What do you do with a healthy patient who wants to die?
Ms K was 95. Her face was only softly lined, and her ash-white hair was smooth and silky as a girl's. She was in what one might call quite good health, having survived both a heart attack and a cancer many decades ago. Save a matched pair of titanium hips, her body parts were all factory originals.
By all accounts, her life was still a full one. She was close to her children and their spouses. She had a cadre of friends and neighbors who queued at the door to her hospital unit. She was possessed of an adoring younger husband, a stripling of 89. Indeed, he treated her to an extremely long, lingering kiss with evident tongue, in full view of the medical team as well as of their son (who sighed, "This is like a bad romance movie!" as he edged out the door).
And yet, she was decided on death. Quite decided. One day she declared that she would no longer eat, and that was that. "I'm 95 years old," she said, "and it's time." No coaxing, wheedling, or caviling; no gnashing of teeth and no rending of garments could dissuade her. After a few days of this, her distraught family brought her to the ER. After it was duly determined, via the usual sequences of poking, prodding, and sticking with needles, that she suffered from no medical illness, psychiatry was called.
After much ineffective discussion, Ms K was diagnosed with depression (though she professed no sadness) and brought into the hospital. She lay there for days refusing food and medications, even basic nursing care. Far from the etheral candle flame near snuffing out, Ms K held court from her bed, directing her frantic relatives to fulfill various social obligations and execute a litany of domestic chores.
Stymied, the psychiatry team consulted the hospital ethics board. The ethics board was equally flummoxed. Its concern was to rule out the possibility that Ms K was acting in her right mind, and not out of a reaction to depression or pain. A meeting was held with the physician team, the patient, her husband, and her son and daughter-in-law.
According to the family, this desire for death wasn't like Ms K at all. Generally she was quite life-loving and had never expressed a wish to die. At the same time they admitted that she seemed quite of sound mind otherwise, that her personality was pretty well unchanged and her mind continued to be the steel trap it had always been. They did note that she had always been very pain-averse, that she was at the beginning of a long course of physical therapy to recover from a hip replacement, and that she'd been pretty well exhausted by the physical therapy for the replacement of her *other* hip a few years ago.
Of course the very fact that she'd undergone the second hip surgery - and that her surgeon felt her 95-year-old hip was appropriate for replacement - suggested that both she and the surgeon had expected her to have quite some life left to make use of it.
The best we could figure out was that she'd just decided she would rather die than go through more physical therapy. But that seemed a bit... dramatic, didn't it? Then again, from what her family said, Ms K was nothing if not dramatic.
As an aside, I'm not opposed to the choice of a dignified, peaceful, planned exit when it's the only choice over an imminent and pain-filled one. That doesn't sound like mental illness to me. But that is pretty different from this. It's pretty different when a dying patient chooses the time and the means, versus a healthy - but aged - one choosing to end her life for no clear reason. Especially when she's nested in a network of people who would be devastated by her passing, but unspeakably more so by her *intentional* passing. When you think about it from that perspective, it starts to sound a little bit selfish in a way.
What to do about Ms K? A masterful ethicist managed to convince her that in order to let her have her wish of self-starvation, we would first have to be convinced that she was not depressed. And one way for us to do that would be for Ms K to give us a trial of... eating. And taking an antidepressant. In order to prove that her course of action was entirely voluntary, she'd have to show us she could change it.
Somehow this made sense to Ms K, and she agreed to take the antidepressant - but not to eat. So there she was, dutifully tossing back a Lexapro every morning but steadfastly refusing to eat while her desperate family surrounded her bed, alternately threatening and cajoling her.
Meanwhile, we called in the pain team. Ms K had never really complained of pain to us, but given the recent hip surgery and the trepidation about physical therapy, we wondered if there was more than she was letting on. The pain team came up with an improved regimen for her, and that did seem to improve things.
So how did this all turn out? After a week or so without food but snappy as ever, Ms K realized this undertaking was going to last longer than she'd bargained for. It looked as if starvation was going to be more trouble than it was worth. One day she asked for breakfast, and that was that. I suspect the pain from the hip surgery was the real problem; but Ms K never let on. She just acted as if this was a temporary redirection and she was going to find a better method of suicide sometime soon. But she didn't seem acutely dangerous, and her family promised to keep a close eye on her; so after she'd gotten her electrolytes back in balance we discharged her from the psych unit.
You never really do know what's going on with most patients until you've been with them a while. One of my psychiatry preceptors has said that the reason the patient gives for coming in is almost *never* the real problem. At the time I thought that was exaggerated but I'm starting to come around. I guess if psychiatry were more straightforward it wouldn't be nearly as interesting.
Ms K was 95. Her face was only softly lined, and her ash-white hair was smooth and silky as a girl's. She was in what one might call quite good health, having survived both a heart attack and a cancer many decades ago. Save a matched pair of titanium hips, her body parts were all factory originals.
By all accounts, her life was still a full one. She was close to her children and their spouses. She had a cadre of friends and neighbors who queued at the door to her hospital unit. She was possessed of an adoring younger husband, a stripling of 89. Indeed, he treated her to an extremely long, lingering kiss with evident tongue, in full view of the medical team as well as of their son (who sighed, "This is like a bad romance movie!" as he edged out the door).
And yet, she was decided on death. Quite decided. One day she declared that she would no longer eat, and that was that. "I'm 95 years old," she said, "and it's time." No coaxing, wheedling, or caviling; no gnashing of teeth and no rending of garments could dissuade her. After a few days of this, her distraught family brought her to the ER. After it was duly determined, via the usual sequences of poking, prodding, and sticking with needles, that she suffered from no medical illness, psychiatry was called.
After much ineffective discussion, Ms K was diagnosed with depression (though she professed no sadness) and brought into the hospital. She lay there for days refusing food and medications, even basic nursing care. Far from the etheral candle flame near snuffing out, Ms K held court from her bed, directing her frantic relatives to fulfill various social obligations and execute a litany of domestic chores.
Stymied, the psychiatry team consulted the hospital ethics board. The ethics board was equally flummoxed. Its concern was to rule out the possibility that Ms K was acting in her right mind, and not out of a reaction to depression or pain. A meeting was held with the physician team, the patient, her husband, and her son and daughter-in-law.
According to the family, this desire for death wasn't like Ms K at all. Generally she was quite life-loving and had never expressed a wish to die. At the same time they admitted that she seemed quite of sound mind otherwise, that her personality was pretty well unchanged and her mind continued to be the steel trap it had always been. They did note that she had always been very pain-averse, that she was at the beginning of a long course of physical therapy to recover from a hip replacement, and that she'd been pretty well exhausted by the physical therapy for the replacement of her *other* hip a few years ago.
Of course the very fact that she'd undergone the second hip surgery - and that her surgeon felt her 95-year-old hip was appropriate for replacement - suggested that both she and the surgeon had expected her to have quite some life left to make use of it.
The best we could figure out was that she'd just decided she would rather die than go through more physical therapy. But that seemed a bit... dramatic, didn't it? Then again, from what her family said, Ms K was nothing if not dramatic.
As an aside, I'm not opposed to the choice of a dignified, peaceful, planned exit when it's the only choice over an imminent and pain-filled one. That doesn't sound like mental illness to me. But that is pretty different from this. It's pretty different when a dying patient chooses the time and the means, versus a healthy - but aged - one choosing to end her life for no clear reason. Especially when she's nested in a network of people who would be devastated by her passing, but unspeakably more so by her *intentional* passing. When you think about it from that perspective, it starts to sound a little bit selfish in a way.
What to do about Ms K? A masterful ethicist managed to convince her that in order to let her have her wish of self-starvation, we would first have to be convinced that she was not depressed. And one way for us to do that would be for Ms K to give us a trial of... eating. And taking an antidepressant. In order to prove that her course of action was entirely voluntary, she'd have to show us she could change it.
Somehow this made sense to Ms K, and she agreed to take the antidepressant - but not to eat. So there she was, dutifully tossing back a Lexapro every morning but steadfastly refusing to eat while her desperate family surrounded her bed, alternately threatening and cajoling her.
Meanwhile, we called in the pain team. Ms K had never really complained of pain to us, but given the recent hip surgery and the trepidation about physical therapy, we wondered if there was more than she was letting on. The pain team came up with an improved regimen for her, and that did seem to improve things.
So how did this all turn out? After a week or so without food but snappy as ever, Ms K realized this undertaking was going to last longer than she'd bargained for. It looked as if starvation was going to be more trouble than it was worth. One day she asked for breakfast, and that was that. I suspect the pain from the hip surgery was the real problem; but Ms K never let on. She just acted as if this was a temporary redirection and she was going to find a better method of suicide sometime soon. But she didn't seem acutely dangerous, and her family promised to keep a close eye on her; so after she'd gotten her electrolytes back in balance we discharged her from the psych unit.
You never really do know what's going on with most patients until you've been with them a while. One of my psychiatry preceptors has said that the reason the patient gives for coming in is almost *never* the real problem. At the time I thought that was exaggerated but I'm starting to come around. I guess if psychiatry were more straightforward it wouldn't be nearly as interesting.
TIP:
Enter the amount, and click "Tip" to submit!
Bellwether Vance
Stephanie Tames
Redstocking Grandma
Saturn Smith
Heather Michon
LuxeCalmeVolupté
Salon.com
Comments
lier lawyers whining,
reading at night at Open Salon,
bad breath, jammed computer buttons,
lint in the naval hole, cheap wino-politicos,
expensive quack shrinks, women couch slouching,
see-thru-pants,
no clean underpants,
splinter in her skinny ass,
naked volleyball intramural games,
wresting with a crocodiles, Lady P.,
retired military patriots, hag jesters,
children pulling at granny's hairy legs,
grandchildren in congressional diapers,
all the batch of Congress whiskey bribers,
comment deletes, fussy women, cowboy hats,
tourist in the Dc mental hospital wacky wards,
unmatched socks,
undeserved honors...
and tired of sleeping alone. Wine with sulfites that gives her a big breakfast toothache... going to bed way too late ... Yes, saying nighty goodnight. She wears a Aphrodite nighty? Oh, she's depressed at 95 year old without smooching again tonight? She see the DC's DOJ as sheer psychos? O pathetic.
Of course, she's depressed.
Why shouldn't anybody?
She's weary of DC jerks.
I certainly feel sorry for her, though. She seems to have no one who loves her enough to accept her decision. Dear god, I hope I'm not hurried to the hospital and popped into a psych ward if I come to a place -- not suicidal, but simply the decision "It's a good day to die."
And of course all the doctors so proud of themselves; are any of them going to follow up, find out how her life actually is a month after discharge? Six months? That's really the end of the story, isn't it? How does she die, in the end? (She will. We all do. One death each.)
Why did she get a joint replacement - major surgery requiring a big investment of time and effort - if she was contemplating death? That didn't really smell right. Any orthopod worth his salt would have investigated the motivation and health status of a 95-yo patient pretty thoroughly before giving her a big surgery like that, and it looks like she made it through that review. So something had happened in the short period of time since the surgery that made her decide she didn't want to live anymore.
What interests me is her decision to stop eating, rather than, say, putting a plastic bag over her head. To decide to not eat, and stay with that decision while remaining "sane" in all other ways, seems to me to signal that her body is, indeed, ready to start shutting down.
I liked your last paragraph. If psychiatry were more straightforward it wouldn't involve people, would it?
My aunt, who is 90, says old age is not for sissys...
I'd have given her an infusion of stem cells. Straight into the spinal fluid. See what develops from that...
No, no. I'm being fascetious. I don't quite get why someone didn't just sit down and ask her "why do you want to die, dear?" Or did i miss that? Wheedle it out of her. Figure out what kind of "authority figure" she respects, and send him in there to do the job.
Living with an 83 yr old mom in law affords me the opportunity to witness vast wisdom (and stubborness) but also vast ignorance of the modern means to alleviate life's travails. Find out what is really going on, and fix it. Sounds simple. But as you say , interesting blocking of reality going on...on both sides of the therapist-patient divide..
rated Jim
I am entirely uncertain that it is ethical to decide that a person's real or perceived 'depression' is any reason to deny them self-determination if personal conclusion is their goal and it their manner of exit is not physically harmful to others. The act of 'saving' someone who honestly either dislikes their own life, the way the world is going, or circumstances they cannot change seems ultimately to be a cruel exercise in control on the parts of others. A capacity to place chairs in the lawn and enjoy a good day's sunshine need not be of less value than one in which a person decides for themselves that they no longer wish to exist in a world they dislike or have simply grown tired of.
That landed her in the hospital with a case of diverticulitis, from which she recovered. She did not recover her determination not to eat. She died a month later essentially of dehydration. A very strong willed woman. Mercy.
But I have learned that it is nearly impossible to stop a person from committing suicide that way. It is simple and painless and within each person's grasp if there is just a little will and determination.
Who needs assisted suicide when you can do this?
My father-in-law, a dear man, just stopped taking his cardiac meds and told no one. When he was starting to get into trouble, he asked his adult son who lived with him to stay home that night. He was in his 80's, his wife had been dying of Alzheimer's and in a nursing home for 6 years and he had just made a trip around the country to make sure his kids and grand-kids were doing well.
I think this happens more often than we realize. We just have to move beyond denial that Mom or Dad would ever do this and really think about their circumstances, their lives and their current challenges. I tried to intervene when he was visiting us by getting liquid potassium to replace the awfully big potassium pills he was required to take. I found that unopened bottle when we went for the funeral. He close to do this where no one would intervene.
I can see that sometimes looking ahead is more painful and wearying than stopping the parade, depending on your spiritual beliefs. Both these deaths were very hard for our family. I didn't share what I knew about the self-direction of those deaths until later with some of the family but they all knew within a month. Secrets aren't good either.
I was somewhat surprised to find that a good conservative friend had ideas similar to my own--as he put it, when the time comes, he would just as soon walk deep into our Oregon woods, lay down beside a tree, and be consumed by a bear !
I've seen similar situations in my own family recently, and I can tell you, doctors are overly optimistic. They want to do procedures and make people well (or maybe just collect the fees!) and they don't always think whether the treatment is appropriate given the general situation. They tend to think only of the presenting problem, not the whole patient. When they say "This treatment will fix you up", what you should be hearing is "If anything is going to fix your PROBLEM up, it will be this". And you should ask "how likely is it that that's going to work FOR ME, and what is MY LIFE likely to be like afterward, given my age and general health". I think we would often be surprised by the answers.
I'm not keen on the notion that a 90+ person who decides they've had enough must be "depressed" and must be cajoled into changing their decision. I'm not saying this is a completely equivalent situation, but I was just talking with a friend who's a nurse, and she says they have a 104-year-old patient on life support where she works. She says it's the saddest thing she's ever seen, but the family can't bring themselves to allow the doctors to turn off all the equipment. What is their possible hope? That she'll start aging backward, a la Benjamin Button? Ain't gonna happen.
I guess my point is that of course you don't want to neglect people at the end of their lives, but since when is it MORE up to family members than it is up to the person themselves? What happens the next time this woman wants to do things her own way and the family disagrees? Hospitalization and tubes and distress?
I'm not trying to start any finger-pointing arguments, but I don't see much support for another side of the situation so far....
Why is it that we respect a cat's decision, but not a person's? In the vet's office afterward, still crying, my husband said to the vet, "I guess this isn't the fun part of your job, huh," and the vet said he had felt that way once, until his mother died of cancer. And visiting her every day in the hospital, walking past roomfuls of people who were groaning or gasping or sometimes actually screaming in pain, he came to realize that we allow our pets more dignity than we allow ourselves. That he's honored to be able to provide services that are needed.
To me the point of this story was that given a week or so of not eating, even without all the evaluations & handwringing, chances are she would've come to the exact same conclusion.
She seems like a great person. I'm glad her family cares about her, & I'm glad they actually tried to adjust her pain treatment, but the rest of it ?
A week in the hospital?
It's just completely excessive. This is why the bulk of money is spent in the first & last year of life. The first year, fine, but the last? & as others have noted, even with the new hip & a new attitude, there's still a damn good chance this will be her last.
Sounds callous, I know, but it just annoys me to think of all those out there not getting the treatment they desperately need while others get ... well, this.
I agree with Allie Griffith. I wish we had an option, as human beings, to make a painless and dignified exit. I'm the total opposite of this great old lady. I'm tough as a stewing hen, have a high threshold of pain and don't have any trouble with PT, but after 9 surgeries (that's just the joint ones) I'm seriously thinking about when and how I'm going to bow out. Not yet, while I can still have fun, but when I can no longer "be a cat." (This is how we put it when we put our own cat to sleep.)
But I understand and applaud the doctors wanting to be sure the lady didn't want to die because of pain. I had a friend who committed suicide quite young because of pain from a degenerative condition. For some people, pain can take away the will to live.
He ended up falling at home, in the hospital, and then had a stroke and passed away. Like my grandmother (his sister), a cascade of problems with the stroke as the end.
What an amazing, strong character he was. He had an amazing life and is sorely missed.
Your final comment reminds me of a study I read several years ago concerning the treatment of young asthmatic patients that were having an acute episode of their disease in an ER. The study divided the patients into two groups; one group was treated by the ER physician and the other group had the ER physician call the patient’s family physician for advice about how to treat the patient. The group that was treated with the advice of their family physician had their asthma attack resolve more rapidly and used far less resources (i.e. less costs) than the group that was treated by the ER physician alone.
One of the conclusions of the study was the great value of a physician understanding the history of a patient in providing effective treatment. Your well written post supports the findings of the study and leads one to wonder how the effectiveness of physicians might be undermined when there are increasing pressures on physicians to limit the time they spend in each patient encounter.
I worked in a nursing home for 5 years as a clinical social worker, and I can tell you that her pain maybe did represent a hopelessness within her, just a reminder of another loss which goes hand in hand with aging.
I really liked this, and thank you for sharing your work.