The telephone suddenly rings next to my head, making me jump out of my bed. For a moment, I don’t know who I am… I think I’ve fallen asleep. Then I remember: I’m on-call during the night shift. It’s dark, winter is almost here. At the other end of the call the nurse seems a bit nervous:
– You need to come to the emergency room. I have a suicidal man in front of me and you need to asses him. And we have another one waiting here for a couple of days, in the short time hospitalization unit. Nobody knows what to do with him.
– Perfect.
Of course I’m ironical.
The first patient is almost 100 years old. He is living in a seniors’ residence. Today however, the nurses working there saw him trying to jump from the window. They called the ambulance. He kept telling them that he was in fact doing some vigorous physical exercises in front of the window. They didn’t believe him. He then told them that he was aware that he cannot die if he jumps from the first floor of the residence, as he would more surely wound himself and increase his suffering rather than die. This also didn’t pass. I look at him:
– What happened to you?
– My wife died 2… or maybe 3… months ago.
Silence.
– How it happened? Was it a shock for you?
– No… she deteriorated gradually… She was in a wheelchair… feet problems, then heart problems, then several strokes… then, in the end, she didn’t know who she was…
After a moment of silence, he added, as an excuse:
– She was older than me… so… it was rather normal to leave before me…
I refrain myself to ask for clarification, such as the exact difference of age, but judging by his more than respectable age, she must have been 4-5 years older… she couldn’t have been more…
– Do you have children?
– No.
– Family?
– Just a brother living at the other end of the country. He is also older than me.
So the patient is really isolated, no family, no friends apparently, he has lost his last point of reference: his wife. As demented and cardiac as she seemed to be, she was definitely better alive than dead.
– I want to return to the senior residence, sir.
– I understand, but it seems that you are not only depressed and grieving, but you are also very lonely. And certainly alone now. Who or what guarantees that you won’t try to kill yourself again?
– But I didn’t try to kill myself; I was just doing some sport.
– I don’t think so; many people there have seen you trying to jump.
Silence. Very delicate situation. I contemplate the patient who is looking at me with seemingly intelligent eyes. He doesn’t look demented, he is speaking quite fluently, more fluently than most of the teenagers or young people I usually encounter.
– What did you work in your active years? What was your main profession?
– I was a scientist.
– A what?
– I did research internationally in my field of applied science.
This complicates things further. Intelligent people will skillfully dissimulate their suicidal intentions and will hide plans of suicide. He is very convincing that the 1st floor can’t kill him, he has prepared a good story and he is selling it well. I look at the nurse who begins:
– I’ve spoken with him before you came and I don’t think it’s a good idea to admit an almost 100 years old patient, against his wish, in the locked psychiatric unit. That will kill him faster. It’s going to be horrible for him to see the agitated schizophrenics we have there. Plus, he can get abused, as he cannot properly fend for himself.
I look at her meditatively:
– Damned if you do, damned if you don’t…
– Indeed.
I have all criteria for a high suicidal risk: the patient is having a depressive reaction of bereavement, he is isolated, there are no protective factors, he just failed to jump out of the window. I am in a deep shit.
I look at his current medication: 2 antidepressants, 2 anxiolytics, 1 sleeping drug. There is nothing decent I can add, even if I admit him in the hospital: Do what?!? Add a third more antidepressant?!? To a 100-years-old?!? To what avail?!? Add a sedative so that he can stay asleep all day for the rest of his life and then fall while going to the toilet and break his bones and then die in intensive care of complications from his fractures and from too much staying in bed?!? Psychiatry – in the sense of medication – can’t do anything more here.
I must use my common-sense. And broaden my perspective. Basically, the man has to deal with a loss. In this case it’s the most terrifying loss a human being can sustain: the loss of a loving partner. There is a known study conducted many years ago and, on the first position as the most stressful life event, we find the death of the partner. This beats everything else by a high score. So, how to deal with losing? Medication? No. Psychotherapy maybe? Yes. At almost 100 years old… could psychology be effective?
– Did you see a psychologist, sir?
– Yes, I did.
I am in a bad luck today. But I nevertheless continue:
– And how was it?
– She said, after 2 meetings, that she can’t do anything for me.
The psychologist has cracked, I know it, and he knows it too. It is not easy and it is not for anyone to do a psychological intervention on someone who is old enough so as to find it impossible to define objectives or what the hell you’re actually doing with him. Dealing with such an age can “soften” pretty much everyone.
– Would you like to try, again, to talk to a different psychologist? I mean, you have a problem with losing and this is rather psychological than pathological in the psychiatric sense. Actually, your reaction of sadness is normal if you loved your wife. What is not appropriate is the fact that you wanted to commit suicide…
And then I stop. And I listen to what I’ve just said. How can I know how it feels to lose someone with whom you perhaps spent more than half a century together?!? I am not at all “in tune” with him and his situation… so I bend rapidly the sense of the sentence so as not to give him a chance to replay something that might block my reasoning immediately…
– … although this can be understandable. But instead of focusing on typical psychological objectives…
Such as future plans, growing, etc. – I think, but it’s utterly stupid – so I continue fast…
– … we should rather focus on aspects such as making the most of this last period of your life…
And I bite my tongue when I pronounce “the last period of your life”. I continue while the patient is looking attentive at me:
– In the old age, the focus is rather on acceptance and living fully every day. So perhaps a new psychologist would work with you on this. And, just to mention, why kill yourself faster when death is certain… for us all?!? Don’t worry, it will come to you undoubtedly… as it will come to me and to my nurse present here as well…
I know I am paradoxical. I struggle to say something “intelligent” and I can’t. Or I seem not to be able to. The patient gets out of his silence:
– I’d like to try again, but this time with a man. A man psychologist.
– Okay, we will see what we can do.
Perhaps he believes that a man can better understand him. Or perhaps the previous psychologist, being a woman, reminded him of his wife. Or, possibly, he was making some sort of private projections on her, and sky is the limit for such projections that nobody will ever get to know… I continue, existentially:
– Sir, as you know, loss is part of this life. We cannot avoid loss and we also can’t avoid suffering. And the way we lose truly defines us, as any idiot can win but few people can skillfully deal with setbacks.
– I don’t know if I can go on without her… I no longer know who I am…
– But you already did that before!
– When?
– When you were young, before meeting her… There is a time in your life when you could live without her because you didn’t know her yet… and she didn’t know who you were either…
I struggle in an inner battle. I know that I must make him aware that he exists outside the couple and it is important for him to… remember it… The nurse knows what I also know: he and his wife were in a fusional relationship and therefore, he has no meaning and purpose in her absence. But what I hope is that he is intelligent enough to realize this.
A couple of moments later, while he is “assimilating” what I just said, I simultaneously reconnect with reality and with myself. I remember that I am the on-call emergency psychiatrist and “emergency” means fast, fast, fast; the emergency room is not a suitable place for a psychological intervention. Then, one part of me is mirroring myself – “the hero with an invisible (mental) sword in his hand”, “fighting for the life of this suicidal man” – while another part of me is asking “What the hell are you doing here?” Finally, a different part of me is telling me that it is useless to fight for a 100-years-old who will, more likely sooner than later, die of old age and gain almost nothing from our encounter since time is not on his side. To which another part of me replies that everything – but everything – in psychiatry – and in life in general – is nonsense, is futile, and will be finally lost anyway.
I decide, against the rules, and following the common sense, not to admit the patient in the psychiatry unit. He looked interested to meet the new psychologist. Or he pretended to, so as to escape from the hospital. What I can say for sure is that, since our discussion, the nurses in the seniors’ residence definitely feel nervous. My “professional image” and my “reputation” have surely had a blow…
The nurse returns after accompanying the patient to his bed, where he will wait the ambulance that is going to bring him back “home”.
– What do we have next?
– The abandoned patient.
– The what?
– Well, he has dementia and we can’t find a temporary home for him, as he was rejected from his residence because of recurrent episodes of confusion and violence. He is no longer who he used to be before. We are under high pressure to accept him, as the geriatric department is full. Argh… this system is falling apart… we are no longer who we used to be before…
– Well… let’s see him!
– See… only… as you can’t talk to him. He is completely lost. He doesn’t even know who he is.
I ponder: What is better: to be painfully aware of your situation, such as the patient before, or to be comfortably numb and not even know who you are?
– Has he any family?
– Yes, he has 4 children.
– Alive?
– Yes.
– Where are they?
– They are not here.
– They no longer know who is he?
– Apparently no.
