The Patient Was…

The patient was a 94 year old woman who lived alone on the Upper West Side of Manhattan. She did not have any specific, serious conditions, but she was quite frail. Short in stature at less than five feet, and now slightly bent as well, weighing just shy of ninety pounds, she was mostly confined to her apartment. She had a devoted niece who lived in New Jersey, visited her weekly, and shopped for her bringing food that could be eaten cold or easily warmed in the oven. Her niece also helped to manage her finances which were sufficient to keep her living independently, as she devoutly wished.

At the time the patient was under my care, frailty was considered just a consequence of the normal aging process. Nowadays, frailty is recognized as a somewhat specific syndrome, not uncommon among the geriatric population. Patients who are deemed significantly frail are at risk of poor health outcomes, due to a variety of causes, Estimates of the prevalence of frailty among the elderly range from 5 percent to 17 percent of older adults.

On her visits to my office, always accompanied by her niece, the patient repeatedly expressed her greatest fear: loss of independence and confinement to a nursing home. She was not afraid, she assured me, of dying; and living in a nursing home represented, literally, a fate worse than death.

Despite age and frailty, she had a spirited manner, an optimistic outlook, and an engaging personality. And she delighted in reminding me not only about her aversion to nursing homes, but her plans to avoid one.

In frank terms, she described that during her prior years of care under other physicians, she had carefully saved medications with sedative properties that had been prescribed for her at various times. She now had, she said, a rather large supply hidden away in her apartment. If she developed some condition or illness, or anything happened that made her believe she was destined for a nursing home, she planned to swallow the pills and end her life.

I did not argue that being in a nursing home was a satisfactory way of living. I did not contend that loss of independence was not so bad. I did not contest her beliefs about a good life or a desirable one.

What I did argue was that her attempt at suicide would likely fail.

Data on suicides are readily available. Women are more likely to attempt suicide than are men, but men are more likely to actually die by suicide. These differences in suicide attempts and completions are believed to be due mostly to differences in the methods of suicide chosen by men and women. Men are more likely to choose violent and more lethal means of suicide, such as firearms,  hanging, or jumping from heights. Women, on the other hand, are more likely try to overdose on medications.

I explained to the patient that killing oneself by overdosing on medications is not so easy. You can underestimate the amount of drug you need to take. You may vomit up some of the pills you ingest before they get absorbed into your system. The effects of the first pills you take may hamper your attempt to swallow the rest. The pills may spill from the bottle or your hand, and land where you can’t reach them. And so on.

We had this discussion repeatedly when she visited the office. But she was adamant in her wishes and about her plan, and her niece was aware of what she had in mind.

One day, I got a frantic call from the niece. She had called the patient but gotten no answer. Believing that her aunt might be in the bathroom, she waited a bit and called again. When there was still no answer, she rushed into the city to her aunt’s apartment, where she found her unconscious on the floor, with an open pill bottle near her and pills strewn about on the bed and on the floor. An ambulance was summoned, and the patient was transported to the hospital where she was admitted under my care.

On arrival at the hospital the patient was unconscious but breathing on her own without need of respiratory assistance. Her heart beat was regular, and her blood pressure was only slightly lower than her normal range. She was given oxygen just as a routine measure, an IV (intravenous) infusion was started to maintain her fluid intake, and her vital signs were monitored. Nurses, medical interns and resident physicians saw her regularly. They reported no change in her condition.

I saw her twice daily, as I did all my hospitalized patients. Her condition remained stable. On each visit, I touched her arm and held her hand, and told her that I was there to examine her.

On the afternoon of her third or fourth day in the hospital, as I entered her room, I saw her eyes flick open for an instant, then shut again. It was very quick but I was sure of what I had seen. As I told her I was there and touched her arm, she opened one eye and moved it back and forth as if to see if there was someone else in the room with us. Apparently satisfied that we were alone, she opened both her eyes and looked right at me.

“I blew it,” she said, “didn’t I?

“What do you mean?” I answered. “Tell me what happened.”

She proceeded to tell me, somewhat haltingly, but easily understood, that she had gotten up from a chair in her apartment to go the bathroom. She felt a bit dizzy but made her way to the bathroom. When she got up from the toilet, she was lightheaded again, and immediately concluded that she was having a stroke and that meant that she would wind up in a nursing home.

So, she went to her hidden cache of drugs, sat on her bed, and began to swallow them. She started to gag, threw up some of the pills, swallowed some more, then threw up some again. Then the bottle slipped from her hand, pills spilled on the bed and the floor, and when she tried to reach down for the bottle that had fallen to the floor she fell from the bed.

“So I blew it, like you told me,” she said. And she was right.

And she hadn’t had a stroke. When she got up from her chair to go the bathroom, her blood pressure fell slightly, which caused her to feel dizzy. When getting up from the toilet the same thing happened.

A fall in blood pressure on getting up is very common, especially in the elderly. It is often compounded by slight dehydration as people reduce their fluid intake to avoid having to go to the bathroom so often.

The sad irony was that in misdiagnosing herself, she managed to create the one circumstance she dreaded. The adverse results of her abortive suicide attempt were just enough to make independent living unfeasible.

She was admitted to a nursing home where she remained for the rest of her life.