Sometimes Crazy Can Be Sane (Part 2)

(Posting delayed because of major developments in the case; see end.)

It turns out that the answer to "what do you do with a situation like this?" is "cheat!" Specifically, defer decisions as much as possible to the next day when hospital administrators, lawyers, experienced consult attendings, and so on, are available. The patient himself did us a favor -- he let himself be admitted for pain control and monitoring, thus sparing me the problem of figuring out how to make a case for commitment. Thankfully, he also didn't crash during the night. If he had, we'd have been in trouble. I wasn't on, but had I been, I'd have probably recommended resuscitation despite his do-not-resuscitate paperwork. A patient can always die another day, but if you decide you were wrong in withholding care, you can't bring them back to life. Now, that probably would have gotten the hospital sued for battery, but I still think it would've been right.

The ensuing days were a flurry of ethical and legal consultation, both internally and with the county evaluators who determine whether we're allowed to hold someone for involuntary treatment. Ultimately, they decided that he could and should be held -- not because we could diagnose major depression or any other form of known mental disorder, but because he had an "emotional disorder". In essence, wanting to kill yourself is per se evidence that you are crazy. (The availability of "not otherwise specified" diagnoses, such as "Depression NOS" instead of "major depressive disorder", helps.) Exploration of that ethical concept, particularly in a state with a Death With Dignity act, is beyond the scope of this blog, and also beyond the scope of this author's sophistication.

So, he spent some time on the inpatient psychiatric unit. Specifically, he spent three business days, which is the duration of a legal hold. During that, he talked with yet more psychiatrists (in total, this guy saw something like ten to fifteen shrinks and mid-level psychiatric practitioners within a single week) and of course, didn't change his underlying personality structure or life philosophy one iota. He did get his hearing aids. They didn't help much. Mainly, being as his brain is functioning just fine, he learned the basic rule: if you say you're going to kill yourself, they lock you up. When you say you're not going to kill yourself, they have to let you go. His 72 hours expired, he told the judge "heck, no, I'm going to give living a try", and home he went -- right back to the same favorite armchair in which he shot himself just a week earlier.

I visited him a couple times while he stayed with us, hoping that maybe I could make a bit of a connection, not as a doctor but as a human being. He claimed to his other docs that it worked and that he was glad to know someone else cared about him that much. I remain skeptical. About a week and a half after he'd left us, I tried to give him a call at home, and got his daughter. (Unsurprisingly, with that hearing, he doesn't use the phone much.) While I did find out that he was alive and in relatively good spirits (good), he was also working to try to talk his primary MD into prescribing medication for physician-assisted suicide (not so good).

Half of me feels like I just didn't try hard enough. The other half points out that a 90-year-old man on blood thinners is going to die soon enough of something; within 3 years if the Social Security tables are accurate. He knows what he considers quality of life, and he knows he's not getting it. I never could decide whether I have any right to interfere with that thinking or with its eventual outcome. In the meantime, I've added the Seattle Times obituaries to my usual set of browser tabs. He's going to show up there eventually; the only question is whether it's in a month or in a year.

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The Sequel:

The above was written roughly early March. Since then, I'd corresponded once or twice with his daughter via email; never with the patient himself, although I did drop him a snail-mail note when he spent two weeks in assisted living (daughter was taking a trip to China). Came back undeliverable, but eventually forwarded to his home. It wasn't much, and I still don't know whether it's more annoyance than help, but it felt necessary.

Yesterday, as I was getting ready for bed, I got another email from his daughter, informing me that he'd passed away earlier that week. She didn't say, but the subtext suggests that it might have been hastened a bit. Rationally, I think this is the right outcome based on his values, but I still can't help but feel a bit sad.