The contribution of demoralization to end of life decisionmaking

Some psychiatrists believe that "demoralization syndrome" is a diagnosable cognitive disorder characterized in its extreme form by morbid existential distress. If they are right, then it should be an important part of our thinking about end of life decisionmaking. A demoralized patient would be unable to think reliably about the remainder of her life, and therefore incompetent to decide to commit physician-assisted suicide. The pointlessness of a wretched existence, in which meaning and purpose are lost and despair is pervasive, can lead to a wish to die. This mental state may develop in association with the suffering of the chronically medically ill and of the dying. Should a plea to hasten dying be viewed as a rational request for merciful assistance, or is it symptomatic of a suicidal mind disordered through illness and warranting a therapeutic response? Out of the clinical and ethical debates about end of life decisionmaking, a fundamental question has arisen: is demoralization no more than a comprehensible human and emotional response to a state of dire bodily disease, or can it be a pathological process deserving of diagnosis as illness? In this paper, I explore demoralization as a "dimensional" state of mind--that is, as a mental state ranging from a normal response to perceived helplessness to a morbid form of existential distress. The impact of demoralization upon a person's capacity to give informed consent across a range of end-of-life decisions is a pivotal question. Demoralization influences a person's "assumptive world" and may, as I shall show, interfere with his appreciation of clinical data pertinent to decisionmaking. Clinical and legislative implications arise when severe demoralization is recognized as a morbid state of mind. Acceptance of Dying No argument exists concerning the capacity of people to accept rationally the reality of their death. Indeed, sociologists have described this as a quest of the modern palliative care movement: to help patients face their dying with open awareness and courage, the 'ideal' of a heroic death in the supportive care of their family, friends, and community. (1) This acceptance of dying is commonly identifiable within the narrative of many patients, especially the very elderly, as they anticipate what their future might hold. The following clinical account helps to illustrate their mental state. Giuseppe, a married, seventy-five-year-old Italian, suffering from lung cancer and recurrent chest infections, caused his oncologist concern when he expressed a wish to die. He appeared very sad as he spoke of his limited future, his frustration at a considerably restricted exercise tolerance, and the boredom that set in at home. He was the youngest of three children born to a farming family in Northern Italy, his education cut short by the onset of World War II when he was just fourteen. After serving in the army, Giuseppe traveled to France where he married and fathered two daughters. In the 1960s, the family migrated to Australia, where Giuseppe worked as a leading hand in the building industry until retirement a decade ago. He was proud of the respect he had earned for his contribution to the workplace, and especially of his family--"the very best!" He delighted in completing the crossword puzzle daily. While volunteering an acceptance of his diagnosis, he described waves of sadness that came over him when he thought about his life ending. Yet when conversing more generally, he was interactive, spontaneous, could share a joke, and his mood was dearly reactive to the environmental context. His interest in sport and classical movies sustained his enjoyment of life. There was no hint of a clinical depression. Acknowledging that his health was considerably compromised, he explained that he did not want to go on living with illness. He stated, "My chest is no good at all. I don't know about my future. …