Depression is factor In withdrawal from life-sustaining treatment

Newswise — As debate about the right to die and end-of-life care continues to swirl around the country, new research from the University of Iowa shows that for some patients and their families, these decisions should include consideration of both physical and mental health.

UI researchers followed a group of end-stage renal disease patients undergoing three-times weekly kidney dialysis. The team was led by Elizabeth McDade-Montez, a doctoral student in psychology, and Alan Christensen, professor of psychology in the UI College of Liberal Arts and Sciences and professor of internal medicine in the UI Roy J. and Lucille A. Carver College of Medicine, and also included Jamie Cvengros, a graduate student in psychology, and William Lawton, associate professor of internal medicine. They determined that depression was a factor in more than 40 percent of the patients who made the decision to end dialysis treatment. Since kidney dialysis is a life-sustaining treatment, the decision to end treatment is in effect a decision to end life.

Published in the current issue of Health Psychology, the research showed depression as a major factor even after adjusting for things like age and disease severity that might also contribute to the decision to end dialysis treatment, Christensen said. This is of particular concern as increasing numbers of patients are making this choice, he said. Research shows that about 20 percent of deaths among end-stage renal disease patients are due to patients' voluntary withdrawal from dialysis treatment.

The study followed 240 end-stage renal disease patients for four years, beginning with an evaluation for symptoms of depression. Those with high scores on the depression assessment, meaning they exhibited more or stronger symptoms of depression than average, were 42.6 percent more likely to withdraw from dialysis treatment.

"Decisions to withdraw from dialysis have progressed far beyond only the physically sickest patients ending treatment," said Christensen, who has studied the psychological impact of living on kidney dialysis for the past 17 years.

Christensen said he was initially persuaded that there was the need for depression evaluation for dialysis patients considering the decision to withdraw from treatment after an experience with a patient who had initially decided to abruptly end treatment but was determined to be suffering from depression. After accepting and undergoing treatment for depression instead of ending his dialysis treatment the patient lived for several additional years with a greatly improved quality of life. Now he has the research data to support his clinical observations.

"It's a difficult position for physicians, who want to provide the best care for their patients, but feel pressure to allow patients to determine their own destiny," Christensen said. "But it's really a clinical issue: Is there some factor that is influencing the patient's decision to stop treatment? If there is, and it's a factor, like depression, that is potentially modifiable with medication or therapy, then the decision to address the depression first, has to be paramount."

End-stage renal disease is a chronic illness, but not a terminal one, Christensen said. Patients can live many years on dialysis, but some begin to feel that the treatment is too intrusive, impeding their ability to live a normal life and making them feel that life on dialysis is no life at all. The problem, Christensen said, is that "depression itself colors these very perceptions and attitudes."

Based on this new research, Christensen recommends that patients considering ending a life-sustaining treatment like dialysis be evaluated for depression and that if depression is found to be an issue, physicians negotiate with these patients to continue dialysis for a period of time while being treated for the condition.

"Patients need to know that depression fluctuates over time and can be treated effectively with medicine and/or psychotherapy. If they can be persuaded to give it time, they may find that they choose differently when making the decision clear of depression symptoms. That's all we want: for doctors and patients to make the best decisions on a case-by-case basis," Christensen said.