Use of ketamine for reversing acute depression in a critically ill pretransplant patient

A 68-year-old with a history of ischemic cardiomyopathy, chronic kidney disease, hypertension, and anxiety was admitted to the intensive care unit (ICU) in cardiogenic shock. After an intubation and several days in the ICU, he expressed hopelessness with further care and was considering a transition to hospice. The treatment team was concerned that clinical depression was influencing his decision. After obtaining consent, depression was treated with 0.5 mg/kg of intravenous ketamine for 3 days, with rapid and significant improvement in his mood. He made an informed choice to pursue a workup for heart transplantation. Besides improving his mood, ketamine led to vivid subjective experiences. This case provides a qualitative account of the patient's experience. It raises crucial questions about the influence of depressive symptoms in decision-making in critically ill patients and the potential role of ketamine in the rapid resolution of depressive symptoms and subsequent changes in care decisions.