical Ethics' Roles in Withdrawing Life-Sustaining Treatment

Abstract: Background/significance: In end-of-life care, CL psychiatrists are often asked to assess decision making capacity (DMC). Clinical ethics consultants assist with difficult decisions involving uncertainty or conflict about values (Carrese 2012). We discuss their roles and compare demoralization with MDD, through analyzing ethical dimensions of withdrawing life-sustaining hemodialysis in a young patient.

Case: Ms. A is a 27-year-old patient with granulomatosis with polyangiitis complicated by ESRD on hemodialysis for seven years. Her psychiatric history included MDD; PTSD; tobacco, cannabis, and cocaine use disorders.

She presented to the ED with passive SI and abdominal pain with one week of missed hemodialysis. Ms. A repeatedly declined medications, diagnostic labs/imaging, and dialysis. She consistently stated, “I do not want to live like this anymore,” referencing chronic illnesses and hemodialysis dependence. CL psychiatry was involved for concerns about MDD exacerbation.

CL psychiatry determined she had DMC to decline dialysis; the patient’s distress and wishes to withdrawal treatment stemmed not from MDD exacerbation, but from demoralization over five years of declining health and psychosocial stressors. An interdisciplinary team including clinical ethics, palliative care, and CL psychiatry worked with her to determine goals of care. After discussions, Ms. A's code status was switched to DNR as her values were independence and comfort, rather than longevity. Her mother was supportive; she was discharged to hospice where she died within two weeks.

Discussion: CL psychiatry assessed DMC and the patient’s emotional distress, while the clinical ethics consultant assisted with addressing the challenging decision of withdrawing dialysis and pursuing hospice care. Demoralization, progressive despair over loss of control, is distinct from MDD; both are considerations when assessing DMC (Clarke 2002). Regarding ethics, Ms. A's consistent, strong desire for hospice (autonomy, informed consent, and nonmaleficence) outweighed physician obligation to beneficence (Varkey, 2021). Other ethical considerations were the act/omission doctrine, the doctrine of double effect, and active versus passive euthanasia. In accordance with the quadruple aim, we address moral distress clinicians may experience after necessary respect for patient’s autonomy to withdraw dialysis, effectively ending life (Bodenheimer 2014).

Conclusion/Implications: In decisions involving life-sustaining treatment withdrawal, CL psychiatrists’ play an important role in assisting with DMC assessment, mood disorder symptoms, and interdisciplinary discussions.

References

Bodenheimer, T. and Sinsky, C. (2014) ‘From triple to quadruple aim: care of the patient requires care of the provider’, Annals of family medicine, 12(6), pp. 573–576.

Carrese, J. (2012) HCEC pearls and pitfalls: suggested do’s and don’t’s for healthcare ethics consultants, J Clin Ethics. Available at: https://pubmed.ncbi.nlm.nih.gov/23256404/

Clarke, D. M. and Kissane, D. W. (2002) ‘Demoralization: Its phenomenology and importance’, Australian and New Zealand Journal of Psychiatry, 36(6), pp. 733–742.

Varkey, B. (2021) ‘Principles of Clinical Ethics and Their Application to Practice’, Medical Principles and Practice, 30(1), pp. 17–28.