The Mirror

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I could see myself in her eyes, only hers looked back at me with the wisdom of her years, with rings like a tree around them to show it. She lay in bed looking up at me, flat, emotionless, defeated. I knew if she had rings I could count them-there would be around 80-but the look she gave me evoked more certainty than a number could even define. It was if she begged, “Please,” and in that instant I felt torn between letting her die and, conversely, helping her want to live.

She was a physician-a neurosurgeon. She had given herself to her patients for over 50 years, but as her mind dulled and her hands slowed and she no longer worked with the mastery that she had before, her life unraveled. She lost her job, her mentoring, and ultimately her happiness. Even her family did not know who she was without her skillful hands and brilliant mind. Without her tools, she could not bear to live.

Hearing her story before even having met her, I felt defeated, like perhaps she was as terminal as it gets in our profession. She had tried not once but twice in the past few months to end her life. When pills failed to kill her she tried again-only to survive a gunshot that should have killed her. Everyone around her, her friends, family, and other doctors, had resigned themselves: she was determined to die and she would die. They even began to research assisted suicide and ways to help her. But we were psychiatrists! Perhaps naively I believed, if we could not help her, then who would?

But another part of me wondered about my moral judgment. If I were her in 60 some-odd years and I could no longer practice medicine-what I hope will continue to be a source of pride and joy in my life-would I want to be saved? Would I be lying in bed, begging a trainee, with the same longing look, to put me out of my misery? Was there mercy in letting her end her life? Was it wrong and even paternalistic to want to prolong it?

I was torn. I did not want to believe we could let her die without trying to help save her, but I felt her pain. I wanted to believe there was a difference between mental pathology and real desires, and if she could only get better, maybe her desire to die would change. Maybe if she were happy, she would want to live-even in a life without medicine.

Initially, we tried to adjust her medications. Each morning I would smile kindly and ask how she felt. Each and every day she would tell me with conviction that she still wanted to die and that if we discharged her, she would end her life.

The medications do not seem to be working, I thought to myself as I turned to walk out of her room . . . a fact I knew she must have been thinking, too.

One day I pivoted around to face her and said, “Dr. T, you have so much more to impart to a trainee like me. It makes me sad that you want to die.”

She looked up at me again, “What year are you in training?” While I answered, she paused as if that time in her life was flashing before her eyes. She then quietly responded, “It’s nice when you first start out, but not as nice in the end.”

I wondered if she was right. I pictured myself in my old age and I worried if I, too, was resigned to the same fate . . . discouraged and hopeless, with life no longer worth living, thinking about and trying to die by my own hand. Was this what happened to all great doctors?

Yet, we did not want to give up. We had one more ace to play, which, ironically, was a tool she knew well: ECT. She had seen it decades before, and even though it was more primitive back then, she did not hesitate to consent. Perhaps it was easier for her to place her hope in a procedure than in medication or therapy. Maybe, if we were lucky, through a procedure she might find herself again.

Each day, as I had before, I went to see her. I asked her to tell me a story from her career, and begrudgingly she complied. Each story was more fantastic than the last. She constructed an autobiography for me, and I, as her doctor but also as a trainee learning from an expert, listened intently. Maybe I was hoping to learn how to be like her. Or, maybe, I was looking for how not to be.

As expected during an ECT course, no changes were evident in the first 4 treatments. But even as we approached day 6, she still very much wanted to die.

Day 7 came and went with no change.

On day 8, however, she smiled at me. I asked her if she felt any better, and she adamantly said no. But with her grin, I regained a bit of hope.

Each procedure day afterwards, she became brighter and brighter. She smiled more often, she laughed more frequently, and she even opened her blinds to sunlight and left her room during the day. She was a completely different person than the one I had first met. I had a feeling that from the darkness, the real doctor was emerging.

As her MADRS decreased, so did my own insecurities about my future and my profession. She was getting better and we had helped her get better. She was not terminal and I would not be either. My future was not hopeless after all.

On her final day of 3 times a week ECT, she again asked me my year of training, but this time asked if I liked being a psychiatrist.

I responded, “I am a second year, and I do. . . I think I may love it.”

She looked back at me and said with a joking smile, “You don’t have the hands of a surgeon, or the demeanor. It’s a good thing you are a psychiatrist.”

I looked back at her, laughed briefly, and said, “Is that a bad thing?”

She reached out her hand to shake mine and said, “If you were not a psychiatrist, who would have saved my life?”

Disclosures:

Dr. Gold is starting her third year of psychiatry residency at Stanford University in Stanford, CA.