Dying

During my psychiatry rotation, I was consulted to see a woman for depression. Four months prior to admission she received a liver transplant for accidental acetaminophen overdose. She began feeling depressed after the surgery because of poor body image related to the surgical scar. She believed she had gotten to the point where she needed to be taken to an inpatient psychiatry ward to take a break from her life and reorient herself to her situation. One week prior to admission, she came into the ED complaining of depression, requesting to be admitted. The attending informed her that the inpatient ward was for very sick people and it did not seem appropriate based on the information she was telling us. The attending further informed her that there was insufficient reason to commit her because she did not pose a risk of harm to herself or others. She left with the impression that she needed to be actively suicidal to be admitted. One day prior to admission, she ingested a bottle of acetaminophen while sitting in her car in a garage, with her husband and two kids in the house. The husband saw her and asked if she wanted to be taken to the hospital, but she said no. The next morning her father came and took her to the hospital.

In the hospital she denied suicidal ideation, saying that she never wanted to hurt herself and currently doesn’t want to either, but felt that she needed to get admitted to psychiatry at any cost. Because of her actions and despite her denial of suicidal ideation, she was admitted. She clearly had a number of psychiatric problems, including a personality disorder that impaired her insight and judgment. I thought that she would realize that inpatient psych wasn’t really the place for the therapy she needed and that she would eventually find appropriate help. I was wrong.

Two months later I overheard her being discussed during my neurology rotation. She was in the hospital for altered mental status. Imaging of her brain showed diffuse cortical changes consistent with carbon monoxide poisoning. My initial reaction was that she attempted to kill herself again, but she was found at a residence without a garage. The story of what exactly happened has not been fully explained, but it is not hard to imagine what will happen next. We have heard of three potential suicide attempts (two acetaminophen overdoses and one carbon monoxide overdose). One of these days she will succeed.

I’m writing about depression because most of us do not consider it a terminal illness, although 35,000 Americans die from it yearly. Eleven times that amount attempt suicide. Because of risk assessment, looking at various demographic data and emotional/support factors, we can convince ourselves that we are doing our best to prevent their deaths. But suicide is wholly unpredictable. Imagine a cancer that vacillates between indolent growth and aggressive symptomatic expansion. How will you ever know if you’ve treated it? I believe this woman will likely kill herself. She is on the verge of doing it already and has exhibited repeated worrisome behaviors. She is dying from her disease and traditional therapies have not been successful. She is a dying patient and there is nothing medicine can do. She is my dying patient and there is nothing I can do.