(128) C-L service Initiates Palliative ECT for Catatonia in a Terminal Cancer Patient: A Case Report

‎Background/Significance: Though there is consensus that treating psychiatric disorders aligns with the ‎palliative care philosophy, electroconvulsive therapy (ECT) has been historically considered invasive and potentially ‎dangerous at the end of life. Few studies have examined palliative uses of ECT, and none have explored palliative ECT ‎for acute catatonia at the end of life.‎

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Case: We present a 78-year-old male with a history of catatonic schizophrenia, chronic obstructive pulmonary ‎disease, coronary artery disease complicated by myocardial infarction, and metastatic gastroesophageal junction and ‎colon cancers treated with immunologic therapy, complicated by autoimmune hepatitis. He was admitted medically ‎due to acute mental status change while receiving methylprednisolone infusion for autoimmune hepatitis. The ‎consultation-liaison psychiatry (CL) service was consulted for concern of catatonia. The CL service noted stupor, ‎withdrawal (requiring enteral feeding), mutism, gegenhalten, grimacing, and autonomic instability and calculated a ‎Bush-Francis score of 17, consistent with catatonia. The patient's outpatient risperidone was discontinued and a ‎lorazepam trial was initiated but limited by sedation. Robust trials of memantine, methylphenidate, and amantadine ‎were completed. The patient slightly improved but remained catatonic and unable to communicate for weeks in the ‎setting of ongoing corticosteroid treatment. After extensive psychoeducation by the CL service in interdisciplinary ‎family meetings, four ECT treatments were completed with significant improvement in catatonic symptoms for days, ‎including meaningful family interactions. The first two treatments were well tolerated. The third and fourth ‎treatments were associated with hypertension and desaturation. Given medical complications unrelated to ECT, ECT ‎was no longer thought to be viable, and the patient was transitioned to comfort care.‎

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Discussion: We presented the case of an ECT-naïve older male with metastatic cancer hospitalized for acute ‎catatonia for whom the inpatient CL psychiatry service initiated ECT to rapidly improve end-of-life interactivity. By ‎improving interactivity and decreasing the intense anxiety commonly associated with catatonia, ECT can increase a ‎patient's quality of life. Similarly, the few case reports exploring palliative ECT have demonstrated communication ‎improvement and symptom relief across multiple psychiatric disorders.1,2 As in our case, the need for ongoing risk-‎benefit analysis in these medically ill patients was highlighted. However, these cases described the continuation of ‎prior ECT courses for chronic psychiatric conditions in psychiatric settings after patients received a terminal diagnosis. ‎Ours is the first case involving palliative ECT for acute catatonia in a medical setting. The CL service played a crucial role ‎in psychoeducation, ECT initiation, and ongoing goals of care discussions.‎

‎Conclusion/Implications: CL psychiatrists are uniquely positioned to guide treatment planning discussions for ‎terminally ill patients with catatonia. ECT can be considered as a palliative intervention for these patients and patients ‎with other psychiatric disorders. ‎

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References: ‎
‎1. Mulder ME, Verwey B, van Waarde JA. Electroconvulsive therapy in a terminally ill patient: when every day of ‎improvement counts. J ECT. 2012 Mar;28(1):52-3. doi: 10.1097/YCT.0b013e3182321181. PMID: 21983761.‎
‎2. Rasmussen KG, Richardson JW. Electroconvulsive therapy in palliative care. Am J Hosp Palliat Care. 2011 ‎Aug;28(5):375-7. doi: 10.1177/1049909110390203. Epub 2010 Nov 17. PMID: 21087947.‎