I was irritated as I looked down at my phone, blinking in
the sunlight. I was out for a walk with my baby, whom I barely get to see
during the week, and he had just fallen asleep. So there he was, peaceful and
cherubic in my arms, as I basked in his little-ness, and now, suddenly and most
maddeningly, in the midst of this tranquility, my phone was ringing. The
voicemail came through mere seconds later, followed by a text – CALL ME YOUR
PATIENT ATTEMPTED SUICIDE.
All caps. No punctuation. Nothing else.
I could feel the color draining from my face; my entire body
now puddling around my feet. I was numb.
What?
I frantically started dialing, my nervous fingers fumbling
with the phone, accidentally hitting the baby in the face – his nap be damned
now – all while running through my list of patients in my head. Was it the the
patient I had deemed safe to discharge to shelter despite their claims of
suicidal ideation if they didn’t have permanent housing, or the patient who
denied having any psychiatric symptoms, but my spidey sense had warned me that
he just wanted out to get his next drug fix, or was it the teenager whom we had
just diagnosed with likely some psychotic disorder or at the very best,
something on the bipolar spectrum - -- my mind was racing, all while it felt
like time was progressing at a snail’s pace.
Thanks for calling
back Michelle – came the unusually terse greeting from my boss. Did you see this patient? She described my elderly and cachectic patient
with end stage liver disease. My patient who had looked at us aghast when we
asked if he had thoughts of wanting to kill himself and then quoted Scripture,
informing us that such a thing is a sin in the eyes of God. My patient who
readily admitted to being depressed and worried about weighing down his devoted
family with his medical needs, but found solace in his faith, and found comfort
in speaking with us, with the chaplain, with his pastor, requesting no
medications, just therapy please. My patient who had spoken with us openly
about all of this while his wife and daughter sat by his hospital bed, helping
him bring spoonfuls of soup to his mouth, fluffing the bedsheets around him, as
he was so weak he couldn’t even pull his blankets up to his chin.
No no no. I must have read the text wrong. There was no way
this patient could have attempted suicide.
No, he did. He put a
belt around his neck and then tied it to the bed frame.
What?! I asked
again, flabbergasted. There was literally no way.
But yet, apparently there was.
Oh my god.
My mind immediately started spinning off in a new direction,
quickly covering what ifs, coulda, shoulda, wouldas, and if only’s. What had I
done wrong? We used a phone translator, and there were times when I wondered if
we were getting the full story, as our patient would seemingly talk for a
while, and the interpreter would translate a short sentence. But his family had
sat there, unperturbed. Wait, maybe was it because his family was at bedside?
But I had returned when his family was gone, and the patient had continued to
endorse the same beliefs and ideas about wanting to die naturally, about his
faith being comforting to him, etc. He had seemed a bit more curt, but I had
figured it was due to his reluctance to being interviewed again with a phone
translator, which admittedly has long wait times and the occasional dropped
call. And he had smiled indulgently at me when I apologized for the poor phone
connection that made the interpreter ask him to repeat everything he said.
My boss was still talking to me, but to be honest, I could
barely register what she was saying. My mind was screaming with the one
question I wanted her to answer. I had to interrupt.
Is he okay?
I blurted it out, and my voice cracked as I asked.
Yes, he’s on a psychiatric
hold now with a sitter at bedside.
The breath I was unconsciously holding came rushing out.
I deal with suicide risk stratification every day when I’m
at work. Static risk factors, dynamic risk factors, protective factors, means,
ability, firearm possession. All of that boils down to our overall suicide risk
assessment. Yes, he was an older man. Yes, he was hopeless, with significant
pain related to a serious medical condition. Yes, he endorsed wanting to be
dead. But he didn’t have a plan, he didn’t have any means (or so we thought),
and he was actively involved with planning for the future, and he had
significant religious factors at play. All of this weighed with and against
each other, and we had deemed him to be a low suicide risk.
Yet all of this doesn’t matter if someone truly wants to
kill himself. In fact, there have been reports of how once someone makes up his
mind to suicide, the mood actually lifts in a way. There is now an endpoint, a
purpose, a direction for their seemingly otherwise meaningless pain. Was this what happened?
In the next few days we had family meetings, multiple
discussions with the patient alone and with the family, and among our own care team. We saw a different side to our patient. He was less smiley and more snarly. Frustrated with being in the hospital, frustrated with his pain and the lack of relief that the medications gave, he would occasionally try to throw things at us when we came to talk to him. It
came out that in the family’s culture, when a person is dying he or she
attempts to push away loved ones in order to make the impending death easier on
those who will be left in the land of the living. Was that the underlying
irritability lurking behind his smiles and pleasantries? Or was that just plain
ol’ irritability seen in depression? Was it encephalopathy or psychotic depression when he accused his family members of being devils?
