Rapid-Response Treatments for Depression and Requests for Physician-Assisted Death: An Ethical Analysis

Depression is common at the end of life, and there is longstanding concern that it may affect terminally ill patients' decisions to request physician-assisted death (PAD). However, it is difficult for clinicians to determine the role of depression in a patient's PAD request. A recent case series described rapid responses to intranasal ketamine in three patients with terminal illness and comorbid depression who had requested PAD. One patient withdrew her request (which, in retrospect, had been driven by her depression) while the others maintained their requests; in all three, the rapid relief clarified the role of depression in the patients' decision-making. In addition to ketamine, there are other emerging rapid-response treatments for depression, including psilocy-bin with psychological support and functional connectivity-guided transcranial magnetic stimulation. We examine three key ethical implications of such treat-ments: their role in clarifying the decision-making capacity of depressed patients requesting PAD; the potential tension between the legal definition of irremediability in some jurisdictions and the ethical obligations of clinicians; and the likely obstacles to treatment access and their implications for equal respect for autonomy of patients. (Am J Geriatr Psychiatry 2022; 30:1255-1262)

Automated summary

Depression is a common issue for terminally ill patients, and it may affect their decision to request physician-assisted death (PAD). Recent research has shown that certain treatments, such as ketamine, can rapidly relieve depressive symptoms in these patients. These treatments have important ethical implications, including their role in clarifying decision-making capacity, the tension between legal definitions and clinicians' ethical obligations, and the obstacles to treatment access and respect for patient autonomy.