Palliative Electroconvulsive Therapy: A Case Series

Abstract:

Introduction: Palliative care is the standard of care for patients with serious illnesses that negatively impact quality of life and functional status. Clinicians caring for patients with serious illnesses may consider the use of electroconvulsive therapy (ECT) since it is the gold-standard treatment for some psychiatric conditions. Little has been published in the literature exploring “palliative ECT” or ECT in the setting of serious illness, at the end of life, or for a palliative indication.^1–3 In this case series, we aim to characterize patient and procedural characteristics among a sample of patients who were considered for or received palliative ECT.



Methods: We conducted a single-center retrospective case series reviewing the indications, outcomes, and regimens of palliative ECT. We included patients who had an ECT consultation, in addition to either a palliative care consultation or a do-not-attempt-resuscitation (DNAR) code status between 2018 and 2023.



Results: Among 31 patients who had ECT consultations, 21 patients received ECT. The cohort was predominantly female (70%) with a mean age of 67.6 (range 25-90). Catatonia (61%) and treatment-resistant depression (39%) were the most common indications for ECT consultation. Factors that precluded ECT administration included anesthesia safety concerns due to medical comorbidities (40%) and concerns about the likelihood of benefit from ECT (30%). Surrogate decision-makers consented in 86% of cases. Several unique themes emerged from this data, including 1) Patients with serious illness who had an indication for ECT experienced improved quality of life with ECT, 2) Patients with pseudodementia and catatonia may be misdiagnosed as rapidly progressive dementia and can be effectively treated with ECT, 3) Patients were commonly referred to palliative care for a primary psychiatric diagnosis, and 4) ECT may be given with palliative, as opposed to curative (meaning remission of psychiatric illness) intent for psychiatric disorders.



Discussion: This case series offers insights into the clinical utility of ECT among patients with serious illness, and identifies cases when ECT was pursued or deemed unsuitable. Palliative ECT may be helpful in scenarios of life-threatening psychiatric illnesses, terminal diagnoses with comorbid treatment-refractory psychiatric illness, and diagnostic uncertainty with rapidly progressive dementia.



Conclusion: This case series highlights factors that inform risk-benefit assessments and decision-making regarding palliative ECT, which can reduce suffering and improve patient quality of life.