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(152) Depression and the Capacity to Refuse Hemodialysis


Authors:

Dax Volle, MD – Resident Physician, UCLA

Maya Smolarek, MD – Resident Physician, UCLA

Isabella Morton, MD, MPH – Resident Physician, UCLA

Keerthan Somanath


Co-Authors:

Presenting Author: Dax Volle, MD, UCLA
Co-Author: Maya Smolarek, MD, UCLA
Co-Author: Isabella Morton, MD, MPH, UCLA
Co-Author: Keerthan Somanath, MD, UCLA

Abstract:

Background/Significance:

Capacity is a core feature of the decision to withdraw life-sustaining treatment. Depression may impair capacity to make such decisions. This case report highlights salient aspects of the capacity evaluation of a patient with depression who chose to stop hemodialysis (HD).


Case:


28 y/o male with MDD, ESRD due to FSGS s/p failed DDRT on HD, and HCV with multiple admissions for sequelae of missed HD and one psychiatric hospitalization for MDD/SI presented for dyspnea after multiple missed HD sessions.

Creatinine was 15.40 and he was altered and agitated. HD was initiated and creatinine stabilized to 9. Psychiatry consulted after patient stopped HD sessions and reported SI. During consult, patient reported plan to stop HD as well as several weeks of depressed mood, insomnia, anhedonia, worthlessness, anergia, amotivation, and inattention.

He understood the benefit of continuing HD (sustained life) and the risks (death) and alternatives (HD continuation, transplant) of stopping HD and indicated preference to stop while acquiescing that he would not wish to die if his depression were treated.

After three days without HD patient developed hyperkalemia and ECG changes which were felt to be imminently life threatening. Psychiatry ruled that patient lacked capacity to stop HD and non-voluntary HD was started.

This patient was ultimately psychiatrically hospitalized, treated, and discharged. Before he was lost to follow-up 6 months ago he was still receiving HD.

Discussion:

Depression may lead to ‘Concretized Emotion-Belief Complexes’ where rigid beliefs may cause a breakdown in the appreciation component of capacity as individuals are rendered unable to appreciate non-negative future possibilities.

If appreciative ability remains intact, depressed individuals may still lack ‘decisional authenticity’ as their decisions may not reflect their ‘true’ autonomous self as they do not possess a minimal level of concern for their own welfare. Without this, any claim of capacity is jeopardized as patient is not accountable for their decision to receive treatment or not.

Conclusion/Implications:

Our conclusions were based on our determination that depression was rendering the patient unable to manipulate information rationally, especially as he acquiesced that he would not wish to die if depression were treated. This raised concern that a negativistic outlook prevented him from fully appreciating the ramifications of his choice to discontinue treatment.

This case highlights not only the interplay between depression and the capacity to withdraw life-sustaining treatment, but also the complex considerations that consultant psychiatrists must explore before making recommendations regarding capacity in such cases.
References:

Hindmarch T, Hotopf M, Owen GS. Depression and decision-making capacity for treatment or research: a systematic review. BMC Med Ethics. 2013;14:54

Baruth J, Lapid M. Influence of Psychiatric Symptoms on Decisional Capacity in Treatment Refusal. AMA Journal of Ethics. 2017, Volume 19, Number 5: 416-425

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