Evelyn

Practice Stories

Evelyn

Evelyn was married and had 3 loving daughters and a loving husband.  She suffered from a chronic depressive illness that had required multiple hospitalizations prompted by suicidal thoughts and intent.  These episodes occurred in spite of the fact that she always kept her office appointments and was compliant with all treatments prescribed.  This admission to the hospital was again prompted by depression but it was occurring within a different context.  She had for quite some time been receiving renal dialysis for kidney failure and had decided to discontinue it, knowing that this would result in her death.

She couldn’t sleep at night, her energy was low and she had little appetite. Her speech was slow and impoverished. Her affect and mood were severely depressed. She did not say that her decision regarding discontinuation of dialysis was a way to kill herself..    However, I was concerned about her capacity to make a rational decision while in such

a severely depressed state.  I discussed my concern with her and her family and proposed that she should not make this decision until her depressive symptoms had improved. When she balked at this idea I said that I would then feel compelled to refer her to the court with the question of whether she was competent to make that decision at that time.

I explained to her that I would in no way attempt to influence her decision once her mood had improved.

With this threat and the encouragement of her family she agreed to continue her dialysis and accept further treatment of her depression. A day or two later I was making hospital rounds accompanied by a psychiatric resident. I, among other things, was trying to teach her how to interview patients in a way that would allow them to express their feelings.

When I approached Evelyn she was lying in her bed, staring blankly at the ceiling.  A direct question as to how she was feeling was met by silence.  Other questions about her care, family visits, etc. were met with the same mute response.  I then indicated that I suspected that she might have lots of thoughts and feelings she might wish to share at a later time. In addition I indicated that I would make sure extra time would be available if she should feel more like talking on the next day.  Having said this, I, with the resident tagging along, walked away.  Just as we reached the doorway of her room she shouted, loud enough to be heard throughout the entire unit, “Goodbye Asshole!”

In the ensuing couple of weeks her depression lifted and we were on the good terms we had shared in the past.  At that time she once again considered whether she should or should not continue with her dialysis.  She decided to discontinue it and her family and I were comfortable with the fact that she was now competent to make a decision only she could make.

JohnB McAndrew MD

2006