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Clinical Considerations

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Assessment of clinical depression is important in any patient with HIV, but this is especially true when questions arise regarding the patient’s mental functioning. When slowing, forgetfulness and concentration problems are present, the clinician must attempt to differentiate the effects of depression from early signs of the HIV–Associated Dementia. This is best done by inquiring into the mood state of the individual and being alert to atypical signs of pessimism, feelings of worthlessness, and suicidality. Since most patients diagnosed with an HIV–Associated Dementia are aware of their declining mental capabilities, they may be understandably depressed. This, coupled with the well established and broad range of psychosocial assaults associated with HIV, creates a high risk situation for patients who are also experiencing cognitive impairment.

If signs of depression are present, the depressive condition should be appropriately treated. Depression can further encroach upon the mental capacities of an already impaired individual. Assessment of suicide potential is also important in these patients in light of the increased incidence of depression in patients with subcortical disease (for instance, as is true in Parkinson’s or Huntington’s disease). Crisis resources should be available to the clinician involved with this population in the event that an impaired patient experiences suicidal intent. The unique mix of psychosocial trauma with a probable biologic contribution to depression in this group creates fertile ground for suicidal intent and planning. The clinician must be vigilant and resourceful when signs of suicidality are present.

It is important for psychotherapists who work with people with AIDS to improve their skills in differentiating between an individual who is suicidal and one who rationally wishes to choose what is known as “Self deliverance” from the ravages of the end stages of a terminal illness. Most patients with end stage AIDS who discuss wanting to end their own lives often suffer from inadequately treated pain or an untreated depression. Once these conditions are successfully treated, some people still feel that “Enough is enough” and it is time to die. Self deliverance is about dying with dignity. This is not always simply about the control of pain in end stage illness. It is about suffering, and suffering can take many forms that compromise quality of life.

Many patients seen by the authors who discuss wanting to have the means available to end their own lives do so long before the onset of dementia. These same individuals express the fear that if they become demented they may lose their ability to act on their desire to rationally end their life. This is where there are serious ethical issues for the professional who supports a patient’s right to choose the timing of his or her own death. Clearly once an individual has lost the ability to think clearly there is a question about how rational can the decision to end one’s life be?

In one study 83.3% of people with AIDS said that euthanasia or assisted suicide was a choice they were considering, and reported that the knowledge that they could take their own lives helped them to cope. Many stated that they liked to be in control of all aspects of their lives, so it made sense that they be in control of their deaths. Many PWAs fear that once they become demented they will lose their window for “Self–deliverance,” and discuss with trusted friends concrete plans for being helped to end their own lives. Even for health care professionals who believe in assisted suicide, one foundation of this belief is the ability of the patient to make a rational choice for him or herself. Once a person has become demented he may no longer be able to have the cognitive ability to initiate self deliverance. Therefore prior planning and specific instructions are crucial if this has been the planned choice of the neuropsychological impaired PWA prior to the onset of symptoms of dementia. Obviously this places enormous strains upon his or her care partner who will be responsible for initiating an assisted suicide.

Psychotherapy may also serve as a supportive environment for patients wishing to discuss estate planning, advanced medical directives, medical power of attorney and living wills. In addition to the legal issues inherent in these topics there are significant emotional ramifications to concretely planning for the end of one’s life that become complicated as cognitive impairment sets in. Because wills and other legal documents are sometimes contested after death based upon allegations of diminished mental competency, referral for neuropsychiatric evaluation is one way of possibly establishing the patient’s level of competency by a second mental health professional prior to death. It should be noted that compromised neuropsychological performance alone does not necessarily render a patient incompetent.

In many cases, counter–transference issues arise for therapists who work with patients diagnosed with HIV–Associated Dementia. Professionals who work with cognitively impaired patients frequently experience counter–transference problems because of their own inability to reverse the course of the mental deterioration. As the case cited earlier in this article illustrates, it is not helpful to treatment when both the therapist and patient avoid bringing up indications of the onset of symptoms of AIDS dementia complex during the course of psychotherapy. Presentation of symptoms of HIV– Associated Dementia gives both the patient and therapist concrete evidence of the fact that HIV disease is progressing, and this raises a host of understandable feelings, most often powerlessness and anger, that the clinician must be prepared to recognize in order for them not to interfere with effective treatment. These dynamics are particularly important for clinicians because HIV is still a relatively new, lethal, and predominantly sexually transmitted disease that was first identified in socially stigmatized groups. Identification and acknowledgment of counter–transference issues are crucial and require the clinician to have adequate self–awareness to respond effectively.

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