Reading this essay, A Major Problem With Compulsory Mental Health Care Is the Medication, made me think of the following anecdote. I’ll say more about compulsory mental health care (also called involuntary psychiatric treatment) and involuntary medications in a separate post.
Long time readers (from 2004—close to 20 years ago! thanks for spending decades with me!) will recall a physician I dubbed the Special Attending. (In this post from 2019 I identify him by his first name, Matthew.) I am certain that I wrote about the following anecdote at the time it happened; I was upset and distressed. The Special Attending was not a desirable flavor of “special” at this point. Frankly, I believed he was unnecessarily cruel and unfeeling.
I was an intern on the general medicine service. The patient was an elderly, frail woman with multiple medical conditions. She looked and sounded ill; the numbers from her blood and imaging studies confirmed her health was deteriorating.
The senior resident, the other intern, and the medical students all expressed concern about her viability. She looked miserable; she told us with her weak voice that she felt exhausted and uncomfortable. Why are we still poking and prodding her? we wondered. What are we doing?
“We should put her on comfort care,” someone offered. This quickly became the team consensus. We all knew the adage: Cure sometimes, relieve often, comfort always. With confidence that bloomed from the shallow earth of inexperience, we believed that none of our interventions would cure her. The pathway to relief, from our distressed perspective, was only through comfort care.
We—probably me, since this was my patient—proposed this plan with certainty to the Special Attending.
“No,” he replied. It wasn’t that he uttered only one syllable and nothing more. He was frowning. Though I had only worked with him for a few days, it was clear that he was radiating disappointment and disapproval.
Maybe it was me; maybe it was someone else with more courage who finally sliced into the uneasy silence by asking, “Why?”
Because we haven’t tried everything yet, he tersely answered, making no eye contact with any of us. There are still things we could do.
After rounds, we grumbled as a team. “Why is he making us do this?” we whined. “We’re the ones who have to tell her about next steps and do all the things. She’s not going to want this. She’s already suffering so much.”
See, the thing is, we couldn’t tolerate her suffering. We couldn’t bear to witness the deterioration of her body. We didn’t want to try another thing that would fail and prolong our mutual suffering. And what better way to help us escape than by limiting options and withdrawing?
So what does this anecdote have to do with involuntary psychiatric treatment?
My own view is that involuntary psychiatric treatment (inclusive of detention and medications) is a bad outcome. It means that multiple systems failed. The Big We either did not intervene earlier or care to intervene sooner. The Big We didn’t create or maintain enough options to avert this undesired result.
(To be clear: I have provided involuntary psychiatric treatment. It’s not an option I ever want to choose. I never feel great about it.)
We must create as many options as possible for people to receive care and treatment. We must tell people about these options and eliminate barriers so people can access them with ease. When you’re already feeling terrible, the last thing you want to do is climb uphill to knock on doors that won’t open.
It’s hard to witness suffering, but dealing with our discomfort is a problem for us to solve. For those who are suffering, they should not have to solve our discomfort, too.
In retrospect, I wish the Special Attending had explicitly talked with the team about our distress from witnessing the woman’s suffering. It doesn’t have to be a “processing” conversation or “touchy feely”. It could have been something like, “It’s hard to witness someone who is really sick. Our job, though, is to think of and share all treatment ideas with patients. They trust us to help them, so we must try. We can’t give up and look away, though, just because it’s hard for us. We are talking about this woman’s life.”
In the end, we talked with the woman about another treatment plan. She agreed to it. It didn’t help. And that’s when the Special Attending said, “Now we can talk with her about comfort care.”
Maria Yang, MD 