Devastating illnesses can bring patients to the brink of a seemingly agreeable suicide. The role of the psychiatrist can be to look coldly through the pain and determine if there is a way to save the patient's life and make it worth enduring. Then the clinician must be prepared to enact what he perceives.
In 1986, my mentor and suicidologist, Dr. Edwin Shneidman, asked me to see a patient that he had consulted on. Before I did, he told me the following:
The patient was a 64 year old man, housebound from end stage Parkinson's Disease. He had requested to be put out of his misery. He not only desired to be allowed to die, but had asked for help to accomplish the deed. He was unable to get out of bed to retrieve his stockpile of pills or his handgun.
This man previously had been a successful professional athlete. He had also been an example of fortitude and persistence to his wife of 30 years and to his four sons. He had continued as a coach, hiding the early signs of Parkinsonism from his players and children, saying he did not want to be pitied. For six years; he functioned-fairly well. But during the last two, he had deteriorated drastically.
He had exhausted most of the benefits of the anti-Parkinsonism drugs and was obtaining progressively less relief for his tremor while having increasing negative side effects - severe involuntary movements (athetosis) - from the L-dopa. His neurologist had cofirmed that the disease was indeed progressing and the L-dopa becoming less effective. But the neurologist did not feel the disease had reached an end stage, believing it might not for several more years.
After hearing a history and description of this difficult situation, I phoned the patient and his wife to arrange a house call. Then I drove the 45 minutes it took to reach their home. The weather was roasting and my air conditioner was on the fritz, so I found my anxious anticipation becoming mixed with irritation.
When I arrived, the patient had been "readied" for my visit, I discovered, by having been moved from bed. He had donned a robe and was sitting in the darkened living room. He had a wizened, almost emaciated appearance, was unshaven, and generally looked awful. In the room, I caught glimpses of early photos of this man. In them he looked vigorous.
I introduced myself and said I had come at the request of the previous doctor and of the patient's wife. The continual bob and weave of his head was as unsettling to observe as it was for him to talk through. I asked him why he thought I was there. He replied, "They probably want you to talk me out of doing away with myself. They think I'm depressed. I'm not. I'm just realistic. How do you think you'd feel, if you were a hostage to this disease?"
I didn't know what to say. I asked him, "Why did you go along with having this visit?" (Privately, I wished I were back in the safety of my office with patients who wanted to be seen.) He answered, "I have to admit, I did feel better after I saw the other doctor. He was so kind to come out to the house that, when he insisted I see you, I went along with him."
Then he proceeded to tell me much about himself - particularly how he always had been a man of action, a doer rather than a thinker. Now he could do very little, and had been reduced to a housebound invalid. "They would take it badly if I killed myself. But each day lasts forever, and I don't know how much longer I can hold on," he related in a beaten voice.
I wanted to buy more time, so I asked if he could promise me not to take any drastic action until I saw him again. The next time I wanted to see him with all his children and their spouses. We arranged this meeting for the following Sunday, giving his children from out of town time to come. As a final note, after I felt some rapport had developed, I quipped to him that if I were going to make the effort to drive this long distance in this awful heat with a bum air conditioner, I, would expect him to be shaven, groomed, and fully dressed for the family meeting.
Before this second session, I tried to establish in my mind a common goal for this family. It seemed important to each member to believe that he or she had given his or her best effort. There would be less guilt to haunt them, thereby, after he died. It was imperative to enable each person _o understand all the others' points of view. A helpful beginning technique would be to ask different persons what they believed other family members felt about this meeting. This empathogenic technique usually keeps interest of all participants high because they are allowed to hear how other family members view them.
The family meeting began with me being surrounded by a clean shaven, well groomed, street clothed patient; his wife; four sons; and four daughters-in-law.
I selected the oldest son to speak first, asking him how his father probably felt about this meeting. He replied that he felt his father went along with it to satisfy other family members, but was skeptical that anything positive would be accomplished. When asked what he had hoped his father might feel and what he feared his father may feel, he replied, "I hope my father will find a reason to live. That he will realize that he doesn't have to do anything to earn our love. I'm afraid that he'll nod, or agree to what we want now, but then he'll go back on it as soon as his suffering increases."
Other members of the family expressed similar sentiments. The youngest son's wife wept continually throughout the meeting. The patient's wife spoke very little. The patient nodded agreement frequently, but in an obligatory, insincere manner. Multiple suggestions were made as to hov the patient might usefully spend his time. On several occasions, I tried to translate different persons' points of view, to make them comprehensible to. the others. It seemed important that the patient know he was loved but, yes, he was a burden. He was not imagining that. It was emphasized that he himself was not the burden, rather it was his illness. As he felt helpless against-his illness, his family felt helpless against his despair.
Furthermore, it seemed clear that the family wanted to believe him, but distrusted him. They believed that he still would end his life, if he had the chance. When confronted with this, he promised not to attempt to end his life, and to give a psychological approach to his suffering a chance.
The meeting lasted about 90 minutes. By its end, the family felt a good deal more unified, as all of them had expressed their personal fears and hopes. I left the family with two books to continue to help them understand each other.
I gave The Diary of Anne Frank to the patient. Like Anne Frank, he was in an occupied country, occupied by his unwelcome disease. I emphasized that, just as she was forced to create a new world for herself, behind her bookcase in Amsterdam, he was now challenged to learn a new way to enjoy and appreciate life, now that physical mobility no longer was available to him.
I gave Death Be Not Proud by John Gunther to the eldest son. I told him that this book might help him appreciate the struggle to keep hope alive and despair at bay. Gunther had depicted this so poignantly, telling of his son who would die of a brain tumor shortly after he tenaciously completed high school. The book also might help him and other family members to balance savior-like zeal with a realistic goal of reducing suffering.
The days passed, the disease progressed. The patient accepted a trial of antidepressants, but developed urinary retention and a urinary tract infection. He was hospitalized, and felt even more demoralized and suicidal.
The eleventh hour had been reached, and I arranged another family meeting. At it, every family member agreed to allow the patient to take his life. In that meeting, I suggested that until shock therapy (ECT) was tried, not all reasonable options had been exhausted.
They were aghast at the suggestion of such a "primitive" 'method of therapy. But I told the family my belief that in years to come ECT would probably be shown to be a very effective treatment in properly selected patients. Since it was now available, I argued that the controversy prominent in the media should not prohibit its use. It would be a shame, I concluded, to see it confirmed as a therapeutic modality, as I believed it would be, and to be concurrently haunted by the knowledge that it had not been tried before their loved one was allowed to commit suicide. The family agreed to allow it to be tried. In a unified confrontation with the patient, they "insisted" he give it a try, if not for himself, then for them.
Before the therapy was tried, I consulted with other psychiatrists, who agreed that ECT was indicated. Then a course of inpatient ECT was given. I was pleased and vindicated that there was a striking remission of not only the patient's depression, but of many of his Parkinsonism symptoms as well.
Maintenance ECT since, at a frequency of one treatment per month, has kept the patient's functioning at an optimum level. At present, the patient and his wife continue outpatient psychotherapy.
And after that they came to my place.
EPILOGUE: That patient went on to have many additional years of reasonably good quality life (they even sent me a picture of him horse back riding) before he finally died seven years ago. It left me with two enduring lessons. First, to project yourself into someone's suffering and think I'd feel and want to do the same thing is to miss out on a treatable illness. Second, to extend life without giving people a reason to live is at the very least short sighted and at worst is against the Hippocratic Oath to "first, do no harm."
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