10
DIFFERENTIATING SADNESS AT THE END OF LIFE FROM CLINICAL DEPRESSION

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When a terminally ill patient with less than six months to live decides to hasten death because of intolerable suffering despite meticulous comfort care, it is not the same as a depressed patient becoming suicidal. Typically, the word suicidal is used for patients whose psychiatric conditions make them temporarily and irrationally want to end their lives because of acute psychological distress. By contrast, the term hastening death is more appropriate for patients whose medical conditions are terminal and who make a rational choice to shorten the dying process by days or weeks to avoid intolerable suffering. Understanding the difference between suicidal depression and hastening an imminent death is essential to protecting the right of terminally ill patients to remain in control and choose the manner of their death while at the same time protecting vulnerable psychiatric patients whose safety needs to be ensured. If you or a family member are terminally ill, understanding this distinction may also be key to defending against any suggestion that refusing unwanted medical treatment or wishing to hasten death is tantamount to being suicidally depressed when it is simply making a rational end-of-life choice.


REVISITING DAVID’s CASE

In Chapter 7 on hastening death, we discussed the case of David who in his early sixties developed a recurrence of cancer at the back of his tongue. Further treatment with surgery, radiation, or chemotherapy was not possible at the time. Given the location of David’s cancer, as the tumor grew he faced severe anxiety and agitation as his ability to breathe became compromised. Even meticulous comfort care and pain management could not prevent a bad death in David’s case.

When David made the decision to hasten his death, he experienced considerable relief. David was appropriately sad facing the end of life, but he felt grateful for the extra years he had had after earlier aggressive medical treatment for his cancer had twice restored him to reasonable health. Would he have liked to have that option available to him again? Of course. But he accepted with dignity that this was no longer the case.

After David’s recurrence was diagnosed, he experienced some apprehension and difficulty sleeping in the weeks before he broached with his wife Abigail and me the possible hastening of his death. Once he had brought his plan of a barbiturate overdose into the open, however, he felt overwhelmingly relieved. David knew he had made the right choice for himself.


MARK’S SUICIDAL DEPRESSION

In contrast to David, Mark was a young man in his thirties who became severely depressed when his fiancée Carolyn was killed in a tragic car accident just months before they were to be married. Mark and Carolyn had dated for five years and had been engaged for two. Mark simply could not imagine life without Carolyn. The senselessness of her death (she was killed by a drunken driver) was overwhelming.

As Mark sank into a morbid depression, he developed insomnia, lacked appetite, dropped fifteen pounds, lost all interest in work or pleasure, and finally became suicidal. As the date of what would have been his wedding approached, Mark’s family and friends became alarmed as he expressed thoughts of joining Carolyn by committing suicide. Finally, Mark’s family brought him to an emergency room where he was hospitalized against his will in a psychiatric ward to ensure his safety.

Fortunately, Mark responded well to a combination of psychotherapy and antidepressant medication. Once he was no longer depressed, his suicidal thoughts were in his words “unfathomable” and an “irrational reaction to Carolyn’s death.” Mark resumed his career as a computer programmer, eventually began dating, and married another woman. He ultimately came to feel that was what Carolyn would have wanted him to do. Certainly, he would have wanted Carolyn to move on with her life had their fates been reversed.

Note the contrasts between David’s case and Mark’s. David was terminally ill with recurrent cancer of the tongue for which no treatment was available to restore his health, and he faced a gruesome death in a matter of weeks. David was dying, not living. He made a rational choice to shorten his death under the circumstances.

By contrast, Mark was in excellent physical health. He had a long, satisfying life to look forward to if he could overcome his depression over Carolyn’s death. His suicidal thoughts were an irrational escape from his acute psychological distress. Whereas David needed his family and doctor to support hastening his death, Mark needed his family and doctors to ensure his safety at a time when he could not.


SYMPTOMS OF DEPRESSION VERSUS TERMINAL ILLNESS

Depression can be thought of as having both psychological and physical symptoms. The psychological symptoms include feeling helpless, hopeless, and worthless. The physical symptoms can include insomnia, lethargy, lack of appetite, and weight loss. In general, as patients become more severely depressed, they develop more severe physical symptoms of depression and have increasing difficulty functioning. A mildly depressed patient may feel depressed but have minimal physical symptoms of depression and be functioning fine, but a severely depressed patient like Mark may have severe physical symptoms (severe insomnia, weight loss, and fatigue) and be unable to function.

The American Psychiatric Association has identified nine symptoms of depression:1



  1. Depressed mood for at least two weeks
  2. Markedly diminished interest or pleasure in activities
  3. Significant weight loss or weight gain
  4. Insomnia or oversleeping
  5. Agitation or listlessness
  6. Fatigue or loss of energy
  7. Feelings of worthlessness or excessive, inappropriate guilt
  8. Diminished ability to think or concentrate, or indecisiveness
  9. Recurrent thoughts of death or suicide

Note that the physical symptoms of depression can also be caused by terminal medical conditions. For example, fatigue, difficulty sleeping, lack of appetite, and weight loss can all be symptoms of many cancers. If a terminal patient’s physical symptoms can be accounted for by his medical illness, they should not be counted toward a diagnosis of depression, according to the American Psychiatric Association guidelines for diagnosing depression.2

In terms of psychological (as opposed to physical) symptoms of depression, the psychological core of depression is paralysis and self-recrimination, rather than genuine sadness. Genuine sadness is cathartic and empowering in contrast to depression, which is paralyzing and self-reproaching. Mark felt helpless, hopeless, and worthless in his suicidal depression. By contrast, David felt appropriately sad and empowered in his decision to hasten his death.

Suicidal thoughts can occur not just in depression but in other psychiatric conditions as well. The same general principles apply.


HASTENING DEATH VERSUS SUICIDAL DEPRESSION

When patients are not suicidal but instead are making a reasonable choice to hasten death, all of the following criteria are met. The patient is:


By contrast, when a psychiatric patient is suicidal, the above criteria cannot all be met.

If you or a family member is having difficulty differentiating the desire to hasten death in the face of suffering at the end of life from what we normally think of as the desire to commit suicide, you can always consult with a psychiatrist. But, be sure to consult with a psychiatrist empathetic to the possibility of hastening death in terminal illness. If your decision to hasten death meets all of the criteria set forth in Chapter 7 on hastening death and you feel confident of your decision, your appropriate sadness should not be mislabeled depression. Nor should unwanted psychotherapy and/or antidepressant medication be pressed upon you.

Ending life in a rational decision not driven by psychiatric illness becomes more difficult when the problem is not terminal (defined as six months or less to live), but rather is a nonterminal condition of unrelieved suffering or distress, such as can occur in persons with oncoming dementia, infirmity and dependence on dialysis, certain cases of quadriplegia, totally disabling Parkin-sonism, and other similar progressive or persistent disorders. There is no easy answer or obvious guideline for such a person, but clearly instances occur in which it could be rational to wish for the end of life in a nonterminal situation.