(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.
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.
Tuesday, April 13, 2010
Friday, April 2, 2010
Sometimes Crazy Can Be Sane (Part 1)
Admittedly, I'm only an intern, and I don't do my serious consultation psychiatry rotations until next year, but this is certainly the most interesting consult I've seen in my life thus far. To set the scene, I'd agreed to take a second call on a weekend (normally we only have one call night per week) in order to be off on a future weekend with my wife. It was 4 PM, on a shift that ends at 8. I'd seen multiple consults, hadn't actually written my notes, and was trying to get the med student out the door when the pager (ah, the pager) rang. It was the attending down in the psychiatric ER, who has to deal with things on her own on the day shift when the resident's scurrying around the hospital doing consultations. She had for me what she described as "an interesting and educational consult":
Step one when doing such consultations (after regaining one's composure and being careful not to swear in front of impressionable young students) is to establish the medical picture, so that you can understand whether the patient really gets what's going to happen or not happen to him. The picture, in this case, is that he really did shoot himself thrice with a .22 handgun -- twice in the head and once in the chest. I still do not know what happened; our best theory is that he had old and poorly stored bullets[3]. A .22 is not big, but should be able to do substantial damage from point-blank range. These bullets didn't even crack his skull. The one in his chest put a hole in his lung, but didn't deflate it or otherwise compromise him. He's 90 years old, mostly healthy except for a heart rhythm problem, some orthopedic pain, and now some holes in his body. At that moment, he wasn't fixing to die, but anyone who's worked in trauma knows that someone can go from looking fine to crashing in a very short time.
So off I went, with a new medical student in tow, to see our unbreakable man. What we found was a thin but hale-looking fellow, totally covered in blankets (it's cold in the trauma bay), and totally awake and alert on a gurney. Despite being shot three times, he denied being in pain. He also denied being able to understand us -- he's got miserably bad hearing, and in fact, the only way you can ask questions is to lean down and shout them slowly and clearly into his right ear. Now, a psychiatric interview is meant to be both diagnostic and therapeutic. In the process of the patient providing data, the physician provides reflections and interpretations that are hopefully able to help someone feel better, or at least feel respected and understood. Shouting short phrases into a patient's ear somewhat limits the delicate subtlety of these techniques.
Nevertheless, shout we did. We shouted "Why did you want to kill yourself?", "Are you depressed?", and various other personal questions, and he told us his story. He's a local boy who finished college, then heard a recruiter's pitch and ended up in the Navy on the Pacific side of WW2. (It turns out that the Japanese weren't just trying to bomb tropical atolls, but were quite active in the North Pacific and up into the Aleutian Islands, and both Puget Sound and Alaska were actually considered to be part of the battleground.) He didn't see enough combat to get traumatized, but did see enough to earn himself a long naval career, including time as a junior officer and a whole lot of desk work. When he retired from the service, he took another job in a totally unrelated field, and when he retired from that, he worked as a volunteer for over a decade. Way back at the start of it all, he married a girl he'd known since he was a young man, and they stayed married over 50 years.
That's where the trouble began. A bit over a decade ago, she developed Alzheimer's, and began to dwindle. He traces his thoughts of suicide back to that time, when he realized the prospect of life without the woman he'd loved for more than half his life. He went so far as to propose a joint suicide to her -- they'd go out to the garage, shut the door, run the car, and pass on together. (It's hard to describe how simultaneously romantic and creepy the story is as he tells it.) She decided that wasn't the right path for her, but shortly afterwards died suddenly of "natural causes", leaving him alone. That's when he decided to take the next step and buy the gun. According to him, the only thing that kept him going was his daughter. She was in the area, recently divorced, and he figured he'd move in with her to keep her company. Fast forward 10 years and she's remarrying, in retirement herself, traveling the world, and generally doing quite well. From our patient's perspective, he's no longer needed, he can't work, he can't drive, his friends are all dead, and he's just costing society money. Hence, he spent a few months writing his note and obituary, and on a day he knew she'd be gone, he brought out the gun and attempted to remove himself from the world.
Normally, when someone's got genuine major depression, they show other signs besides feeling worthless and suicidal -- they stop eating, they can't sleep, nothing brings them pleasure anymore, they can't think well enough to even read a book, and so on. He had, at least on the surface, none of that. He can enjoy life -- he just doesn't, because his worldview is totally focused on being a productive breadwinner, not on being someone who just sits back and enjoys extended retirement. His memory's pretty much intact, he actively reads and can discuss philosophy and metaphysics, and he's got tons of interesting history archived there in his brain. From his perspective, the preservation of that history isn't worth the cost of his room and board.
There's a lot of details I'm leaving out in order to keep the veil of privacy over him, but it was clear that if he left the hospital that night, he'd end up trying to take his life again. Not that day, but eventually. His family and other social supports weren't going to stop him, nor could his primary doc. Hence the quandary -- there was a duly executed legal document and an apparently cognitively intact patient seeking to refuse medical care. If he were mentally ill, I'd have the power and the obligation to have him committed for involuntary treatment -- but treatment of what, if I can't fit him into the diagnostic criteria for depression? If he's not mentally ill, and if we let him refuse treatment, is the hospital abetting a suicide? Am I as a psychiatrist becoming complicit in a suicide? Is that ever something that could be allowable under professional ethics codes? Can I bring into the picture the fact that I genuinely like this guy and want to save his life?
Not the sort of questions you want to be trying to answer on a Sunday evening with minimal senior backup available. Ponder it for a bit; in Part 2 I'll tell the tale of what actually happened.
[1] Rat poison in accurately measured pill form. Thins your blood so it doesn't clot. You get put on it when you have a history of forming clots in your blood vessels that would otherwise break loose and swim to inconvenient places like your kidneys, your coronary arteries, your pulmonary arteries, and especially your brain. Relatively minor trauma suddenly becomes an Interesting Experience.
[2] A complex concept that can be oversimplified as"We want to do X and he won't let us. Is he nuts? And if he's nuts, can we just do it to him anyway?"
[3] My preferred explanation is that God wants the dude alive for some reason. The patient is not impressed with this theory.
The medical ED called me. There's a 90-year old gentleman in the trauma bay. He shot himself three times and is still alive and neurologically intact. He's on Coumadin[1]. He's got a DNAR form and is refusing all medical care. They want us to assess him for decision-making capacity[2].
Step one when doing such consultations (after regaining one's composure and being careful not to swear in front of impressionable young students) is to establish the medical picture, so that you can understand whether the patient really gets what's going to happen or not happen to him. The picture, in this case, is that he really did shoot himself thrice with a .22 handgun -- twice in the head and once in the chest. I still do not know what happened; our best theory is that he had old and poorly stored bullets[3]. A .22 is not big, but should be able to do substantial damage from point-blank range. These bullets didn't even crack his skull. The one in his chest put a hole in his lung, but didn't deflate it or otherwise compromise him. He's 90 years old, mostly healthy except for a heart rhythm problem, some orthopedic pain, and now some holes in his body. At that moment, he wasn't fixing to die, but anyone who's worked in trauma knows that someone can go from looking fine to crashing in a very short time.
So off I went, with a new medical student in tow, to see our unbreakable man. What we found was a thin but hale-looking fellow, totally covered in blankets (it's cold in the trauma bay), and totally awake and alert on a gurney. Despite being shot three times, he denied being in pain. He also denied being able to understand us -- he's got miserably bad hearing, and in fact, the only way you can ask questions is to lean down and shout them slowly and clearly into his right ear. Now, a psychiatric interview is meant to be both diagnostic and therapeutic. In the process of the patient providing data, the physician provides reflections and interpretations that are hopefully able to help someone feel better, or at least feel respected and understood. Shouting short phrases into a patient's ear somewhat limits the delicate subtlety of these techniques.
Nevertheless, shout we did. We shouted "Why did you want to kill yourself?", "Are you depressed?", and various other personal questions, and he told us his story. He's a local boy who finished college, then heard a recruiter's pitch and ended up in the Navy on the Pacific side of WW2. (It turns out that the Japanese weren't just trying to bomb tropical atolls, but were quite active in the North Pacific and up into the Aleutian Islands, and both Puget Sound and Alaska were actually considered to be part of the battleground.) He didn't see enough combat to get traumatized, but did see enough to earn himself a long naval career, including time as a junior officer and a whole lot of desk work. When he retired from the service, he took another job in a totally unrelated field, and when he retired from that, he worked as a volunteer for over a decade. Way back at the start of it all, he married a girl he'd known since he was a young man, and they stayed married over 50 years.
That's where the trouble began. A bit over a decade ago, she developed Alzheimer's, and began to dwindle. He traces his thoughts of suicide back to that time, when he realized the prospect of life without the woman he'd loved for more than half his life. He went so far as to propose a joint suicide to her -- they'd go out to the garage, shut the door, run the car, and pass on together. (It's hard to describe how simultaneously romantic and creepy the story is as he tells it.) She decided that wasn't the right path for her, but shortly afterwards died suddenly of "natural causes", leaving him alone. That's when he decided to take the next step and buy the gun. According to him, the only thing that kept him going was his daughter. She was in the area, recently divorced, and he figured he'd move in with her to keep her company. Fast forward 10 years and she's remarrying, in retirement herself, traveling the world, and generally doing quite well. From our patient's perspective, he's no longer needed, he can't work, he can't drive, his friends are all dead, and he's just costing society money. Hence, he spent a few months writing his note and obituary, and on a day he knew she'd be gone, he brought out the gun and attempted to remove himself from the world.
Normally, when someone's got genuine major depression, they show other signs besides feeling worthless and suicidal -- they stop eating, they can't sleep, nothing brings them pleasure anymore, they can't think well enough to even read a book, and so on. He had, at least on the surface, none of that. He can enjoy life -- he just doesn't, because his worldview is totally focused on being a productive breadwinner, not on being someone who just sits back and enjoys extended retirement. His memory's pretty much intact, he actively reads and can discuss philosophy and metaphysics, and he's got tons of interesting history archived there in his brain. From his perspective, the preservation of that history isn't worth the cost of his room and board.
There's a lot of details I'm leaving out in order to keep the veil of privacy over him, but it was clear that if he left the hospital that night, he'd end up trying to take his life again. Not that day, but eventually. His family and other social supports weren't going to stop him, nor could his primary doc. Hence the quandary -- there was a duly executed legal document and an apparently cognitively intact patient seeking to refuse medical care. If he were mentally ill, I'd have the power and the obligation to have him committed for involuntary treatment -- but treatment of what, if I can't fit him into the diagnostic criteria for depression? If he's not mentally ill, and if we let him refuse treatment, is the hospital abetting a suicide? Am I as a psychiatrist becoming complicit in a suicide? Is that ever something that could be allowable under professional ethics codes? Can I bring into the picture the fact that I genuinely like this guy and want to save his life?
Not the sort of questions you want to be trying to answer on a Sunday evening with minimal senior backup available. Ponder it for a bit; in Part 2 I'll tell the tale of what actually happened.
[1] Rat poison in accurately measured pill form. Thins your blood so it doesn't clot. You get put on it when you have a history of forming clots in your blood vessels that would otherwise break loose and swim to inconvenient places like your kidneys, your coronary arteries, your pulmonary arteries, and especially your brain. Relatively minor trauma suddenly becomes an Interesting Experience.
[2] A complex concept that can be oversimplified as"We want to do X and he won't let us. Is he nuts? And if he's nuts, can we just do it to him anyway?"
[3] My preferred explanation is that God wants the dude alive for some reason. The patient is not impressed with this theory.
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