Tres and a Most Dramatic Case of Suicide
These recollections flows from a recent article in the American Academy of Family Practice Journal on Suicide. Some interesting summary points are made in my short review in this blog.
Most doctors I know have had patients attempt suicide. A few succeed. While memorable, the experiences I saw were relatively rare in a general practice. With respect to learning my craft, many subjects in clinical medicine had to be learned from scratch. I did not come to medicine with a “blank slate” regarding suicide. For example, in college there were discussions about a person’s autonomy and an existential right to commit suicide. Speaking for myself, I was only aware of one person at that time to have completed this act—a friend of my brother’s from High School. So, the discussion was abstract and theoretical and not based on any personal experiences.
This was tested when learning to take histories in medical school. While learning physical diagnosis, my housemate Dwight and I were assigned a woman on a “hold” at UCLA. She had a cancer diagnosis and had tried to overdose on medication. She was not getting out of the hospital without expressing some contrition and a willingness to look at other options. Both Dwight and I felt dirty doing our student history taking and while performing the psychiatric portion of the interview, sensing her need to communicate an intent at odds with what she was feeling. The gulf between our personal experiences, our inexperience, and what she was facing was immense — we knew it. I gave some thought to that existential “right” and all that interferes with it as well as trying to get a reckoning of insight—-both my reading of a patient and a patient’s reading of themself.
I detect in many people failures of self-knowledge—of insight and with age I have grown to distrust many judgements and decisions made by patients—-and acquaintances.
My early training nearly ruined my ability to assess suicidal risk. Second year in the County Hospital found me routinely admitting teen aged girls for having ingested unknown quantities of unknown pills (I think it was mom’s penicillin….) to the ICU which was designed for the care of seriously ill and dying patients. After a year of such patients, giggling with friends who came to visit and parents who were frustrated or angry with the drama and expense this all represented, I developed a thick skin interpreting a patient’s words regarding intent.
My first year in practice (Salinas) provided an opportunity to improve my understanding of suicidal risk. I had a frail old woman who saw me twice a year and mostly came for social contact—her medical problems were controlled and not very dramatic. She came in one afternoon with a significant burn on her right hand. That was not why she was in that day but she was forthcoming. “Well, sometimes, I kind of space out and while I was cooking the other night, I was standing by the range and when I came to, I had this burn on my hand.”
What is wrong with that picture?
“You don’t remember getting burned?”
“Not really.”
“Do you have other times when you ‘space out?’”
“Yes……one time, I was watering the lawn and when I came to, I was pretty wet, lying in the lawn with the hose on, and I have no idea for how long. The lawn was soaked though.”
My inclination was to worry that she was having some sort of seizure—not the dramatic convulsive kind but the temporal lobe kind that is often described as “spacing.”
She lived alone in the rural county. She drove rarely but when she did, she was on a county highway. The law in California regarding my responsibility was clear. I referred her to a neurologist and arranged for an EEG to be done ASAP, and I also reported her problem to the Department of Motor Vehicles.
She was in the process of her evaluation when she presented, angry and desperate. “Dr. Moeller, I live alone. My car is what allows me to live in my home. I have no one to depend on and I must be able to drive. This letter from the Department of Motor Vehicles tells me that my license is suspended and I can no longer drive. Why would you do this to me?”
Why indeed? The law provided the regulatory rational for what I did but so was the very real concern that such a spell while driving would be a serious problem for her and anyone on the road with her. This explanation was not accepted. “I have had this problem for years and no one ever thought I needed this sort of attention and I have never been in a car accident in my life.”
We agreed to disagree and I never saw her again.
Later, I did hear from one of the residents at the county hospital that she had been admitted to the ICU after an overdose. She had attempted to commit suicide with medication (I no longer recall which medication). She was stable and would be able to be discharged, but her driving restriction and now a suicide attempt was going to land her in a nursing home for awhile. Her world literally fell apart. I was full of remorse and wanted to see her and try to help her reconcile what had happened. The resident warned me off. “Please, do not try to see her. She is very clear on that point and we have assigned her a new doctor.”
That is a burden of being a physician, I told myself. That is part of the job and the responsibility. I did the right thing but bad things flowed from that decision, just like bad things would have likely flowed had I not taken the action that I did. A good lesson of life, right? Everyone can be doing the right thing and the system can still deliver crappy results.
In Olympia, years later, I met a woman from the opposite point in life. She was a young twenty-something who was strikingly beautiful. Heads turned when she came into the clinic. She came from the “wrong side of the tracks,” however and just a few sentences of conversation found me sympathetic to how physical beauty does not protect a person from the changes a tough life can impose. She had not completed High School and came from an emotionally abusive home life. She was on her own and working a minimum wage job. She presented originally with symptoms of a pelvic infection and indeed, she had both primary Herpes and Gonorrhea diagnosed on our first visit. She was treated for these and given her symptoms of depression, began an antidepressant—-she improved in follow up visits, I was heartened to learn of a new stable job and new boyfriend, one who was a college graduate which she identified as a step up for her. She spoke dreamily one day of their possibly getting married.
She got pregnant unintentionally. Her boyfriend would not hear of her having the baby nor would he marry her. He pressed forcefully for an abortion and she complied. Not long afterwards, it became apparent to me that she was depressed despite her antidepressants; she was open to counseling. I collaborated with the therapist seeing her and we thought that while she was in a tough situation she making progress.
We had no clue. I learned from the coroner that she committed suicide. She waited for the boyfriend to open the door to their apartment, made eye contact with him, and then without a word, pulled the trigger of a pistol she had aimed at her own chest.
I had lots of my daily work to help keep me preoccupied from dwelling on this over and over and yet, I dwelled on every visit and every interaction I had had with her, over and over. Her therapist and I spoke of it. The head of the behavioral health department suggested we have a meeting to do a “psychiatric autopsy” of her care. It was a pretty awful hour spent for all of us—-with a cat of nine tails. No conclusion was reached other than to say, “the standard of care was met. Nobody made an error.” Except, she committed suicide with a gun. My cynical self believes that people this intent will not be thwarted and they know how to say the right things when the pointed questions come. But the questions don’t go away: were there things that might have been that did not occur.
The laws in Washington are confounding in this regard. If you think someone is going to harm themself, you take yourself out of it and call a state licensed provider who specifically is assigned the job of determining the risk and the legal tools needed to involuntarily hold a person against their will with suicide in mind. In my experience, it is a tough experience and I have learned that unless you are brandishing a gun or walking in front of moving trucks, they will find a reason to suggest that out-patient care later in the week is an adequate plan. The reason for this lies in both the expense and the lack of available sites for care—- as well as acknowledgement that in our country, putting someone in a care facility against their will should be the exception, for exceptional circumstances—- like brandishing a gun or running in front of moving trucks—-and otherwise, that appointment next week will have to do.
A retired man of some seventy years present to my practice a few years before I retired. He was depressed and contemplated suicide. My existential argument had many boxes checked: he had had colon cancer and part of his treatment after surgery included radiation treatments to the abdomen and pelvis, This caused colitis and bladder problems that were inconvenient and painful. There was a significant chance he was not cured of his cancer despite this treatment. This was a problem that evolved over a year during which he also developed severe spinal stenosis that precluded his being able to cycle—-a huge source of pleasure for him in retirement. The spinal stenosis rendered him weak, with poor balance; complicating this picture was an evolving peripheral neuropathy ie pins and needles and odd sensation in his legs that were possibly worsened by some of his cancer treatments. He had surgery on his back with a prolonged recovery and his follow up with me a few months after that surgery made the hair of my neck stand straight up. He did not feel the surgery helped and in fact was worse.
He was at the end of his rope.
I asked the critical nine questions asked to screen depression. He got a nearly perfect score and this included suicidal thinking. “Do you have a plan?” I asked,
He smiled, “I sure do.”
“What is it?” I asked.
“I have forty oxycodone, a bottle of Benadryl, some anti nausea pills, and bottle of vodka. When I do this, I will be in the woods and after ingesting everything, will put a plastic bag over my head.”
This, is a serious plan with intent and means in place. I told him I needed to have him evaluated unless he could promise me he would not act without talking to me and his wife about it first. He agreed to this and in fact signed a note to that effect. I reviewed this with a psychiatrist the same day. I checked in with the patient every day and thankfully, within a week, his crisis had passed. He was in fact better.
I retired with him stable and two years later, when in for a flu shot, we ran into each other and we both nearly cried in getting to see each other and superficially, “catch up.”He had suffered but was stable and getting more out of his life.
It was gratifying.
My grandson, Tres, would be involved in my last year of practice with a patient who was involved with a suicide and this story is the stuff of an HBO special. HBO specials and BritBox mysteries find me laughing at how unprepared the average GP is assessing the common symptoms that we see and which are sometimes caused by poison. The idea that a doctor would seriously consider attempted murder on the list of possible causes for symptoms is an unusual one in the world of fatigue, ill-defined abdominal pain, general pain, brain fog, and so on. We have all signed death certificates not so much for certainty in the diagnosis, the kind you might hope for after an autopsy, but with a statistical look at the most likely cause given what one can find in the medical record. It is actually fun to do but I would not want to bet money on the accuracy of the diagnoses. Coroners and families don’t want autopsies done unless a crime is likely and most deaths in a medical practice do not rise to that level of concern.
The concern came up when a nurse called to let me know that a patient of mine had been murdered by his wife. Tres and I had visited him and his wife within the last month.
“Doc, tell me about how I get the drugs for death with dignity.” I am not afraid of that question but was troubled in this case. Mr. Doe had terminal emphysema and heart failure. We had discussed his death and dying on a few occasions, and he was already comfortably in Hospice. He was not on death’s door nor was he in pain. Why would he ask about the State’s death with dignity statute?
What was going on was his wife. Mr. Doe was a remarkably self-reliant man with a long life of hard work. As he failed (he was in his eighties) and it became clear he needed to be on Hospice, we had many good talks. When the book, Boys in the Boat was published, I saw a role for his character in the narrative of living in Washington state during the depression. He’d survived, had good stories, and did not express regret. He did have a serious concern that he dwelled on: his wife.
I had never met the wife; he related to me that she was home bound, painfully shy, and dreadfully afraid of physicians. She had not been to a physician for years. The burden of grocery shopping, paying bills, and fixing up the house belonged to Mr. Doe, even as he failed physically. He loved her greatly and feared for what would happen to her when he died. He had a son in town but as we explored this resource, it was pretty clear that there would be no easy way to support her. I offered a few suggestions on how to help her. He took the advice and within the month came with his request. We talked a bit; I went through the criteria for the statute to apply to him personally but before we finished, I asked questions about his motivation.
He hesitated and I caught it. “Are the pills for you?” I asked? He did not respond directly. I said, “To comply with the law, I have to assume you are dying in the next six months with little hope of meaningful change in your condition. I don’t expect that yet, and couldn’t engage with that process. If the pills are for your wife, I would go out of my way to avoid prescribing them to you even if you did have less than six months.”
“I understand Doc; just wanted to see what you thought.”
I gave this some thought. Mrs. Doe was not my patient. I said, “Mr. Doe, how would you feel about my coming out to your house under the pretext of seeing how you are doing with Hospice and all, and make your wife’s acquaintance and see if we can strike up some sort of relationship. Maybe that is something we can work on and sort out before your illness really closes in. Maybe I can help her directly.”
“That’s a great idea Doc. Would you really do that?”
I would, and I did. First, however, I had words with the hospice nursing staff and alerted them to the concern I had about Mrs. Doe and the potential for her suicide. They were aware of her anxiety and frailty, and agreed to have a social worker evaluate and get back to me. I received some assurances in the coming weeks that all was well and that the son was brought into planning for the future—for both of them.
I enjoy home visits and decided to use an old ploy from when Amber was little. I had baby sitting duties with the grandchildren that summer, on my afternoons off. I invited Tres to come along with me and visit, “a grandfather” whom I needed to see. Tres liked the novelty and happily joined me as we drove through a very old trailer home park and after a few misses, found a small hidden alcove with a beautiful double-wide trailer under a large oak and with a perfect lawn framing it. Mr. and Mrs. Doe came to the porch and I helped Tres, ( 5 years old) out of the car. As we turned to make eye contact, I could see Mrs. Doe was transfixed by Tres. Her two pugs wagged their stubby tails, snorted and approached.
“They are friendly!” the Does chimed in and Tres held back against their sniffling and curious circling of us both. We went inside. Tres and I sat on the couch and the Does sat in their Barka Lounges. Mrs. Doe smiled and stared—-and stared. I made nice with Mr. Doe, reviewed his medications, reviewed his use of oxygen, and admired his house. My small talk with Mrs. Doe was mostly declined though she would manage a question or two about Tres’s interests, age, and general view of life. All the while, the pugs converged on us both.
It was summer and Tres wore shorts. The pugs sniffed his knees and left little snail trails of slime which he would wipe with his hand and on to his shorts. His suppressed anxiety was oddly blended with his attempt at being sociable with the couple. Mrs. Doe admonished the dogs, called them over to herself only to lose track and the process was repeated a minute or two later. I lost track of time and was exploring my options for conversation when this five year old boy, back erect, hands in his lap, and polite smile on his face gently began to move his right leg and tap his knee to mine in a rhythmic fashion. Lethe (my mother who did not suffer children easily) would have been proud of his composure under fire and the signal was received. I stood up as did Tres, we expressed our happiness with the visit and left. Tres’s endurance of the snorfling pugs was a cute story over the next week.
Six weeks later, I came home after a busy and long Friday. I had just finished dinner when the call came in. “Dr. Moeller, this is the consulting nurse. I just received a call from the Thurston County Coroner regarding a murder – suicide of one of your patients.” I asked if a name had been given. “It was a Mr. and Mrs Doe; it appears she shot her husband and then committed suicide.”
The newspaper identified the address but would not divulge names. I did not get a call from the coroner and after nearly a week, I called. I identified myself and then the case of interest.
“Oh yeah. That was a doozy.”
I started to explain the concerns I had voiced to Hospice about the fragility of the wife but was cut off. “We talked to Hospice quite a bit and are satisfied that they did a good job with her. The scene was confusing and at first we thought she had killed him and the committed suicide. The shotgun was in the bathtub where her body was, leaning in had first and he was on the floor with a head wound. When we cleaned up the scene we came to a very different conclusion.
“How so?” I asked.
“She was not killed with a shotgun; she was shot with a 22 in the back of her head. This puzzled us greatly and the son, who had found them was present and knew that his father had a 22. We could not find it in the bathroom. He opened the gun safe and there it was---and it had been recently fired. We think he killed her, put the gun in the safe and then shot himself with the shotgun. In fact, there was a shell that had blood on it that was standing end up on the tub’s rim. We think it misfired, was ejected, and he placed it there before taking a second shot.”
I recounted the discussion about Mr. Doe contemplating suicide for his wife and whether I had missed an opportunity to have a more robust intervention. The coroner let me off easy. “I don’t see it. No policeman would have had any standing or likely interest in try to force the weapons out of the house. I think Mr. Doe would have known how to manage that conversation and any trust between the two of you would have been toast.”
I don’t pretend to have had a clue about the world those two lived in that last year with his failing health and her likely mental health problems. The image I developed of him talking in those visits with time to talk and no need for dramatic changes in medication or treatments had left me with that character we all know from movies and books from before World War II. He had a clear orientation in life, was analytical, gave it time, made a decision, and acted.
The outcome was shocking; I feel badly for the son who was on the scene and who had some “heads up.” I would like to think, like with the old lady from Salinas, I might have somehow made things better to prevent this outcome, but I don’t really believe it. And I wrestle with the notion of looking the other way when he asked for Death with Dignity, knowing it was not really intended for himself.
Nope, I don’t think so.
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