Another dilemma about the shrink

This week, I saw an elderly patient. He had been to the emergency room several times over the last ten days, referred by his family doctor (rightfully). The time he presented to me, the family doctor had sent him with an angry letter, saying he couldn’t understand why we didn’t hospitalize the patient, and to please deal with him.

According to the family, the patient had refused to be hospitalized. But he had continued to feel unwell, and agreed, with much convincing, to return to the emergency room.

The first thing that the patient said to me was that he was a very independent person, that he did not want to live out the end of his life very ill and did not want any invasive procedures. He said that everyone needs to be in charge of his own life and live how he chooses. He also said that the last time he was here, everyone had just jumped on him, wanting to put tubes in him, and never explained anything. I listened for a long time.

The patient has a metastatic cancer, but a slow growing one, with a good prognosis. His newest symptoms were almost certainly, in my eyes and the eyes of another doc I consulted, due to a local expansion of his cancer which was damaging an organ. It was an organ that is crucial to life and health. While he couldn’t be cured, a minor procedure could alleviate the pressure and spare the organ. He had refused.

Among the multiple documents from the prior ER visits and the family doctor and the oncologist was a letter that the patient had been sent to the local psychiatric court for a hearing to declare him incompetent, the reason being that he was “passively suicidal” by refusing treatment, and that he had said he wanted to die.

I briefly inquired – he had said, in fact, that he would rather die than lose his independence, that he “didn’t want to live like this” in a fit of frustration after one of the ER visits, that he had decided that he had lived long enough and that if this cancer complication would kill him, that would be an acceptable end to him, more acceptable than invasive treatment.

His affect was a little flat and down, and I’m sure that if I dug deep enough, I could have found some paranoia and maybe even light delusional thinking. He repeated himself a lot about his dignity, about needing things to be explained to him. There was probably some rumination in there. But in the ER, my job was to treat his physical illness according to his wishes.

I got to the point where I needed a list of his medications, which we got when his daughter called his wife at home. Nothing unexpected. But then, after that, his son said, “Wait, what about the medicine you got from Dr. Y, the psychiatrist?”

“Oh…I don’t take it.”

It was perphenazine.

Apparently, when he had come before, as soon as they had identified the impingement on the ultrasound, they had immediately wanted to put a stoma in, relieve the obstruction right then and there. He refused. This was the incident which had caused him to say that no one explained anything and they all just wanted to cut him open against his will.

My first task was damage control. I promised the patient that I would never do anything to him without his permission. Then I promised him that while I care about his health and his life, his dignity was more important to me. I explained that this was not a prison, that he was free to refuse or leave whenever he wanted.

I had to repeat myself several times. As I said, he was somewhat perservative about his fear of losing independence, being less than a man, having things done to him without explanation or permission.

Then I explained to him exactly how the pressure was damaging his organs. I explained what we could do to save his organs, showed him a sample of the kind of implant we would use, and explained exactly how it would be inserted. I called both an oncologist and an interventional radiologist to talk to him and explain. I also had to repeat this several times. I also arranged for it to be done as an outpatient procedure instead of insisting on hospitalization then and there. I did keep him longer than he wanted to try to stabilize him medically as a bridge to the procedure, but he agreed.

But in the end, he agreed to the procedure, and not reluctantly. I was afraid that if he went home, he’d change his mind, but today he showed up with no hesitation, underwent the procedure (which is uncomfortable, bordering painful), went home, and according to my conversation with his daughter after, did not swear off doctors.

I like dealing with elderly patients. I’m thinking of doing a subspecialty in geriatrics. I am sure he has some depression, and some light paranoia, and maybe even some delusional thinking. But is it really delusional thinking if he can be talked out of it? Is perphenazine treating the patient, or treating the family and the doctors? Would a lighter, antianxiety medication make it easier for him to make clearheaded decisions without his excessive fear? To be fair, since he didn’t take the med, and didn’t have it with him, I didn’t know what kind of dose was prescribed. But for a frail elderly man, this seemed excessive – like it was treating the family and doctors’ complaints that he was prickly and hard to deal with, while blunting what makes him him – his independent streak.

In the elderly, a lot of times you see some delusional thinking, a little bit of paranoia – but to me it seems like it comes from loneliness and loss of independence, and being treated like a child, combined with less cognitive reserve. I am not a psychiatrist, much less a geriatric one, but it seems to me that this is quite different than usual delusions in psychiatric illness, because it is so common, usually can be dealt with with patience at least temporarily (though it tends to return). I suppose it responds to antipsychotics, but just because it does doesn’t necessarily mean it has to be treated with them.

Here’s the real rub: Dr. Y. is my psychiatrist, the one I bitch about here all the time. Lately, the Cymbalta has been making me flat, has really harmed me cognitively, has completely destroyed my ability to write, has probably made me a worse doctor, though it has controlled the mania and the rages and the mood swings, and made me less prickly, less stubborn, less independent and fierce. I have complained about all of this to my psychiatrist, and he insists that the change in me is for the better. I kept asking him whether he is treating me or my environment. His exact words were, “The easier you are on your environment, the better it is for you.”

Until now, I had given him the benefit of the doubt, because he likes me and I do think he wants what is best for me. And that maybe I’m not the most objective judge of my own behavior and personality.

But now I see another, totally unrelated patient being treated the same way, and I think it is inappropriate, and I’m wondering. I know it is hard to judge another doctor’s actions because maybe I saw the patient on a much more lucid day or maybe things were different. I’m wondering if he is the one who referred him to the court. And most of all, I’m wondering…should I be shopping for a new shrink?