In this instance, the patient's absolute refusal of food and fluids was interpreted as a suicidal gesture due to depression. Herrmann, N., “Electroconvulsive Therapy for a Depressed Patient with Global Aphasia.” Psychosomatics 31: 115–116, 1990.Google Scholar

Mulley, G.P., “Differential Diagnosis of Dementia.” British Medical Journal 292: 1416–1419, 1986.Google Scholar

Overman, W. Jr. Stoudemire, A., “Guidelines for Legal and Financial Counseling of Alzheimer's Disease Patients and Their Families.” Am J Psychiatry 145: 1495–1500, 1988.Google Scholar

Kim, K.Y. Hershey, L.A., “Diagnosis and Treatment of Depression in the Elderly.” Int'l J Psychiatry in Medicine 18: 211–221, 1988.Google Scholar

See Colenda, supra note 6.Google Scholar

Ibid.Google Scholar

See Mulley, , supra note 3.Google Scholar

See Colenda, supra note 6.Google Scholar

Ibid.Google Scholar

Ibid.Google Scholar

See Mulley, , supra note 3.Google Scholar

Two cases in which patients who showed pathological crying following right inferior frontal brain damage had concomitant “severe endogenous depression” are described in Ross, E.D. & Steward, R.S., “Pathological Display of Affect in Patients with Depression and Right Frontal Brain Damage.” The Journal of Nervous and Mental Disorders 175: 165–172, 1985.Google Scholar

Robinson, R.G. Lipsey, J.R. Rao, K. Price, T.R., “Two-Year Longitudinal Study of Post-Stroke Mood Disorders: Comparison of Acute-Onset with Delayed-Onset Depression.” Am J Psychiatry 143: 1238–1244, 1986.Google Scholar

See Colenda, supra note 6.Google Scholar

Ibid.Google Scholar

E.g., in one study of 37 patients who were artificially ventilated between 1968 and 1984, of the 21 patients still alive, 18 said they would wish to be temporarily ventilated again. Gardner, B.P. Theocleous, F. Watt, J.W.H., & Krishman, K.R., “Ventilation or Dignified Death for Patients with High Tetraplegia.” British Medical Journal 291: 1620–1621, 1985. But see, Maynard, F.M. & Muth, A.S., “The Choice to End Life as a Ventilator-Dependent Quadriplegic.” Arch Phys Med Rehabil 68: 862–864, 1987, and Wolff, K.R., “Determining Patient Competency in Treatment Refusal Cases.” Georgia Law Review 24: 733–757, 1990, for examples of patients believing otherwise.Google Scholar

House, A., “Depression after stroke.” British Medical Journal 294: 76–78, 1987.Google ScholarPubMed

Williams, G.O., “Management of Depression in the Elderly.” Primary Care 16: 451–475, 1989.Google Scholar

Factors precipitating depression in the elderly include physical illness, loss of an important relationship, institutional living, loss of autonomy, loss of financial resources, loss of occupational identity, coexisting psychiatric disorders, drugs, alcohol, physical and emotional illness and genetic-biologic vulnerability to depression. Simon, R.I., “Silent Suicide in the Elderly.” Bull Am Acad Psychiatry Law 17: 83–95, 1989.Google Scholar

In addition, patients with dementia are much more likely to have defects in naming, writing, calculating and motor praxis, but these differences are usually seen only in the later stages of dementia. See Stoudemire, supra note 6.Google Scholar

See Mulley, , supra note 3.Google Scholar

Brown, J.H. Henteleff, P. Barakat, S., “Is It Normal for Terminally Ill Patients to Desire Death?” Am J Psychiatry 143: 208–211, 1986.Google Scholar

Simon, , supra, note 22 at 86.Google Scholar

Gutheil, & Bursztajn, , note 2 supra.Google Scholar

Howe, E.G., “Forensic Issues in Critical Care Medicine.” Problems in Critical Care 2: 171–187, 1988. Few courts explicitly document the factors leading to a competency evaluation. Wolff, supra, note 18 at 734 n.10.Google Scholar

An illustrative case is reported in Jackson, D. & Younger, S., “Patient Autonomy in Health Care Decisions.” New England Journal of Medicine 301: 404–408, 1979 (At 406). In this case, a 52-year-old man who had progressive physical disability due to multiple sclerosis had previously adapted successfully to his handicaps. He then became “morose and withdrawn” and expressed a “strong belief” in patients’ and his own right to die with dignity. His withdrawal and depression coincided with the diagnosis of probable cancer in his mother-in-law. When the mother-in-law's diagnosis was made, his wife spent more and more time satisfying her mother's needs. The patient had “too much pride” to complain to his wife about feeling abandoned. After he acknowledged his needs in discussion with his care providers and family, he withdrew his request that he not receive supportive medical efforts.Google Scholar

Roth, N.H. Meisel, A. Lidz, C.W., “Tests of Competency to Consent to Treatment.” Am J Psychiatry 134: 270–284, 1977; Drane, J.F., “The Many Faces of Competency.” Hastings Center Report 15: 17–21, 1985; Schwartz, H.I. Blank, K., “Shifting Competency during Hospitalization: A Model for Informed Consent Decisions.” Hospital and Community Psychiatry 37: 1256–1260, 1986; Applebaum, P.S. Roth, L.H., “Clinical Issues in the Assessment of Competency.” American Journal of Psychiatry 138: 1462–1467, 1981; Hoffman, B.F., “Assessing Competence to Consent to Treatment.” Canadian Journal of Psychiatry 25: 354–355, 1980.Google Scholar

Peterson, L.M., “Refusing Medical Treatment.” Perspectives in Biology and Medicine 31: 454–460, 1988; Kaye, M. Bourgouin, P. Low, G., “Physicians’ Non-Compliance with Patients’ Refusal of Life-Sustaining Treatment.” Am J Nephrol 7:304-312, 1987; Howe, E.G., “Final Choices—Autonomy in Health Care Decisions.” The Journal of Contemporary Health Law and Policy 6: 449-482, 1990.Google ScholarPubMed

See, e.g., In re: Petition of the Department of Veteran's Affairs Medical Center, No. M45 (U.S. District for Southern District of New York, 16 and 17 August 1990). In this case, a 78-year-old man who had diabetes developed wet gangrene in one foot. His wife, acting on her husband's behalf, stated that she believed he would rather die than lose his foot, that she was uncertain that her husband had wet gangrene and that she believed that her husband's doctor had an unfounded desire to “cut.” The court rejected this patient's wife as surrogate decision-maker because she was not sufficiently objective and appointed a guardian who would consent to her husband's amputation over the patient's wife's objection.Google Scholar