depression that isn't

What do you do with a healthy patient who wants to die?

Ms K was 95. Her face was only softly lined, and her ash-white hair was smooth and silky as a girl's. She was in what one might call quite good health, having survived both a heart attack and a cancer many decades ago. Save a matched pair of titanium hips, her body parts were all factory originals.

By all accounts, her life was still a full one. She was close to her children and their spouses. She had a cadre of friends and neighbors who queued at the door to her hospital unit. She was possessed of an adoring younger husband, a stripling of 89. Indeed, he treated her to an extremely long, lingering kiss with evident tongue, in full view of the medical team as well as of their son (who sighed, "This is like a bad romance movie!" as he edged out the door).

And yet, she was decided on death. Quite decided. One day she declared that she would no longer eat, and that was that. "I'm 95 years old," she said, "and it's time." No coaxing, wheedling, or caviling; no gnashing of teeth and no rending of garments could dissuade her. After a few days of this, her distraught family brought her to the ER. After it was duly determined, via the usual sequences of poking, prodding, and sticking with needles, that she suffered from no medical illness, psychiatry was called.

After much ineffective discussion, Ms K was diagnosed with depression (though she professed no sadness) and brought into the hospital. She lay there for days refusing food and medications, even basic nursing care. Far from the etheral candle flame near snuffing out, Ms K held court from her bed, directing her frantic relatives to fulfill various social obligations and execute a litany of domestic chores.

Stymied, the psychiatry team consulted the hospital ethics board. The ethics board was equally flummoxed. Its concern was to rule out the possibility that Ms K was acting in her right mind, and not out of a reaction to depression or pain. A meeting was held with the physician team, the patient, her husband, and her son and daughter-in-law.

According to the family, this desire for death wasn't like Ms K at all. Generally she was quite life-loving and had never expressed a wish to die. At the same time they admitted that she seemed quite of sound mind otherwise, that her personality was pretty well unchanged and her mind continued to be the steel trap it had always been. They did note that she had always been very pain-averse, that she was at the beginning of a long course of physical therapy to recover from a hip replacement, and that she'd been pretty well exhausted by the physical therapy for the replacement of her *other* hip a few years ago.
Of course the very fact that she'd undergone the second hip surgery - and that her surgeon felt her 95-year-old hip was appropriate for replacement - suggested that both she and the surgeon had expected her to have quite some life left to make use of it.

The best we could figure out was that she'd just decided she would rather die than go through more physical therapy. But that seemed a bit... dramatic, didn't it? Then again, from what her family said, Ms K was nothing if not dramatic.

As an aside, I'm not opposed to the choice of a dignified, peaceful, planned exit when it's the only choice over an imminent and pain-filled one. That doesn't sound like mental illness to me. But that is pretty different from this. It's pretty different when a dying patient chooses the time and the means, versus a healthy - but aged - one choosing to end her life for no clear reason. Especially when she's nested in a network of people who would be devastated by her passing, but unspeakably more so by her *intentional* passing. When you think about it from that perspective, it starts to sound a little bit selfish in a way.

What to do about Ms K? A masterful ethicist managed to convince her that in order to let her have her wish of self-starvation, we would first have to be convinced that she was not depressed. And one way for us to do that would be for Ms K to give us a trial of... eating. And taking an antidepressant. In order to prove that her course of action was entirely voluntary, she'd have to show us she could change it.

Somehow this made sense to Ms K, and she agreed to take the antidepressant - but not to eat. So there she was, dutifully tossing back a Lexapro every morning but steadfastly refusing to eat while her desperate family surrounded her bed, alternately threatening and cajoling her.

Meanwhile, we called in the pain team. Ms K had never really complained of pain to us, but given the recent hip surgery and the trepidation about physical therapy, we wondered if there was more than she was letting on. The pain team came up with an improved regimen for her, and that did seem to improve things.

So how did this all turn out? After a week or so without food but snappy as ever, Ms K realized this undertaking was going to last longer than she'd bargained for. It looked as if starvation was going to be more trouble than it was worth. One day she asked for breakfast, and that was that. I suspect the pain from the hip surgery was the real problem; but Ms K never let on. She just acted as if this was a temporary redirection and she was going to find a better method of suicide sometime soon. But she didn't seem acutely dangerous, and her family promised to keep a close eye on her; so after she'd gotten her electrolytes back in balance we discharged her from the psych unit.

You never really do know what's going on with most patients until you've been with them a while. One of my psychiatry preceptors has said that the reason the patient gives for coming in is almost *never* the real problem. At the time I thought that was exaggerated but I'm starting to come around. I guess if psychiatry were more straightforward it wouldn't be nearly as interesting.