“I’m happy that you’re moving on to new things, Dr. M. I just wish you’d still be around to see me get better.”
Sitting at my new hospital cubicle workstation, O’s hoarse voice rang out in my ear as her obituary on my screen sucker punched me in the gut.
While I was gallivanting around New Zealand last month pondering what my transition from primary care to hospitalist medicine would bring me, she was contemplating the matter of her own death.
“Dr. M, that note is ready for you now.”
Thanking my new scribe, I tried to anchor myself to the here and now. It had been a one and a half months since I last stepped foot in my old primary care office.
I was a hospitalist now.
You’re not responsible for this, M. This is not your fault.
Squeezing my eyes shut to stop the onslaught of burning tears only brought visions of O down on the ground, clasping the pill bottle with my name on it. Of course they were prescriptions that I wrote… she wouldn’t have had the time to find a new PCP 2 weeks after I had left the clinic.
I recalled the last time I had seen her, just 4 weeks prior to her suicide.
“I’m so happy with your progress on weaning off your Klonopin and Ambien! Let’s make a plan so we can be sure you won’t have withdrawals from these last steps.”
It had taken three years of building trust to bring her to that point. Trust in me, trust in herself to see if she could let go of the security blanket these meds gave her. Even as I wrote out the weaning schedule on a calendar printout, I could sense how tentative she was.
“Will the new guy have a copy of this? I mean, for after you leave? I don’t want to start from scratch, you know?”
I tried to give my best reassuring smile as I recalled the first time we’d met. Trembling from anxiety, within 5 minutes she dumped out her feelings of abandonment when her previous PCP had just closed up shop with barely any notice, leaving her scrambling to find a new primary care doc. Through tears, she cried,
“You better not get pregnant any time soon, because I don’t know if I can take another person leaving me right now. And yes, I know that makes me sound crazy, but it’s not like you hadn’t figured that out by now.”
Over 3 years, she slowly leaked out bits and pieces of her story.
The loveless marriage and her husband’s countless affairs – only divulged when I offered STD screening with her routine pap smear. The constant put-downs and frustration of only being able to meet his sneering comments with tears. The panic that greeted her in the morning when she made their morning pot of coffee – would today be a good day or a bad one? The ever present fear that a good morning meant a terrible evening – in her mind, this is what drove her to Klonopin.
She knew the dire situation she was in, but O felt helpless – what could a woman who had been out of the workforce for 25 years possibly do to keep herself afloat?
Her story continued to pull at my heart strings against my better judgment as I refilled her Klonopin and Ambien prescription regimen exactly how her old primary care doctor had prescribed. Each monthly visit ended with me offering up my domestic violence resource handout and me saying,
“O… you don’t have to live like this. I’m not saying life outside the life you’re living now is going to be easier, but it can be on your terms. These meds… are not the answer.”
Baby steps
Although O repeatedly rejected my suggestions to go to counseling, she did start to trust herself and moved toward establishing healthier boundaries. Eventually I saw less and less of her as she started weaning off her meds. Each appointment she seemed to blossom more into the confident woman she never thought she could be.
It buoyed my heart that I’d be able to guide her on these final steps to go completely off her Klonopin and Ambien before I left primary care – a mini personal victory after coaching her to this point for 3 years. Something I could hold on to as a win during a time when I felt I had none.
And now she was gone
“I’m happy that you’re moving on to new things, Dr. M. I just wish you’d still be around to see me get better.”
Scrolling furiously through her frustratingly barren obituary on her funeral home’s website, I was struck by how fitting a metaphor it was for her loveless life.
Her family hadn’t even bothered to put up a picture of her. Instead there was some boat drifting off into the sunset – a stock photo, no doubt. Only a birth date and date of death were listed. No loving homage to this woman who had shared in their lives for decades – not even an effort to write a few sentences.
I had always wondered if the story she told me was just a glimpse of how she perceived reality, but even in death, her story was consistent.
Who could withstand a lifetime of loneliness surrounded by the people who were supposed to love her?
Maybe you still don’t know the whole story, M. Maybe the circumstances of her death left her family so ashamed, they didn’t know how to address it and opted to leave her obituary blank.
You know this shame… you know exactly what’s fueling your rage.
Had I created the perfect storm for her suicide?
Did the weaning schedule I put her on give O the opportunity to stash enough away to take her final dose?
Did the vacuum of my retracted support suck her into a black hole when she would have otherwise come in to see the doctor she trusted with everything?
Had she just told me she was getting better so I wouldn’t feel guilty as I walked away?
“It’s not your fault,” J told me.
But what if it was?
***
We often times don’t talk about our patients’ suicides and the toll it can take on us. According to Dr. Dinah Miller, a psychiatrist interviewed in this Medscape article, this conversation is uncommon even among psychiatrists.
Let’s start having some real conversations about this topic because the reality is, patient suicide happens and often our shame causes us to suffer in silence. Leave a comment below or feel free to email or direct message me on Facebook/Instagram.
***
Photo taken at Lake Marian in the Fiordland National Park, South Island, New Zealand.
Oh geeze M, I am so sorry.
Thanks Shannon… me too.
Dr. M- just so, SO devastated to read this. You are not alone. So many of us have been in this position, grappling with feelings of guilt and “what if’s”, it is just the most unimaginably awful feeling in the world. In my first year of practice, one of my patients had a stillbirth while I was on vacation, and to this day I always return from a trip with a sense of doom, waiting to find out what tragedy occurred in my absence (how dare I leave!) But no amount of doctor’s lounge commiseration and story sharing can erase the feelings. This job is eff-ing brutal. Which is why we need to look after ourselves and find the balance that will allow us to persevere. Don’t let this cast a shadow on your new beginning. You did everything in your power for this patient (just as we do for our oncology patients, chronic illness patients… others who also ultimately succumb to their struggle). Take care of yourself, thinking of you and sending a virtual hug. -Kristina
Kristina,
Thank you so much for your kind words. Fortunately I had a stretch of time off after discovering this, so I’ve been able to re-equilibrate. But it’s always hard for me not to dwell, which I think is something most of us struggle with. Anyway, I appreciate you sharing your experience with me. Thanks for the virtual hug!
M
I am sorry to hear about this. I believe that I previously read about “O” (maybe not, maybe someone like her) on your blog. This is a tough one. I know that you know that you are not responsible for her actions and the outcome, but I also know that it’s hard to separate yourself from them, too.
When I was a proceduralist, every complication made me feel terrible, from the lowly, self-limited skin site infection to the devastating deaths (3, over 20+ years). In the latter cases, a part of me died with each one.
In the Hospitalist setting, you are going to have to steel yourself as you will see quite a bit more of this.
Thank you for sharing your experience. Unfortunately I can commiserate with having the knowledge that my actions directly caused someone harm… it’s still hard to sit with that.
With that being said, I really don’t struggle when I understand that sometimes it’s just time for someone to go. It’s merely the nature of life. I was actually called the “hospice queen” when I was a resident because I had a high conversion rate of getting people to change code status and/or agree to hospice/palliative care consults.
Sometimes death is a blessing.
Suicide, though, is something I have a hard time wrapping my mind around, especially since things seemed to be going so well with O. As a hospitalist, I’ll perhaps be shielded from the impact since there won’t be 3 years invested in those relationships.
That’s the hope, anyway… we’ll see how that works out.
This is what happens when you care – a lot. Without dwelling on the “is it or isn’t it your fault” question (it isn’t), I think we need to focus on how to continue investing emotionally in our patients’ well-being, without succumbing to the guilt that an event like this can inflict.
I’m not sure there is really a perfect answer for this, as I don’t believe there is some sort of “set it and forget it” rule that we can apply to our practice of medicine in this particular setting. It takes consistent positive self-talk and a healthy dose of confidence to come through to the other side, realizing (1) you’re a great doc, (2) you can exert extreme levels of control over your own life, but you cannot control other people’s actions, and (3) this – or something like this – is going to happen again, and it’s going to hurt. And that’s normal.
Your numbered lists are always helpful (and no, I don’t mean that facetiously!).
It has always been a hard balance to strike for me – how do you care without drowning in the emotion and how do you harden enough without numbing yourself to everything?
This is the shit they don’t teach you in training, but it’s so crucial for the profession.
Suicide is so hard. I don’t know if it is because the volitional nature of the act makes it seem more preventable, but mental illnesses are the hardest diseases we treat. Our tools are rudimentary at best, and we have so little control over the causes and environments people live in. It just so damn hard.
In medical school, our Psychiatry professor made a point of emphasizing that 10% of the time depression is a fatal disease. Obviously, in the form of suicide. It helps me to try to remember that if anyone had cancer, heart disease, diabetes and struggled with it for many years while suffering greatly and eventually succumbed to it, we would be sad, but also accept it as an unfortunate natural outcome of the disease.
I think mental illness deserves that sort of deference as well. It doesn’t make the individual loss and feelings of guilt go away. And like Hormone Dr said, it is normal to feel them.
This job changes a person. We cannot bear witness to so much suffering without being changed, and if we allow a space and time to feel these things, I think we become better for it. Taking time to marinate in the grief is what we all need to do more of, I am glad you are in a situation now where you can do that.
I like how your professor framed depression as a fatal disease. I think we definitely do a poor job of viewing it in that way.
I definitely struggled with this one, and still do.
There doesn’t seem to be a right thing to say to make it all better for me, but that is the nature of what we deal with. Thanks for your support as always.
Hey M,
So sorry to hear this, but your feelings are quite common, so I’m glad we get to talk about them in a more open setting. Depression and mental health diseases are very difficult to deal with, and I’m reminded by something one of the psychiatry nurses told me; “we don’t have the medications or definitive treatments to solve/cure ANY mental health disorder at this time.” Think about that. We’ve made progress, and we have meds that help improve depression in some people, or help with mania in Bipolar, but nothing to help solve these issues like HTN or DM medications where we can actually test if the disease is managed. We have a ways to go, and this is not an issue PCPs can solve alone.
Another personal story to put this in perspective. My sister and I went to college together and happened to make friends with two students from abroad. They were both incredibly nice girls, but over the course of our semester, I gradually learned that one was struggling with depression and had since the age of 13-14. She was a citizen of a country with nationalized healthcare, and as best as I can determine, was well established in care and her parents deeply cared about her. She ended up hospitalized inpatient for a few days here and there, and eventually ended up in an intermittent day program so she could continue to work and try to progress in her life. Both her and her parents stayed in contact with my sister and I through e-mail and we’d hear stories about how she was traveling, working, and then in the hospital again. Eventually we received an e-mail one morning that read, “K has been successful in her attempts and ultimately had died by suicide.” Turns out that before her “successful” attempt, she had actually tried to overdose on meds and drown herself on vacations on at least 2 occasions. My sister and I were devastated! No I didn’t prescribe her medications for her but I can only think she was connected with some the best treatment available, and yet she ultimately succumbed to suicide. I think this case more that anything made me realize that while we can assist our patients with mental health diseases, and prescribe medications or treatments, they may ultimately pass away due to reasons that are beyond the control we exhibit. Sometimes as physicians we unintentionally fill this god like position of “solving disease” as noted above when a patient comes back with well controlled BP, or lipids, but the reality is we just help guide our patients that direction.
Finally, one other note from a psychiatrist I worked with. After growing frustrated what I could safely prescribe to one patient vs. another and feeling really limited, I asked, “what can I ******* prescribe this person as he/she could attempt suicide with any of these medications”, yet we had already tried 3-4 different meds of different classes and were approaching using some TCAs as adjuncts. He told me, just give what you think she would benefit from and in small doses with close follow-up. She could attempt suicide with any medication we prescribe her to help treat her disease, or she could attempt suicide with countless other products she has around the house (alcohol, tylenol, Benadryl, cough medication etc.) Our place is to attempt to help her, but I can’t eliminate all the risks of the disease. The risk of untreated disease is death or suicide, and the risk of treatment is the same, although hopefully less so. Hope that helps 🙂
In any case, know that you tried your very best to help her, and none of us are guaranteed any outcomes. Keep your head up and try to help others the best you can Medicine is a demanding profession in so many different ways…
Sean, thank you for your sharing your story.
You’re right – we do the best we can. My ability to accept this has grown over the last couple of years as I’ve come to realize that just because I will something to happen doesn’t make it so. I wish I had that wisdom when I was younger, but I’m the type of person that needs to break my back from trying to move mountains before I realize it was never meant to be 🙂