Mind Reading
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《新英格兰医药杂志》
I was called in to see a man I did not know. No one knew him. His usual doctor was on vacation, and the social worker who paged me was covering for another social worker.
"Can't it wait a week?" I asked. The patient had been in the hospital for three years without a psychiatric evaluation.
"I don't think so," the social worker said. "He hasn't taken food or fluids for two days. But," she added, trying to encourage me, "he does take every pill."
The consultation question was the patient's competence. Did he mean to kill himself? The chart gave no help, with its notes full of vital signs and bowel functions. Three times a day, he received a cupful of medications: pills for seizures and diabetes, hypertension and constipation, depression and anxiety. The social worker who didn't know him was correct; he took them all, then turned his head from the pudding that followed.
The nurses had a somewhat fuller picture. Before his admission, he had manned a carnival booth with his wife, crossing the country from one school parking lot to the next. They had no children, and their lifestyle was raucous. He smoked and drank in carnival quantities until, in his late 50s, a stroke left him half paralyzed and speechless.
His wife had signed the medical directives form on admission. She had checked off "care and comfort measures only." Now she no longer visited and was not returning phone calls. An off-duty nurse had spotted her in the local market with a different hair color and a new man. The nurse shook her head to remember it. "I didn't tell him anything," she said, "but he knows. She doesn't come anymore. I try to feed him, and he pushes my hand away with his cheek. I say to him, `You know if you do that you're going to die,' and he shakes his head yes. But if he wants to die, then why does he take all his pills?"
I went to the patient. His wheelchair was locked in front of the TV, his right leg dangling off the footrest, his right arm contracted at the elbow and wrist. There was a documentary on about the first lunar landing. His eyes were open, following the dusty steps of Buzz Aldrin, while a nurse tried to coax a spoonful of pudding into him. I wondered if she was familiar with the hangar strategy: spoons full of unwelcome cereal circling the closed mouth of any one-year-old. The plane comes in for a landing, and the hangar opens reflexively. It is a useful approach in a pinch.
I had to refer to the consult form for his name. When I introduced myself, his eyes moved from the form to me. Then they closed, firmly but without offense. I thought it was a sensible response to a stranger who has been called in to make critical decisions without intimate knowledge. I hoped I would have done the same myself.
I apologized for interrupting and left. Looking back through the doorway, I saw his eyes open and fix on the television. He seemed perfectly alert and historically involved. The nurse sat on the edge of his bed and said something. He nodded, and they watched together. Giant steps for mankind were being made.
The covering medical doctor waited at the nursing station. "Sad, sad," he said busily. "What do you want to do?"
Competence is a legal state. The decision, especially when intervention is involved, must be rendered by a judge. But judges rely heavily on psychiatrists' opinions in issuing their own. Competence is also a function-specific state, and it comes in shades; someone might be competent to handle his finances but not competent to refuse his medications. He could be full of insight and judgment in one setting but not in another. It easily becomes confusing. A person with dementia who refuses hip-fracture repair may not comprehend his medical situation sufficiently to weigh the risks and benefits of surgery. On the other hand, a schizophrenic patient who is full of interior conversations may understand that he has a broken hip, that surgery is required to fix it, and that both accepting and refusing treatment come with separate risks.
Medical competence has a number of components. Ethicists diagram them for clarity. The patient must have cognitive capacity. He must concentrate and attend, register information and retain it. He must comprehend his diagnosis, undistracted by a treatable set of circumstances including psychosis, suicidal depression, and delirium (any of which can impede insight and judgment). He must be able to weigh the risks and benefits of accepting treatment — food and drink, in this case — and must understand the consequences of refusing them — here, it meant death.
On a blackboard with colored chalk, the variables of cognition, understanding, and judgment create a complex but manageable set of intersecting circles. This case did not feel manageable. I tried to break it into its components. Cognition: difficult to assess in the absence of speech and given the patient's refusal to comply with any exam; however, he seemed able to maintain attention to television, to follow simple commands, and to respond to the nurses, who had not reported deterioration in these capacities.
Impediments to judgment: psychiatrically, someone had diagnosed depression at some point (I could find no note about it) and started an antidepressant; maybe he was inadequately treated. Electroconvulsive therapy (ECT) will rapidly alleviate life-threatening depressive symptoms, including the refusal to eat or drink. But it cannot remedy personal devastations. It can't, for instance, return missing love. Here, I leaned lower over the consult form and hoped that no one could read my thoughts. The man had sensible reasons to wish for death — no future health to anticipate, no one to anticipate it with.
Other reversible impediments: Was he delirious? hyponatremic? hypercalcemic? hypoxic? febrile? septic? having a second stroke? Blood tests and imaging would rule these conditions in or out. Was there a physical reason he couldn't swallow, such as pain? But why, why did he take his pills?
Nobody at the nursing station wanted to petition for an emergency guardianship to force feedings or ECT on a man with seizures, diabetes, hypertension, hemiparalysis, speechlessness, and lovelessness. Tacitly, I knew, I was being asked to document the reasoning behind the majority opinion. If he had come to a decision in sound mind, we wanted to support it on paper. The paper part was critical. Families of ghosts can be litigious.
The nurse who had been trying to feed him came up to the station. "God bless him," she said. "I wouldn't wish that life on a dog." Heads nodded. Even those of us who did not know him could agree on this. I was scribbling away, behind schedule, trying to imagine those clean intersecting circles on the board. But ultimately, we who didn't know him were not making judgments according to those clean criteria. We were making them on the basis of our own impressions of his life and our own standards of living.
I passed the consult form to the covering doctor. We agreed that it was easy enough to check for reversible signs of mental-status change. If nothing leapt out of the laboratory tests or vital signs, treatment would not be forced. It was the best we could do but incomplete; our answers did not rise to the complexity of the questions he had raised. I went back to my own floor, and the doctor went to his.
A world full of less imperative tasks intervened after that. It might have been a month or so later that the social worker and I met in parallel cafeteria lines. We had almost passed one another before I recognized her and remembered. What had become of the consult patient? Had anyone ever understood why he took his pills but refused his food — extended one arm for help and used the other to fight it off?
"He died a couple of days after you saw him," she said, sounding as if she, too, had just remembered. Even regular members of his health care team had been unable to reconcile his contradictions. They could not feel certain that his actions were intentional. But, given the absence of an acute reversible condition, they could not justify interrupting him, either.
The social worker and I stood together uncomfortably. When our separate lines began to move at different paces, the space between us widened. Neither of us mentioned the patient by name. I thought afterwards that we might both have forgotten it.
Source Information
From Harvard Medical School, Boston.(Elissa Ely, M.D.)
"Can't it wait a week?" I asked. The patient had been in the hospital for three years without a psychiatric evaluation.
"I don't think so," the social worker said. "He hasn't taken food or fluids for two days. But," she added, trying to encourage me, "he does take every pill."
The consultation question was the patient's competence. Did he mean to kill himself? The chart gave no help, with its notes full of vital signs and bowel functions. Three times a day, he received a cupful of medications: pills for seizures and diabetes, hypertension and constipation, depression and anxiety. The social worker who didn't know him was correct; he took them all, then turned his head from the pudding that followed.
The nurses had a somewhat fuller picture. Before his admission, he had manned a carnival booth with his wife, crossing the country from one school parking lot to the next. They had no children, and their lifestyle was raucous. He smoked and drank in carnival quantities until, in his late 50s, a stroke left him half paralyzed and speechless.
His wife had signed the medical directives form on admission. She had checked off "care and comfort measures only." Now she no longer visited and was not returning phone calls. An off-duty nurse had spotted her in the local market with a different hair color and a new man. The nurse shook her head to remember it. "I didn't tell him anything," she said, "but he knows. She doesn't come anymore. I try to feed him, and he pushes my hand away with his cheek. I say to him, `You know if you do that you're going to die,' and he shakes his head yes. But if he wants to die, then why does he take all his pills?"
I went to the patient. His wheelchair was locked in front of the TV, his right leg dangling off the footrest, his right arm contracted at the elbow and wrist. There was a documentary on about the first lunar landing. His eyes were open, following the dusty steps of Buzz Aldrin, while a nurse tried to coax a spoonful of pudding into him. I wondered if she was familiar with the hangar strategy: spoons full of unwelcome cereal circling the closed mouth of any one-year-old. The plane comes in for a landing, and the hangar opens reflexively. It is a useful approach in a pinch.
I had to refer to the consult form for his name. When I introduced myself, his eyes moved from the form to me. Then they closed, firmly but without offense. I thought it was a sensible response to a stranger who has been called in to make critical decisions without intimate knowledge. I hoped I would have done the same myself.
I apologized for interrupting and left. Looking back through the doorway, I saw his eyes open and fix on the television. He seemed perfectly alert and historically involved. The nurse sat on the edge of his bed and said something. He nodded, and they watched together. Giant steps for mankind were being made.
The covering medical doctor waited at the nursing station. "Sad, sad," he said busily. "What do you want to do?"
Competence is a legal state. The decision, especially when intervention is involved, must be rendered by a judge. But judges rely heavily on psychiatrists' opinions in issuing their own. Competence is also a function-specific state, and it comes in shades; someone might be competent to handle his finances but not competent to refuse his medications. He could be full of insight and judgment in one setting but not in another. It easily becomes confusing. A person with dementia who refuses hip-fracture repair may not comprehend his medical situation sufficiently to weigh the risks and benefits of surgery. On the other hand, a schizophrenic patient who is full of interior conversations may understand that he has a broken hip, that surgery is required to fix it, and that both accepting and refusing treatment come with separate risks.
Medical competence has a number of components. Ethicists diagram them for clarity. The patient must have cognitive capacity. He must concentrate and attend, register information and retain it. He must comprehend his diagnosis, undistracted by a treatable set of circumstances including psychosis, suicidal depression, and delirium (any of which can impede insight and judgment). He must be able to weigh the risks and benefits of accepting treatment — food and drink, in this case — and must understand the consequences of refusing them — here, it meant death.
On a blackboard with colored chalk, the variables of cognition, understanding, and judgment create a complex but manageable set of intersecting circles. This case did not feel manageable. I tried to break it into its components. Cognition: difficult to assess in the absence of speech and given the patient's refusal to comply with any exam; however, he seemed able to maintain attention to television, to follow simple commands, and to respond to the nurses, who had not reported deterioration in these capacities.
Impediments to judgment: psychiatrically, someone had diagnosed depression at some point (I could find no note about it) and started an antidepressant; maybe he was inadequately treated. Electroconvulsive therapy (ECT) will rapidly alleviate life-threatening depressive symptoms, including the refusal to eat or drink. But it cannot remedy personal devastations. It can't, for instance, return missing love. Here, I leaned lower over the consult form and hoped that no one could read my thoughts. The man had sensible reasons to wish for death — no future health to anticipate, no one to anticipate it with.
Other reversible impediments: Was he delirious? hyponatremic? hypercalcemic? hypoxic? febrile? septic? having a second stroke? Blood tests and imaging would rule these conditions in or out. Was there a physical reason he couldn't swallow, such as pain? But why, why did he take his pills?
Nobody at the nursing station wanted to petition for an emergency guardianship to force feedings or ECT on a man with seizures, diabetes, hypertension, hemiparalysis, speechlessness, and lovelessness. Tacitly, I knew, I was being asked to document the reasoning behind the majority opinion. If he had come to a decision in sound mind, we wanted to support it on paper. The paper part was critical. Families of ghosts can be litigious.
The nurse who had been trying to feed him came up to the station. "God bless him," she said. "I wouldn't wish that life on a dog." Heads nodded. Even those of us who did not know him could agree on this. I was scribbling away, behind schedule, trying to imagine those clean intersecting circles on the board. But ultimately, we who didn't know him were not making judgments according to those clean criteria. We were making them on the basis of our own impressions of his life and our own standards of living.
I passed the consult form to the covering doctor. We agreed that it was easy enough to check for reversible signs of mental-status change. If nothing leapt out of the laboratory tests or vital signs, treatment would not be forced. It was the best we could do but incomplete; our answers did not rise to the complexity of the questions he had raised. I went back to my own floor, and the doctor went to his.
A world full of less imperative tasks intervened after that. It might have been a month or so later that the social worker and I met in parallel cafeteria lines. We had almost passed one another before I recognized her and remembered. What had become of the consult patient? Had anyone ever understood why he took his pills but refused his food — extended one arm for help and used the other to fight it off?
"He died a couple of days after you saw him," she said, sounding as if she, too, had just remembered. Even regular members of his health care team had been unable to reconcile his contradictions. They could not feel certain that his actions were intentional. But, given the absence of an acute reversible condition, they could not justify interrupting him, either.
The social worker and I stood together uncomfortably. When our separate lines began to move at different paces, the space between us widened. Neither of us mentioned the patient by name. I thought afterwards that we might both have forgotten it.
Source Information
From Harvard Medical School, Boston.(Elissa Ely, M.D.)