When ECT Becomes Palliative Care: What a Cohort Study Reveals

Wed, 13 May 2026 13:08:02 GMT

Gregg A. Robbins-Welty et al.
Journal of the Academy of Consultation-Liaison Psychiatry. 2025;66:215–223.

DOI: 10.1016/j.jaclp.2024.12.001

“Patients who receive PECT experience reduced suffering and improved QOL. PECT may be helpful in scenarios of life-threatening psychiatric illnesses, terminal medical illnesses with comorbid treatment-refractory psychiatric illnesses, and diagnostic uncertainty with MNCD.”

Research Question

What are the indications, outcomes, and treatment characteristics of palliative electroconvulsive therapy (PECT) in patients with serious medical illness?

Study Location

Single-site retrospective cohort study at Duke University.

Inclusion Criteria

Patients with serious medical illness who:

received an ECT consultation between 2018 and 2023, and
had either palliative care involvement or DNAR status.

How Many Patients

31 patients met inclusion criteria.

21 patients received ECT
10 patients did not proceed with ECT.

Study Intervention

Patients underwent electroconvulsive therapy according to clinical indication.

Common indications included:

Catatonia (64.5%)
Treatment-resistant depressive disorder (35.5%)

ECT characteristics:

Mean acute course: 15 treatments
Mean maintenance course: 26 treatments
Most patients received ECT with palliative intent (81%)
Surrogate decision-makers consented in 76.2% of cases

Medical comorbidities frequently complicated management but often did not preclude ECT.

Follow-Up

Retrospective chart review covering treatment episodes from 2018–2023.

Endpoints

Primary descriptive outcomes included:

Psychiatric symptom improvement
Functional improvement
Cognitive outcomes
Quality of life (QOL)
Safety and complications
Diagnostic clarification

Results

All 21 patients who received ECT experienced psychiatric symptom improvement.
Catatonia patients demonstrated a mean Bush-Francis Catatonia Rating Scale improvement of 17 points (range 8-30; n = 14).
Patients with persistent major neurocognitive disorder (MNCD) demonstrated a mean Montreal Cognitive Assessment (MoCA) improvement of 5 points (range 0-17; n = 8).
Five patients previously diagnosed with were reclassified as depression-related cognitive dysfunction.

ECT improved:

communication (71.4%)
oral intake/hydration (66.7%)
activities of daily living/function (57.1%)
ECT was associated with reversal of life-threatening weight loss in approximately 20% of some patients.
ECT-related complications were uncommon:
one aspiration pneumonia
one episode of bradycardia
No deaths were attributed to ECT.

Other Relevant Information

Many patients had severe medical comorbidities including cancer, heart failure, cirrhosis, COPD, and failure to thrive.
Some patients required ICU-level monitoring during ECT.
Catatonia was frequently under-recognized and misdiagnosed as dementia.
Palliative care consultations were commonly triggered by psychiatric complications such as inability to eat, failure to thrive, or goals-of-care decisions around ECT.
The study highlights the importance of collaboration between consultation-liaison psychiatry and palliative care.

Limitations

Small sample size.
Single-center retrospective design.
Potential selection bias.
Reliance on chart documentation and subjective review of clinical improvement.

Summary and Implications

Palliative ECT appears to be a safe and effective intervention for selected patients with severe psychiatric illness in the setting of serious medical disease. In this cohort, ECT consistently improved psychiatric symptoms, cognition, communication, oral intake, and overall quality of life, while causing few complications.

ECT may also assist diagnostically, particularly in distinguishing depression-related cognitive dysfunction and catatonia from irreversible dementia. The study supports closer collaboration between palliative care and consultation-liaison psychiatry and suggests that ECT should be considered as a palliative intervention when severe psychiatric symptoms contribute substantially to suffering or functional decline.

Comments

Electroconvulsive therapy (ECT) is often framed as a treatment aimed at full remission: for instance, resolving catatonia, lifting severe depression, or stabilizing psychosis. But on medical inpatient units, in the intensive care unit, and alongside palliative care teams, the goal is sometimes different. In such settings, it may be clinically appropriate to prioritize the relief of suffering, restoration of communication, and improvement in eating and drinking. This study addresses that under-discussed clinical reality by describing “palliative ECT” for patients with limited medical prognosis.

Consider ECT as a palliative intervention when the goal is relief of suffering and restoration of function, even if full remission is unlikely. For select patients, ECT may be indicated to improve communication, eating and drinking, basic functioning, and time spent out of the hospital.
When “dementia” is diagnosed in the setting of rapid decline, withdrawal, poor intake, or immobility, keep catatonia and severe depression with cognitive impairment high on the differential—this cohort included multiple cases where cognition improved substantially after ECT.
Medical complexity should trigger careful planning (including higher-acuity monitoring when needed), not automatic exclusion; complications were uncommon and no deaths were attributed to ECT in this series.
Strong collaboration between patients, surrogate decisionmakers, consultation-liaison psychiatry, palliative care, anesthesia, and the ECT service is essential for shared decision-making aligned with patient goals.

CNECT Blog