Lost a Patient, not my fault but I'm ticked off at myself

[whopper]

I had a catatonic patient. I've had her a few times for a few hospitalizations. She had a nasty habit of telling us one thing and then later on not following up with it. Some of it was IMHO cluster B traits.

Well a few days ago, she was at the end of her 72 hour hold and told me she'd agree to sign in voluntarily but wanted her husband present. He couldn't come in till literally just a few minutes before the 72 hours ended. She clearly needed to be in the hospital, still being catatonic and to the degree where she could not ambulate appropriately on her own.

Husband shows up. So I presented her the voluntary papers to sign and she refused. Literally-we're a few minutes away from the deadline so I told the social worker we got no choice. Tell the court we're keeping her involuntary and they'll have to set up a court day.

Now the husband is ticked. He doesn't understand the 72 hour hold process. I try to explain it to him that we had no choice, but he doesn't get it. He's mad, upset, and I've seen this this happen so many times before. Most of us have been there and we try to be nice at first, but after we give the family or friend so much time we at some point have to cut them off and go on with our day. This isn't why I'm ticked at myself.

The husband is an African-American WWII vet that saw action. He's got a medal. The man is a hero.

So it's a few days later, and I'm off from work because I got my job interviews at SLU. The process is stressful, not because they were hard on me (heck they were telling me I was already in, it's just that they have to interview me because the university says they have to do it), but because it was an all-day thing, I was interviewed by top people in the field and while they were very nice, I was somewhat intimidated (my own insecurities-top guy tells me he wants me working by his side-makes me feel like a poseur), I was also house-hunting, and I keep thinking of all the friends I won't see anymore in Cincinnati.

I check EPIC from my hotel room and that same catatonic patient of mine died. I double checked everything and I can't think of anything I could've done. She was geriatric and maybe it was just her time.

OK, yeah that is upsetting, but I can stare at myself in the mirror and still not feel like I did anything wrong. Labs-fine, notes-none showing anything that could have predicted this, meds? All at appropriate levels for her age.

So then I'm reading the social worker's note and her husband showed up to the hospital, was told his wife died, he's devastated, and emotionally collapsed.

Now this is what is pissing me off at myself.

This man is a hero, fought for his country despite that it was at a time when they gave him the message he was a second rate human being for the color of his skin and put him in a segregated unit, he lost his wife and just a few days ago I gave him the standard "Sir, I told this to you several times. This is the law," and then just went on with my day while the guy was very upset, only for this guy to suffer the death of his wife a few days later.

Yeah I know. On an intellectual level I don't think I did anything wrong, but when I look in the mirror I got this feeling that I did do something wrong.

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[OldPsychDoc]

Not entirely the same issue, but this article is deservedly a classic (and included in splik's Top 100) when it comes to helping us start processing what it means that our decisions affect the lives of others in potentially devastating ways: http://ajp.psychiatryonline.org/article.aspx?articleid=173750.

The only other thing I can say is "Been there, Done that."
Stand firm, chief.

 

[xlithiumx]

Having lost a patient to suicide myself early in my PGY3 year, I can tell you that this too shall pass, but dang it's hard in the now. Hang in there.

 

[Wilf]

She clearly needed to be in the hospital, still being catatonic and to the degree where she could not ambulate appropriately on her own.

This is the part of psychiatry I don't agree with. If the husband was willing to take care of her in that state, including giving her her medications, then I think she should have been free to go home to die more peacefully.

 

[Ceke2002]

I don't really have anything of value to contribute to the discussion, I just wanted to say how very sorry I am that you are dealing with what is obviously an emotionally impactful event. I hope you have a colleague you can turn to in a professional capacity to help you through this if you need to decompress. If it means anything you're one of the Doctors on here whose posts I always look out for, because from what I've seen I think you're an excellent physician with a high standard of genuine care for your patients.

 

[whopper]

I've lost patients before. Each time it was not my fault to the degree where my self-directed anger was only momentary at best.

This one wasn't my fault either. I know that. The doctor on duty also triple-checked everything and agrees we didn't do anything wrong in the sense that we could not have predicted this.

I'm upset that I significantly invalidated this man who was only trying to help his wife in a time when he needed my emotional support and then his wife died just a few days later



No I wasn't intentionally a bastard to the guy but I did cut him off at a point when telling him repeatedly that the laws force us to keep the patient after the 72 hour deadline and he had to take it up with the law if he didn't like it.

If the husband was willing to take care of her in that state, including giving her her medications, then I think she should have been free to go home to die more peacefully.

In such a case I would have allowed that if the case was double-checked by another doctor and/or an ethics committee.

The problem there is the husband is physically frail and could not care for his wife with the level of compromise of her ADLs. Each time we had her, she was almost completely frozen in a psychomotor sense and with Ativan, Namenda, and Topamax (all at high dosages) we were able to get her to move around to the point where she could do her ADLs, although very slowly, with nursing support.

Also, at the time I last saw her, we saw no reason to believe she would die within a few days. During her previous hospitalizations, we discharged her to her family and they could not care for her. Within 1-2 days she was back because, due to catatonia, she was not ambulating or drinking and wouldn't take the meds. So the last time we had her we discharged her to a nursing home.

The nursing home (idiotically) discharged her still in catatonia and not being able to care for herself.

ECT was not an option. She had capacity to refuse and told us she'd rather die instead of having ECT.

 

[softballtennis]

This is the part of psychiatry I don't agree with. If the husband was willing to take care of her in that state, including giving her her medications, then I think she should have been free to go home to die more peacefully.

I think it's that same way with parents I know some facilities allow parents to take there kids home and have the parents keep there kids safe, instead of putting them inpatient.

 

[vistaril]

This is the part of psychiatry I don't agree with. If the husband was willing to take care of her in that state, including giving her her medications, then I think she should have been free to go home to die more peacefully.

agree with this.

 

[Caldwell-Luc]

In this case, the husband was not capable of taking care of her. She needed help that he couldn't possibly give her.

 

[vistaril]

In this case, the husband was not capable of taking care of her. She needed help that he couldn't possibly give her.

well then maybe she could go somewhere else. From start to finish, this whole case just has a foulness to it. I mean you have a women towards the very end of her life who didn't want to be in the hospital....her ww2 vet husband of 60 years or whatever didn't want her in the hospital.....and then she dies in the hospital while being held involuntarily. That's the most negative of all negative outcomes in my opinion. Not saying any one person did anything wrong(also not saying it...really don't know and don't care), but just looking at the big picture it is a total fail on all levels.

 

[whopper]

This is one of the things that I don't like about geriatric psychiatry. Occasionally you get a patient that, for example, doesn't want to live or be in the hospital and argues it's none or your goddamned business if they don't want to live.

When a 20 year old tells you that, and there's a good chance they can recover it's one thing. When the person's elderly, doesn't have much time left, and you have to hold them involuntarily for what could be weeks and possibly a significant fraction of the rest of their lives, there's a very depressing aspect to it you don't see in the younger population. In some of these patients, it can take away their dignity.

 

[shan564]

When a 20 year old tells you that, and there's a good chance they can recover it's one thing. When the person's elderly, doesn't have much time left, and you have to hold them involuntarily for what could be weeks and possibly a significant fraction of the rest of their lives, there's a very depressing aspect to it you don't see in the younger population. In some of these patients, it can take away their dignity.

I was having this sort of discussion with a mental health judge recently. What it came down to was that there's a reason why they ask us if our opinion is "to a reasonable degree of medical certainty" rather than "certain." If you think that their mental illness is probably impairing their ability to make the decision that they would make if they were not mentally ill, and you think that you can probably help them, our legal/ethical experts have decided that they should be treated involuntarily. Fortunately, I don't have to make that decision - I can ask the judge to decide for me.

I'm upset that I significantly invalidated this man who was only trying to help his wife in a time when he needed my emotional support and then his wife died just a few days later

He left you no choice. It's annoying that you had to invalidate a war hero, but you would have been providing subpar care if you'd treated him differently for that. He made it clear to you that he wasn't going to understand the situation, and you responded in the only way that he allowed you to.

 

[whopper]

" If you think that their mental illness is probably impairing their ability to make the decision that they would make if they were not mentally ill, and you think that you can probably help them, our legal/ethical experts have decided that they should be treated involuntarily. Fortunately, I don't have to make that decision - I can ask the judge to decide for me.

Occasionally, when I worked on the forensic unit, if you were in a no-win situation, the administration recommended you get the judge, not yourself to decide.

In one specific case, I had a guy that was psychotic (believed he was the CEO of a major recording company and was a major song writer), had HIV, told us he was going to continue to have sex and was in denial he had HIV. He was in the hospital because while psychotic, he sexted someone with pictures of his penis, telling her he was going to go after her.

We got him better with treatment except he was still in denial about the HIV. Now the problem here is I couldn't tell if his denial was an ego-defense mechanism or psychosis. He had no other signs or symptoms of psychosis with antipsychotic treatment. We had him tested, had other doctors check him out and he told us he was going to have sex in the community despite that he had HIV and his violations that got him to us were sexually-related.

I was recommended to just wait till his next hearing. I told the judge I was at a virtual standstill and I could not tell if this was psychosis or not, but I also did not see the guy getting any better in the immediate future since he had been on the unit for about one year.

The judge let the guy go.

 

[Salpingo]

So it's a few days later, and I'm off from work because I got my job interviews at SLU. The process is stressful, not because they were hard on me (heck they were telling me I was already in, it's just that they have to interview me because the university says they have to do it), but because it was an all-day thing, I was interviewed by top people in the field and while they were very nice, I was somewhat intimidated (my own insecurities-top guy tells me he wants me working by his side-makes me feel like a poseur), I was also house-hunting, and I keep thinking of all the friends I won't see anymore in Cincinnati.

Maybe you're feeling guilty about leaving your home and past responsibilities?

 

[whopper]

I don't think it was that. If anything I should've been on an emotional high. The day was at an end, and I'm being told by three highly respected and name-brand doctors in the field that they want to work with me.

My wife was on an emotional high. She called a reservation for a restaurant and the entire time she's trying to celebrate with me while I'm being a total buzzkill and brooding on the death of that patient.

The stress of the new job/move situation did manifest in an argument between my wife and I a few days before the SLU interviews happened. My wife and I were both at fault, and like mental health professionals, after we cooled-off we thought about what happened and pointed out all the things we did wrong (not the other person but ourselves).