Presence

November 8, 2016
Adam Philip Stern, MD

Volume 33, Issue 11

When even listening fails, presence is all that’s left.

“I know you,” he said accusingly.

I reactively put my phone to sleep and slid it into my pocket. I hoped he hadn’t seen me looking at Facebook from within these hospital walls . . . a crime of poor taste. . . beneath the dignity of an attending psychiatrist.

We stared at each other, trying to place the unexplained recognition we shared. His face was familiar, but mostly just struck me as tired.

“I recognize you, too. I just can’t -”

“My wife,” he announced proudly after figuring it out. “Failed tumor excision. You were the psychiatrist. I remember now.”

“Yes!” I responded with more positive emotion than anyone should after the phrase failed tumor excision.

It had been almost 2 years since I first met this man’s wife. I had been called as a resident to perform a safety evaluation on someone who had just found out she had metastatic colon cancer. In the wake of the devastating diagnosis, she had been sent to one of my psychiatric mentors who took very seriously the woman’s casual references to “taking charge of her fate” if it turned out her cancer was inoperable. Maybe it would be better to end it neatly, she wondered aloud in her office.

By the time she woke up from the procedure that failed to rid her body of the tumor, she was accompanied by a one-to-one constant observer and a pink paper designating her a suicide risk. The psychiatrist had told the surgeon to order such scrutiny if the results of the surgery weren’t good.

Consultations like these always boil down to answering a question: does this patient need to be involuntarily hospitalized to prevent her from killing herself?

“I wake up, find out I’m going to die, and have to learn from this lady,” she says pointing at the sitter, “that I’m on suicide precautions! That shrink had no right to tell my surgeon what I had said in her office. That bitch!”

I was in a tough spot. I was the resident psychiatrist who was assigned to tell the surgeon if the patient was safe or not. The patient was railing against one of my mentors for doing exactly what I would have done. She was demonstrating an abundance of displaced anger; it was futile to be angry about her prognosis, but her fury toward the psychiatrist would be heard.

“I don’t want to kill myself! I’m a fighter. I’m going to fight this thing. I don’t care if they couldn’t get it out. I’ll find someone who can.”

I just listened supportively-the old standby when I don’t know what else to do. It allowed the patient to begin the process of considering her own mortality, but it also afforded her the space she needed to eventually convince me that she would not take her own life. She was future-oriented, almost to the point of denial. It wasn’t a good sign for her long-term coping but it was reassuring for her short-term safety. The question wasn’t one of morality or the merits of a painless death. It was dumber than that.

Consultations like these always boil down to answering a question: does this patient need to be involuntarily hospitalized to prevent her from killing herself? From what I had gathered from our conversation, this middle-aged woman-who, according to her surgeon, was fated to die in slow motion from her cancer-wouldn’t need to be locked away for 3 to 7 days for her own protection. Not on my watch.

I took her at her word that she wanted to fight, and if she only had months left, I’d be damned if I were going to force her to spend one minute wasting away on the psychiatry unit. With permission from the patient, I notified my mentor about our conversation and she agreed that as long as she followed up with another treater and was denying suicidal intent, she was free to go without involuntary inpatient treatment.

Now, nearly 2 years later, much had changed. I had become an attending, which means that sometimes I wear sport coats, though I’m confident the patient’s husband had other things on his mind than my attire. He and I were alone in the elevator, and there was nothing that would mercifully prevent me from fulfilling my obligation to ask how his wife was doing.

“We left here last time. Went elsewhere. Found successful treatment after all. Didn’t think we’d be back here, but a couple of nights ago, all of a sudden she couldn’t speak. And now, here we are again.”

I’d be damned if I were going to force her to spend one minute wasting away on the psychiatry unit.

We had reached the lobby and exited from the privacy of our own elevator back into the world. The man’s sister approached and urged him to hurry up, but the patient’s husband’s voice conveyed an urgency that said he wanted to keep our conversation going.

“Let’s go. It’s going to take forever to get out of here,” his sister snapped again.

“Listen,” I said. “Would you mind if, nothing official or anything like that, I just stopped by your wife’s room tomorrow for a visit?”

It was the last thing I wanted to do but literally the only thing I could think to offer.

“That would be so nice. She liked you.”

It was a lie, of course. Her liking me was a figment of her regressed state, just like hating my mentor was a symptom of something else. Splitting into good and bad is one of the most comforting things we do when we’re scared.

I spent the night worrying about how the conversation would go the next day. I knew I was out of tricks.

When I arrived in her room 12 hours later, I felt some relief that her husband was not there. There, in the hospital bed with tubes coming out of her nose and side, was the woman I had met so many months earlier. Her eyes were open, but they were wandering with a rhythmicity I couldn’t follow.

“Hello,” I announced approaching the foot of her bed. “I’m Adam Stern. We met a couple of years ago.”

There was no response but the continued bouncing of her eyes from the midline to the right and back.

“I don’t know if you can understand me.”

I looked at the whiteboard to my left: multi-focal infarct CVA 2/2 hypercoagulable state; DNR.

Her cancer had led to a major stroke.

“I just came by to say hello and. . .”

Once again I took the opportunity to listen, hoping it would save me one more time, but only the beeps and dings of the medical devices could be heard.

“And to say I’m sorry.”

I began to walk back toward the door, but paused at the whiteboard. “I’ll let you rest now,” I said as I wrote in black marker.

Dr. Stern came by for a visit.

I wasn’t sure who it was a message for or if anyone would even read it, but I wanted to leave something behind.

Two days later, when her name had disappeared from the floor’s census, I went back in hoping for some kind of closure. I didn’t find it, but I did notice that my note was still there. It was with her until the end.

When even listening fails, presence is all that’s left.

Disclosures:

Dr. Stern is an Instructor at Harvard Medical School and the Director of Psychiatric Applications at the Berenson-Allen Center for Noninvasive Brain Stimulation at Beth Israel Deaconess Medical Center in Boston.