The Freedom in Accepting Our Limits

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A BETTER PSYCHIATRIST

You were too young. You were supposed to get better. You weren’t supposed to die.

I am 3 months into my intern year and well into a daily routine. Wake up near dawn, put on my weekday best, go to the hospital, and then come home to finish notes and kiss my wife goodnight. But today after lunch, I get a text message and the routine is shattered.

“Did you hear your patient died? He jumped off a bridge last night . . . I’m watching the local news. They identified his body.”

His name was “Ryan,” and he was only 28. He was on the dual diagnosis unit for a week before being discharged. The team had assessed that he wasn’t actively suicidal. Yet two days later, he’s dead.

I am in a state of disbelief and my head is spinning. Was he high or was it deliberate? Could I have done more or did I do too much? What should I have said that I didn’t, or shouldn’t have said that I did? Was it poor judgment to discharge him? I had direct responsibility for trying to help him get better.

Two weeks earlier, Ryan was standing on the side of a bridge when the paramedics found him. He was high on heroin and suicidal, and consequently, he was hospitalized again (this was the third time in a month). His life had completely fallen apart. His family relationships were damaged: he had no intimate partner, support group, or cohesive identity. He was poorly educated and unemployed. He was kicked out of multiple homes and had legal charges pending. He was without a safety net.

After detox, we spent hours together discussing treatment options and I was attempting to help him discover the motivation to stop using heroin. When he was sober, Ryan was introspective, respectful, and soft-spoken. Though he initially seemed encouraged, his interest quickly faded with each passing day without heroin. When asked what his goals were, Ryan said he wanted to leave and start using again.

Psychiatric illnesses are often seen as deficiencies in behavior, character, or personality and qualitatively different from advanced cancer, diabetes, and pneumonia.

Each day, I felt like I was falling short when trying to reach him-I was completely powerless against his opiate addiction. Though I spent considerable effort trying to engage Ryan, he remained aloof and disinterested. I wanted to alleviate his suffering with alternatives to opiates. He was convinced that medicines and psychotherapies were ineffective. His addiction had damaged his life severely. He recognized heroin was dangerous but said it was worth the trouble. Even so, after multiple discussions, Ryan expressed a willingness to follow up with an outpatient program and case manager. I had hoped he was genuinely committed to taking steps toward building a meaningful life and he wasn’t appeasing me to secure his discharge. I suppose the hoping didn’t matter in the end.

I still can’t believe it. I was worried what might happen if you started using again. You said it yourself, that maybe next time you were high you would jump off a bridge. But I wasn’t expecting you to die so soon. I didn’t expect to feel such intense grief, with powerful guilt and shame, even though I knew I gave you my all. But I couldn’t, and wouldn’t, have kept you locked up in the hospital against your will unless absolutely necessary. Even my best effort wasn’t enough to keep you alive.

But maybe keeping Ryan alive wasn’t a realistic goal at all. We routinely discharge terminally ill patients from medical units to hospice care with the expectation that they will die from their terminal medical illness within 6 months. Why should we feel more responsibility for discharging people with terminal psychiatric illness? A dichotomy between “psychiatric” and “medical” illnesses pervades our culture. Psychiatric illnesses are seen as deficiencies in behavior, character, or personality that should be remedied; therefore, they can’t be terminal. Somehow, they are qualitatively different from advanced cancer, diabetes, and pneumonia-perhaps, in part, because we don’t understand psychiatric disorders as well as other specialists understand their areas of medicine.

We reject the idea that young people with advanced psychiatric illnesses should be allowed to die, yet we accept that those stricken with terminal cancer be allowed to die without being stigmatized for having brought it upon themselves. We expect suicide to be preventable but are allowed to say that cancer is untreatable once it progresses to a certain stage, since the treatment is often worse than the disease. Couldn’t we say the same about severe schizophrenia or bipolar disorder, that the treatment is sometimes worse than the illness? But often in severe mental illness, death is less predictable than in cancer and therefore unexpected when it happens.

An occupational hazard

As physicians, we accept death from a medical illness as one possible outcome. When death occurs in psychiatry, however, we often feel shocked and guilty. Even when one provides appropriate care, death is sometimes unavoidable. Imagine you are an emergency room physician treating a patient suffering from a heart attack. Her cardiac condition is treated promptly, appropriately, and effectively; she improves. You feel like you saved her life; that the dangerous part is over. However, two days later, she has a fatal arrhythmia. You begin revisiting everything you did (or didn’t do) for her.

After determining you provided appropriate care, you might accept your limitations and confidently take care of your next patient. Why should suicide be different? Heart disease is the leading cause of death in older adults. And suicide is the third leading cause of death in young adults.

Clearly, I’m not immune to this ultimate “bad” outcome. And Ryan’s untimely death doesn’t mean that I am an incompetent or worthless physician. It just highlights my limitations in treating terminal psychiatric illnesses.

Just as we cannot fully control outcomes in advanced heart disease, we also cannot do so in advanced psychiatric illness. I have and will always try to engage a patient with complete acceptance, unconditional regard, and without judgment. Sometimes that may inspire internal patient motivation to modify behavior. Other times a patient may trust in pharmacological and behavioral interventions. In Ryan’s case, I couldn’t help him find another way to manage his social anxiety and opioid use disorder.

I’m thankful for the chance to know and accept my limits. This acceptance frees me from the impossible expectations of perfection and complete control.

Ryan, I hope you’ve made peace and you’re no longer suffering. You’ve deepened my passion for treating serious mental illness and ensuring that stigma is minimized or eliminated during the process. By sharing your story, I hope my professional colleagues will take the opportunity for self-reflection and growth. I hope we all can accept our limits and muster the courage to continue improving our lives and the lives of others.

Disclosures:

Acknowledgements: I would like to acknowledge the wonderful support and contributions from my wife, Cecilia Huang; my clinical mentor, Antoine Douaihy, MD; my residency program directors, Mike Travis, MD and Sansea Jacobson, MD; and my entire Western Psychiatric Institute and Clinic family.

Dr. Hoftman is a Resident Physician in Psychiatry at the University of Pittsburgh Medical Center, Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania.