Academic journal article Generations

When a Patient Requests Help Committing Suicide

Academic journal article Generations

When a Patient Requests Help Committing Suicide

Article excerpt

The relationship between doctor and patient as it influences decision making.

Mrs. C was a 69year-old woman with a ten-year history of systemic lupus erythematosus. She suffered from severe osteoporosis and muscle wasting as a result of long-term corticosteroid therapy. In spite of profound weakness, deconditioning, joint and skin pain, and multiple osteoporotic fractures, Mrs. C continued to go to work daily at her business, though she spent increasing portions of her work day resting on a couch in the offce. She lived with her husband of forty-five years and had three adult children.

Mrs. C was referred to Dr L, an internist with expertise in palliative care, for assistance in controlling her pain sv mptoms. At the initial visit, in an effort to convey the nature of her illness to the new doctor Mrs. C showed Dr. L several notebooks filled with detailed notes about the course of her illness. Dr. L prescribed several pharmacologic agents for treatment of pain,fatigue, and diminished nutritional status, with some success in terms of lessened pain and improved energy levels.

In the final year of her life, as her functional capacity progressively narrowed, Mrs. C began to speak to Dr L about wanting access to assistance with the timing of her death. When asked why she wanted to do this, she responded that her life was becoming too burdensome, that needing help from others for the simplest activities was unacceptable to her, and that the inability to swallow, or to move without exhaustion and discomfort was becoming unbearable. In further discussion about her life, she described her childhood. She had been adopted from an orphanage at the age of years. Dependency for bathing and using the toilet now evoked the terror; shame, and loneliness of the orphanage for her, greatly increasing the suffering associated with her progressive decline in functional capacity. Thegastrostomy tube that she had reluctantly agreed to when her weight loss became severe was causing severe pain and distress. Though Dr L offered the option of removing the tube, Mrs. C was also distressed by her marked weight loss and opted to maintain the tube at a lower feeding rate rather than remove it at that juncture. She could no longer sit up to read or watch television and was too weak to write. Getting to the bathroom was a major ordeal. She had been a passionate gardener but could no longer participate in any of her hobbies. She expressed concern about the burden that her care posed for her husband, although there were no financial problems affecting her care. Finally, she said simply, ''m exhausted and I've had enough." Subsequently, she became too weak toget into the office and began to spend her days in bed, arising only togo to the bathroom.

Dr L responded by asking her permission to obtain a psychiatric consultation to help in the evaluation of depression. He initiated treatment with a psychostimulant, as well as an antidepressant. EDcisting doses of morphine, begun fm-pain and breathing difficulty, were increased in an effort to relieve her feelings of "total body aching." To be sure that all possible treatments for her vascular disease had been tried, Dr L encouraged her to seek another opinion at another center She reluctantly agreed, saying to her husband that she was just doing it out of concern for the physician. The new rheumatologist suggested intermittent high-dose steroid infusins in the hospital. Having had long and unhappy experience with hospitals, Mrs. C refused this t ment. When Dr L encouraged her saying that it was worth a try, she agreed on the condition that if the treatment failed and she continued to deteriorate further, she could expect help in committing suicide.

Dr L sought a second psychiatric opinion at this point. After lengthy consultations, both psychiatrists agreed that the patient was not clinically depressed. The patient remained adamant in her refusal to enter the hospital for treatment in the absence of a commitmntt flm her physician for an escape route," as she called the prescription for the barbiturates recommended by Derek Humphrey's (1991) book Final Exit Mrs. …

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