As doctors’ reactions to Lauren and her chronic need for medical and surgical intervention illustrated, these patients bring up ethical quandaries and complicated emotional reactions for the doctors involved in their care.
One such example was a mentally ill twenty-year-old man who was winter camping with his family when he heard the voice of Jesus instructing him to cut off his hand with the hatchet he was using to chop wood. Believing it to be a holy command, he did so and returned to the campsite. His distraught parents frantically searched for the amputated hand. When they found it, they packed it in snow and ice and drove the young man, and his severed hand, to the hospital.
Hours passed before the young man was seen by hand surgeons, and when he was, the team expressed concern that too much time had gone by and that as a result the surgery would not be successful. In their decision making, they also discussed with the family their concerns about how the patient’s mental health would affect the likelihood of surgical success. He would need to be lucid enough to follow a detailed regimen of postoperative care, critical for proper healing. The doctors feared that the man’s mental state rendered him likely to jeopardize the fragile reattachment. Any attempt at rejoining the hand to the wrist would be a procedure of at least twenty-two hours in length. If, at worst, he continued to feel compelled to remove his hand or if, at least, he was not well enough to scrupulously care for it once it was reattached, the extraordinary effort and resources required for such an operation would have been wasted. In the end the hand surgeons decided not to operate, citing the passage of too much time since the accident.
The distraught family frantically drove to another hospital for a second opinion, where they were told that their arrival at the first hospital had in fact been within the window of timing where such a procedure would have been possible but that they were now beyond it. The family sought legal redress against the surgeons at the first hospital, believing that the true impetus for refusing care had been a form of discrimination, that their son had been denied appropriate care because he was mentally ill.
It may well have been that the rationale the surgeons expressed—that too much time had passed for the operation to have been a success—was true. However, since the second surgical team disagreed, it is worth considering the ethical issues at play: the dilemma raised as to whether or not this patient was an appropriate surgical candidate, irrespective of time. It is not difficult to imagine that had the patient been psychiatrically well and had severed his hand in an accident rather than on purpose, the surgical team might even have been willing to attempt the procedure at the outermost cusp of the appropriate time frame, given the grave repercussions of the loss of such a vital body part.
So what was the right thing to do for this young man in this scenario? Does every patient deserve a chance at the repair of a permanent and grievous injury—no matter how complicated or expensive—even if there is a substantial risk that the restorative effort will be unsuccessful or, worse, undone? When psychiatric illness also requires medical or surgical care, which takes precedence: the severity of the body’s afflictions or the severity of those of the mind? Can the presence of one type of illness preclude receiving treatment for the other? If the surgeons should be obliged to attempt to reconnect this patient’s hand, would they also be obliged to operate if he cut it off a second time or intentionally interfered with its healing? What criteria would have to be met in order for it to be ethical for a doctor to refuse to intervene?
A patient like this one differs from Lauren in significant ways: He is psychotic, whereas she is seen to be more “in control” of her thoughts and actions; therefore, her self-injury is seen as more volitional. Cutting off a hand with a hatchet is a dramatic onetime act, shocking and tragic, with severe long-term consequences. Lauren’s chronic ingestions, which thus far have been reversible and nonlethal, are seen as more annoyance than catastrophe. Nonetheless, there are many similarities between the two patients: Both have self-inflicted wounds that will have fatal or life-altering consequences if not treated; both are likely—though not guaranteed—to repeat the behavior that caused the injury in the first place. Why, then, is Lauren consistently admitted and treated (even with her own personal treatment protocol) when for the young man camping in winter the decision was not so straightforward?
The answer may lie in the relative complexity of the treatments. Although endoscopy, too, is a medical procedure, it is unquestionably less involved, less time-consuming, and less expensive than limb-reattachment surgery would be. However, given the fact that Lauren has had dozens of procedures and in all likelihood will have more in her future, the cumulative resources required may well exceed those of a onetime surgery, even one as complicated as reattaching a hand.
I wonder if the difference lies instead in reaction versus prevention, in the risks in medicine associated with omission versus those associated with commission. When the young man came in with his hand packed in ice, the worst had already happened. His hand was severed; any action taken by doctors would be an attempt to remediate the situation. The doctors could certainly choose to undertake the heroic task of reattachment, but they needed to weigh the costs and perils against the potential benefit. Whether the risk they counted most heavily was the time that had elapsed since the accident or the patient’s psychosis, in the end they believed that the chance of a good outcome was not substantial enough to overcome the odds of failure.
Lauren’s actions also had already taken place by the time she reached the hospital, but, in contrast to the young man’s amputation, the worst possible damage for Lauren had not yet occurred. With Lauren, doctors were consistently in a position where their intervention could prevent disaster. By sending her to endoscopy and removing the objects she ingested, they averted the perforation of her gastrointestinal tract. If they opted not to treat her, their inaction could be linked to her catastrophe.
This critical difference speaks to the very nature of the distinction between major and superficial/moderate self-harm. For the young winter camper, the key to his recovery would lie in the treatment of his psychosis. Although the loss of his hand is an irrevocable tragedy, our current psychiatric system of care is not bad at treating auditory command hallucinations. In all likelihood, with intensive psychiatric treatment, a safe and structured environment, and antipsychotic medications, we would eventually be able to stop him from believing that Jesus wanted him to maim himself (though almost certainly not within the time frame of any surgical repair and postoperative care that could have occurred). With ongoing treatment, chances are that he might go years, decades, even his whole life without ever trying to hurt himself again.
Those odds are far less likely for Lauren. The crisis and mandatory call to action brought about by her repetitive swallowing are both a symptom of her illness and its fuel. Whatever isolation or trauma may have bred this incomprehensible means of relieving her distress, that gaping hole is now filled with the constant, emergent attention of medical and surgical teams, psychiatric consultants, security guards, even hospital administrators. We attend to her urgent needs—we ethically cannot refuse to do so. But in attending to them, we reinforce her understanding that she can glean care from her ingestions; we strengthen the positive feedback loop of her repetitive self-injury.
As her psychiatric consultant, I felt that my limited time with her underscored the problem with this form of treatment. Because Lauren was primarily a medical or surgical patient, my role with her was limited by definition. I was not primarily responsible for her treatment; my job was only to provide recommendations for the psychiatric component of her care: How could we keep Lauren safe in the hospital? How could we try to keep attention to her at a minimum while providing appropriate medical, surgical, and psychiatric care? The real work of her treatment needed to be done on an outpatient basis, when she wasn’t in crisis, when someone would have enough time to treat her with psychotherapy that would address both this cy
cle and the psychic wounds out of which it sprang.
But this treatment plan for her discharge was not a completely honest one. Lauren was never “not in crisis.” She had been admitted to the hospital twenty-three times in the last four years. She had never maintained any kind of a long-term outpatient therapeutic relationship. Like it or not, realistic or not, we were her primary-care physicians.
During each of my subsequent visits with Lauren, she was dismissive of me, alternating between loud, monosyllabic, often vulgar responses and complete silence. I regained my footing in our clinical encounters, and I stopped taking her vitriol personally. In fact, I’m not at all sure that there wasn’t something appropriate about her response. I was purporting to be there to help her. I would leave the room and write a long note with some minor changes to her psychiatric medications and a set of standard recommendations for outpatient care, knowing that the first was unlikely to help and the second was unlikely to happen. I did it in good faith. They were the “right” recommendations. But I was part of the only treatment plan a crisis-based hospital could muster. I was approaching the patient with a “focus on disease management, not cure.” Like the lightbulbs, the knife blades, and the curtain rods, I was at best a temporary easement, a learned pattern that might diminish distress in the short term but constantly needed to be repeated and never had any kind of lasting effect.
• • •
One night after seeing Lauren, I returned home to find my children getting ready for bed, all warm with shampooed hair and toothpaste drips down their fleece pajama tops. When they saw me setting down my bag and unclipping my pager from my waistband, they raced toward me, tumbling over each other. They had, all day, been listening to the song in Mary Poppins in which Jane and Michael Banks have written the description of their ideal nanny, and they wanted to perform it for me.
“Be an audience, Mama!” my two-year-old boy shouted, as instructed by his older sister, though he had no concept of what an audience might be. I flopped onto the couch to watch as they crooned and giggled to an imaginary nanny, “Love us as a son and daughter. / And never smell of barley water!” As their song gave rise to an improvised dance and they began to march around the living room, I found my mind shifting back to Lauren. It felt out of place to be thinking of her here, with her dark stares and her prickly anger, but I could not shake the feeling that I was doing her a grave disservice. Later that evening, with the kids packed off to bed, Deborah and I sat at our dining-room table, plates cleared, a half-empty bottle of wine between us. I explained to her how I was feeling.
“The system is broken,” I told her. She was unconvinced.
“That may be,” she said. “But how can you discharge her with a plan that you know isn’t going to help her? That you know isn’t going to work?”
“It’s more complicated than that,” I bristled, and Deborah quieted, looking down. I felt anger swell up inside me, and I knew it was because she was right.
The next day at the hospital, as I prepared for Lauren’s imminent discharge, I threw myself into creating an aftercare plan for her that would be more than a formality, one that actually had a chance of helping her break this cycle of admission after admission. Without insurance or money to self-pay for her treatment, Lauren did not have the option of seeing a private psychiatrist or psychotherapist. If she did, she might have been seen by a therapist every week for an hour and a psychiatrist once or twice a month. Instead Lauren was treated by an overextended, publicly funded mental-health center where she was scheduled to see a psychiatrist for twenty minutes four times a year. Of course, in one of the ironies that are all too common in a country with health-care discrepancies, a single hospital admission for Lauren—paid by the taxpayer-funded state medical-assistance program—cost more than a year of private outpatient care would.
I called the psychiatrist at the mental-health center to whom Lauren was assigned and learned from him that one of the center’s only other psychiatrists had recently quit. With an ever-increasing caseload and an ever-shrinking budget, he said, there was no chance of her being seen more frequently. I had him transfer me to Lauren’s case manager to inquire if she could at least be seen by him more regularly. Lauren didn’t keep her appointments, the case manager told me. True, he said, she had no car and lived miles outside the bus route. “Look . . .” He paused. “There’s only so much I can do. I can’t help her if she doesn’t come in.” I asked about the center’s mobile treatment team that goes to patients’ homes, takes them their medications, drives them to their appointments. “I guess it’s possible,” the case manager said. “She’d have to be evaluated by them. Let me check the book.” I waited on hold for several minutes. I was eventually disconnected. I called back. “Oh, hey,” the case manager said. “Yeah, I can book her for an appointment for a mobile treatment team eval. Our first available opening is June twenty-third.” It was now February.
I headed to Lauren’s room. She had been fully cleared by the medical team, and they were awaiting our confirmation that she was safe to leave the hospital. I had her outpatient-care plan in my hands, and it included Lauren’s appointment to be seen by the mobile treatment team, though a long four months away. And much of the plan had a chance only if she diligently followed it and if the realities of her poverty and her limited sources of emotional support didn’t intrude, as they would, as they always had. I knocked on her door, and as I stood waiting for her to respond, I still felt I had done almost nothing for this patient.
“Who is it?” Lauren finally yelled.
“Amazon Brown,” I answered.
In response I heard a sound I had never heard from her: a chuckle of laughter. Then, “Come in.”
As I entered, I thought of something a beloved supervisor said to me during my training, about working with difficult patients. “Sometimes holding all the blackness they feel is the only thing you can do. That’s not nothing. And sometimes it is enough.”
“Hey,” I said. “I understand they’re ready to let you go. How do you feel about that?”
“Oh, Jesus, with the ‘How do you feel?’ shit again,” she moaned, although this time there was a current of nervousness beneath her tone. “I hate this place! I’ve been wanting to get the fuck out of here for days.”
I handed her the number I had for her case manager. “So, Lauren,” I began, “if you can bring yourself to do it, next time you’re upset and you feel the urge to swallow something, you might try calling first.”
“Why would I do a stupid thing like that?” she asked.
“Well,” I said, “maybe they could help.”
She scoffed.
“And more than anything, Lauren, I’m afraid that one of these times you’re going to swallow something and it’s not going to go this way. I mean, I’m afraid you could swallow something and then you could die.”
She rolled her eyes. “Like that’d be so bad.”
“I think it would be,” I said softly. “I think it would be terrible.” She looked up at me, and for a minute I thought maybe she heard me.
“Yeah, well,” Lauren said, “you’d be the only one.”
I held out my hand to her to shake, and she took it. “Take care of yourself,” I said.
To which she responded, “When can I get my stuff and get out of here?”
That evening I wrote in my consult note that I believed Lauren was safe for discharge. I didn’t feel the relief I thought I would at her impending departure. I mostly felt sad. Not because I would be sorry to have her off my service but because I felt that the treatment she’d received this time—like so many other times in the past and surely more to come—was just a gesture, a Band-Aid on a gaping wound.
I headed down the hospital staircase to gather my coat and bag from the psychiatry office. I checked my pager one last time, and when I raised my eyes from its numbered screen, they fixed on the stairwell’s wall ahead of me: the post
er, the horses. Whose woods these are I think I know. / His house is in the village, though; / He will not see me stopping here / To watch his woods fill up with snow.
• • •
When I push open the hospital doors to walk through the many parking lots to my car, sharp, frigid air enters my lungs and makes me gasp. I cough a little. Inhale deeply. The cold air like a stab. My exhalation leaves moisture on my face that freezes instantly and makes my cheeks hurt as I walk. I am moving quickly, hurrying to the car, to home. Each step of my dress shoe on the cold, hard pavement makes my foot ache. It reminds me of the ringing jolt of pain in my hands I’d feel in Little League when I’d hit a baseball hard on a cold day and the bat would send the force straight to my palms. I get it—we all must—how pain can quicken the heart and then, with each pulse’s beat, send a message to the mind. A-live. A-live. A-live.
Months later—it is May—I am standing thigh-deep in the northern Michigan lake of my childhood. It’s a holy place to me, one to which I return year after year. Only a month ago, the lake was frozen stiff, and it will be a good month yet before anyone else in my family will venture into the water. I walk out farther still. The water laps the borders of my swimsuit. I cannot feel my feet. My children are shouting with glee on the dock, egged on by Deborah, who laughs and cheers, “Look at Mama! Look at her in the cold water!” I give a broad wave, take a deep breath in, and then I dive. It is so cold that my whole self hurts. Icicles to my scalp, my eyes. I leap up immediately, spin, and shriek at my children, who jump up and down and happily shriek back. Deborah yells something triumphant I cannot decipher. I wrap my arms around myself and run—splashing frigid droplets in a wide spray around me—toward the dock, their happy voices. I cannot believe this joy, this fullness of my life.
Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis Page 7
