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AUSTIN, Texas -- Although patients may deny potentially life-saving treatments if they are competent to make the decision, there may be certain instances where physicians should still intervene.

A case study presented here Thursday described such a situation, where factors secondary to a patient's severe depression significantly influenced his decision to refuse a needed intervention, as described by Ramaswamy Viswanathan, MD, of SUNY Downstate Medical Center in New York City.

The patient, a 76-year-old Russian-speaking man, initially refused a life-saving pacemaker due to feelings of hopelessness and helplessness. He had been diagnosed with questionable type-1 bipolar disorder, treatment-resistant depression, and alcohol-use disorder. During his hospital stay after an attempted suicide, he experienced several episodes of bradycardia and received an external pacemaker. However, he refused to receive a permanent pacemaker, stating on multiple occasions that nothing could improve his "soul pain," as Viswanathan reported at the American Academy of Psychiatry and the Law (AAPL) meeting.

Competence is typically determined by a patient's ability to understand, appreciate, and reason, said Paul Appelbaum, MD, of Columbia University in New York City, during a panel discussion of the case. However, severely depressed patients may be so distracted by their anxieties, or have little motivation to make a decision in the first place, that they are unable to make an informed choice regarding their treatment. Some may think their physician is trying to hurt them, take their money, or even kill them, particularly elderly patients in which pseudodementia may present, he said.

Patients may also present with comorbid personality disorders that affect their decision-making. For those with severe depression, "it's not as simple as 'this person has bad depression and is in pain and should be permitted to end their lives,'" Appelbaum said.

"The purpose of informed consent is to give patients the opportunity to say no to treatment, but that depends on the patient being competent to make that choice," he said. "When they're not, someone needs to make that choice for them."

The Case at Hand

Since the external pacemaker needed to be removed after 1 week, psychiatrists on the case were pressed for time.

As a result, Viswanathan recruited the patient's 27-year-old grandson. However, the patient still refused to hand the decision regarding his pacemaker over to his substitute decision-maker. Viswanathan said that often when the choice is left to a designated family member, previous estrangement from the family or different cultural contexts could still require further physician involvement. Such was the case here, as the patient had not spoken to his family in years, partially because he was an atheist while his children were raised as Orthodox Jews.

Still, Viswanathan had to find a way to reduce the patient's acute depression and suicide ideation, and proposed administering off-label ketamine. After receiving approval from hospital administration, the idea was met with excitement from the patient and his family. It was only after the ketamine treatment was scheduled that the patient suddenly changed his mind -- finally, he agreed to receive the pacemaker.

What Caused the Change?

The patient stated in an interview with Viswanathan that the change was caused by "family pressure."

However, Viswanathan said it could have also been due to a renewed sense of hope caused by the proposal of ketamine. He also acknowledged that "priming" could have played a role, where if a patient agrees to one treatment (in this case, ketamine), he would be more likely to agree to another (the pacemaker).

And it could indeed have been due to family pressures, as the patient stated, or rather that, after facing severe isolation from his family for many years, the sudden attention he received in the hospital caused his mood to shift. Lastly, it could be that the patient was relatively unstable, and that his decision was not strongly rooted on one side or the other in the first place, Viswanathan said.

What Would You Do?

Physicians discussing the case generally agreed with Viswanathan's proceedings. Some noted that part of the patient's severe depression could have been attributed to cardiological effects that, if treated, would in turn improve the patient's mood. For example, he could have had arrhythmias or decreased blood flow to the brain, where the implementation of a pacemaker might significantly improve his physical energy and health.

Bruce Gage, MD, of the Washington State Department of Corrections, also suggested that instead of evaluating patients on cognitive function alone, psychiatrists should begin to assess patients in a more holistic way.

"There's no doubt we are much more feeling machines than thinking machines," Gage told MedPage Today. "I think the field needs to take a step back and think more about, not only influence of emotion, but also the body -- if his body feels better, then all of a sudden, things are different, and the idea of dying doesn't seem so important to him."

However, it is difficult to perform assessments of how a patient might be feeling, specifically ones that are able to determine competence, said Appelbaum, and in most scenarios data are only available for cognitive measures.

Regardless, Appelbaum said each patient should be approached on a case-by-case bases, and that each state has its own laws regarding physician-assisted suicide.

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