By Jules C. Rosen, M.D.
I was asked to see a 93-year-old woman who was admitted to the nursing home three weeks earlier. She had been eating poorly, had lost more than 12 pounds, and had openly expressed her willingness to die.
Approximately three months prior, she was on a cruise with one of her gentleman friends when she suffered a stroke resulting in paralysis on the left side of her body. She told me that she did not feel depressed, but rather, she was convinced it was her time to die. She had no living relatives in Pittsburgh, where she lived, and would not consider moving to another city for fear of “burdening” others.
After reviewing her symptoms, I informed her of my diagnosis of depression. I explained that depression often is associated with strokes and clarified to her that feelings of sadness are not necessarily dominant. I offered to treat her. She smiled and asked what the treatment would entail. I offered a trial of antidepressant medication. She told me I was naïve and although she refused medication treatment, she willingly agreed for me to see her in one week.
I met with her for twenty minutes weekly for the next three weeks. She told me of her husband who died in 1939, and her only son who was killed in World War II. After years of feeling “lost,” she discovered that she could express herself as a writer. She had published poems, short stories, and magazine articles.
She told me about her travels, her friends, and her lovers. She regretted that she would die before she could complete her novel. That was the only regret she expressed to me. She appeared to enjoy our visits and told me that she looked forward to seeing me again.
However, her appetite remained poor, her weight loss continued, and her death wish persisted. At my fourth visit, we once again discussed her wish to die. By that time, I appreciated the richness of her life and her feelings of accomplishment. I clearly understood her willingness for death.
As my understanding of her grew, she also gained new insights. She understood that her days of travel were over, but not necessarily her days of writing. She seemed to appreciate how I was able to learn from her. Perhaps, this made her feel useful once more. She finally accepted a trial of antidepressant medications.
She died three days later. At first, I felt cheated. If only she had accepted the medication during our first visit, perhaps things would have gone differently. Perhaps she would have regained her appetite and her strength. Some months later, I was thinking about my experience with this dying patient. Could I have been more aggressive in pushing for treatment of her depression?
I realized that although the patient died, I felt secure in my actions. I respected her individuality and her need to maintain control over her life. The time I spent talking with her, reminiscing about the pains and the pleasures of her life, brought her a sense of comfort. This, by itself, was a relief from her only other expressed hope, which was for a peaceful and swift death.
This experience helped me better understand my responsibility as a psychiatrist caring for patients who are facing death. As psychiatrists, we often face the question of how aggressively to treat depression in a dying patient.
Patients who are terminally ill may benefit from antidepressant medications, but there is no evidence to support that belief. Therefore, it is important that we expand our concept of treatment beyond the “pill.” Treatment may involve supportive therapy, hospice care, spiritual counselors, family support, as well as medications.
Despite my patient’s persistent symptoms, and finally her death, I feel that this was a successful treatment. We had developed a strong therapeutic alliance, and she agreed to medication, in this context. Until the end, she maintained control over important aspects of her life, even as that life was slipping away.
This experience has helped me to learn that working with end-of-life depression requires the entire toolbox we bring as healthcare professionals into every patient’s life. It may be discomforting and make us feel powerless, but we must keep in mind that while our capacity to cure is imperfect, our capacity to comfort is unlimited. Understanding our role as the comforter will help us attain the cure for some patients and comfort for others. Death need not be dreaded.