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At Yale Psychiatric Hospital: Respect, Dignity and Kindness
Large picture I did at Yale Psychiatric Hospital, the second one.
The pictures below are actually only 2.5 by 3.5 inches and are artist trading cards. I drew many of them, especially when I did not feel like working on my larger drawings at the hospital.
In mid-February, after a week out of the hospital (and you can read about my hospitalization by scrolling down to the previous post, but, in brief, this had been at Hartford Hospital’s Institute of Living, during which I was kept in seclusion for the larger part of a four week stay and put multiple times, sometimes twice a day for many hours in 4-point restraints. Why? Why? Although I ONCE threw a chair, they told me it was for “not following directions.” To add insult to injury, every incident in which they restrained me was accompanied by three injections in the buttocks of Haldol, Ativan and Benadryl, despite my policy of passive, completely non-violent non-resistance.)
In any event, in mid-February, after I had spent just a week at home, I became acutely psychotic again, and in consultation with the only doctor I trust, a friend drove me to Yale New Haven Hospital’s emergency department. There, after a very long and arduous wait — alas, I cannot say much that is good about Yale’s ED. It felt like the psych/alcohol patients – and there were no discriminations made between the drunks and anyone else — were lined up on their beds in the hallway like buses at a terminal for what felt like “miles.” In fact at one point there was probably a line 15 gurneys long snaking around the corner until I could not see the end.
I was there for two and a half days, maybe longer, I do not recall. In fact, I remember nothing about my ED stay after I was finally “admitted” to the actual psych portion of the ED, as opposed to the hallway. I believe I was finally given medications, but also that I was no longer permitted access to my artist crayons, which meant that I only wanted to sleep and likely did until I was admitted to the Yale Psychiatric Hospital, a street or two away.
To say that my experience at YPH was an order of magnitude better than it had been at the IOL or even at Natchaug Hospital is truly not to give YPH enough credit. I scarcely want to mention the other two hospitals in the same sentence, that is how different Yale is and I say that even though I once considered Natchaug my “gold standard.” No longer, no longer. I think Natchaug was decent once, but only because of the civilizing and humanizing effects that the director of nursing, Sharon Hinton, APRN, had on the hospital. Once she left, the whole place went to pot, as evidenced by my experience during the last two stays, which went progressively from bad to terrible without her there…literally without her protection I was brutalized by a dehumanizing medical staff that had been left to do whatever it wanted to on its own, to hell with the consequences to the patients.
Be that as it may, and we know that the Institute was never humane, Yale took me completely by surprise. I was hard to surprise, and hard to convince that they were for real in their gentleness and kindness, let alone in their determination to treat me and everyone there with respect and dignity. I was certain that they would prove me right, that SOMEONE would be put into restraints, that someone would be violent enough to push their buttons and get 4-pointed. But it never happened, not in the entire three weeks I was there. Not even when a patient threw a punch or a push. Not even when a patient screamed bloody murder or used foul language. Nothing that earned me or anyone else seclusion or restraints elsewhere even came close to pushing the staff’s anger buttons at Yale. Instead, they persisted in using persuasion and gentleness and kindness…and if anyone lost it, if anyone became angry and could not keep it together, so far as I could tell, that staff member took themselves away from the situation to cool down, and did not take it out on the patient.
The most amazing things happened. No one forced me to do anything. Not even to take medication. I agreed to take it, after some discussion with the doctor and social worker…but when I evinced some doubt about the side effects, instead of pooh-poohing them as the doctor had at the Institute, Dr Milstein agreed with me, saying that the Zyprexa definitely increased appetite, and that it was not imaginary or something that was in my control, the way Dr Banerjee did at IOL. Instead, he and the other team members not only agreed to help me control what I ate, but went out of their way – I believe they actually went “Stop and Shopping” – to provide me with my own private supply of raw vegetable snacks in the staff refrigerator to eat at any time of the day…just so I wouldn’t have to be tempted by the hospital snacks of Doritos etc.
Dr Milstein asked me not to worry about what they did or did not do “extra” for me, and I tried not to. But when two large bottles of brand name Diet Coke kept appearing for me every day, and when the resident was sent to buy me batteries for my personal pencil sharpener (with a grinder not a blade), just so I could continue to do my artwork and not rely on the staff to sharpen my pencils in the back, well, I knew 1) they were truly watching out for me and treating me with TLC, or what certainly felt like extraordinary care, and 2) they were in fact spending “extra” money, if not indeed their own money just to supply these special needs…All of which – or NONE of which would have mattered at any other hospital or to any other staff. If I had no pencil sharpener, who would care? If I had to eat hospital food, who gave a damn? Dr Banerjee basically said it was MY fault and only my fault if I gained weight on Zyprexa, that none of his other patients, the good ones, ever did. But at Yale, all these matters were important to me, and so they were important to Dr Milstein to to Chris Simpson the social worker and to the other team members. Not just as a matter of words, but to be taken care of so I could both take the Zyprexa and do art.
Just as important, Dr Milstein took at least a half hour every single day, and I think sometimes it was more than that, simply to talk with me and listen to what I had to say. Even if it was only to rant about how badly I had been treated at the IOL. He repeatedly told me that he just wanted me to learn to trust again, to believe that not everyone was against me or would hurt me…And if I did not learn that precisely, I did eventually come to believe that the staff at Yale were trustworthy and kind and meant what they said about their NO restraints and NO seclusion policy, for everyone. I may had still had frissons whenever someone screamed or threw a fit, panicking, believing that 4-point restraints were finally going to be resorted to. PTSD is not that easily overcome after all. But I grew more trusting, and by the time of discharge, I was able to thank them all for everything, to know that they had gone out of their way for me, and not feel too guilty.
I did a fair amount of art while I was at Yale Psychiatric Hospital. I will post more in the coming days.
To Kill or Not to Kill: Physician-Assisted Suicide?
My brother visited me recently and for some reason we got into a discussion about whether or not we supported physician-assisted suicide. We differed on the fundamentals: Phil, aka Chip, supports assisted suicide in every sense of the word. He thinks that it should be legal for a physician to prescribe a lethal medication essentially for anyone who asks.
This horrified me. Wait, he went on to explain. In his opinion, everyone should have to push a button upon waking in the morning in order to stay alive. If you failed to push it, you die. Meaning that the day would begin with everyone choosing to live, thus having to take responsibility for making that choice. We would start with the premise that every person who “wakes up alive” has chosen to live and cannot claim rightly to be suicidal…I guess that Chip as a psychiatrist, feels too many of his patients do not want to live, but also do not sincerely want to die, and he thinks that they need to acknowledge the latter. That might be good, but I also know that there are those who are so depressed that in their involuntarily mentally incapacitated state, they might not be able to press the “I want to live” button, and thus would die, even though in a healthier frame of mind, they would have chosen to live…
For me, I agree that when terminally ill, a person should have the right to end his or her life, and should be able to do so without interference from authority, legal or medical. I also think that in certain cases, palliative or hospice care helps with this, and already has done, silently and as it were secretly for years: the administration of a sedating dose of morphine when the time is right goes a long way towards assisting a person’s “dying process.” Not a lethal dose mind you, but a dose to “ease breathing” and one from which the physician and all witnesses understand the person will likely never awaken.
(My friend Joe is another case entirely. They turned off his ventilator and dosed him with morphine after 4 years with ALS. I firmly believe that they murdered Joe outright, against his will…But no more will be said of that at the present time.)
On the other hand, let’s face it, if you really want to commit suicide, it is easy to do so if you are able-bodied and not terminally ill: just jump in front of a bus, or out of a tall building’s window. There are a dozen sure-fire ways and they have been used for millennia as an easy way out. The problem is for those who are physically so debilitated that they literally cannot “jump” or swallow the pills or whatever. Yet unless they are forcibly nourished and hydrated through a feeding tube, they can always refuse food or liquid, which it seems is not agonizing after all. That is according to what recent research and personal witness (my own) have indicated. When my friend Lynn L died – essentially from not a refusal to take liquids– she did not suffer acutely from deprivation but seemed slowly to cross into a never-never land. She simply drifted off to an endless sleep and passed away.
The idea that a physician could freely prescribe an overdose of a lethal drug to any someone who came asking for it, that just strikes me as the height of 1) irresponsibility and 2) cruelty, by someone whose job, after all, is characterized by the Hippocratic Oath: primum non nocere or “First do no harm.” If killing a patient is not doing harm, then I do not know what is. I simply do not understand how bloodying one’s hands in the act of killing, no matter how good one’s intentions, cannot but badly affect any so-called healer.
Surely there are other ways to deal with a person’s pain and suffering than to throw up one’s hands and say, well, I cannot help you feel better or live longer, so I will simply shoot or poison or – whatever – you so you feel nothing and don’t have to deal any longer.This completely disregards the inherent value of the struggle itself, and the promise of something worthwhile, if only at the very end at the moment of dying, in having faced the suffering and undergone it fully.
Look, I do not like or want anyone to suffer agony in the last stages of life, and am all for morphine use, liberal or sparing, depending on the patient’s desires and needs. But there is no absolute value in complete suffering or pain relief, not in my book. For me, I insist that I must feel my own feelings, and in that quest, I must decide to feel the pain, emotional or otherwise, rather than dull it with drugs or anything else. Yes, it hurts, but the hurt somehow feels better because it is mine and real, and not the forced dull nothingness of being drugged out of it.
If you have other thoughts about this, do feel free to share them in the comments section. In the meantime, I found this article on the very same subject at Medscape Psychiatry. It was written by ethicist and psychiatrist, Ronald W. Pies, MD and may be found in its original form at this link:
http://www.medscape.com/viewarticle/771274
Medscape Psychiatry > Ethics in Psychiatry
Do We Need ‘Thanaticians’ for the Terminally Ill?
Ronald W. Pies, MD
Posted: 09/26/2012
The Ethical Dilemma of Physician-Assisted Suicide
My 89-year-old mother had been losing ground for some years, experiencing what geriatricians sometimes call “the dwindles.” Toward the end of her life, she was beset by a deteriorating heart; an inability to walk; and occasional, severe gastrointestinal pain. My family got her the best medical treatment available — eventually including home hospice care — and she generally maintained a positive attitude throughout her long downhill slide.
But one day, as I sat beside her bed, she seemed unusually subdued. “Honey,” she said, “How do I get out of this mess?” I had a pretty good idea of what she was really asking me, but I deflected her question with another question: “Ma, what ‘mess’ do you mean?” I asked. “It’s all right,” she replied, smiling sadly, “I’ll manage.”
My mother was doing what she had always done: sparing her children from pain. In this case, it was the pain of dealing with the waning days of her life and the frustration of knowing there was no easy escape from the burdens of dying slowly. “Ma, I’ll always make sure you are getting enough treatment for your pain,” I added, taking her hand — knowing that the prospect of unremitting pain is often an underlying fear of terminally ill persons.
Yet, unspoken in my mother’s question was the issue of so-called physician-assisted dying, sometimes called “physician-assisted suicide” — an enormously heated controversy both outside and within the medical profession. In my home state, Massachusetts, the issue has come to the fore, owing to a November ballot initiative for a measure that would allow terminally ill patients to be prescribed lethal drugs.[1] A closely related bill (H.3884) has also come before the Massachusetts Legislature’s Joint Committee on the Judiciary.
Similar to laws already on the books in Oregon and Washington state, the proposed Massachusetts law builds in numerous “safeguards”: For example, patients would be required to submit their request in writing twice, and those requests must be 15 days apart. As reported recently in the New York Times,[2] fears regarding widespread overuse or abuse of the so-called “death with dignity” laws in Oregon and Washington have largely failed to materialize, at least according to some studies.
Nevertheless, the Massachusetts Medical Society (MMS) has long been opposed to physician-assisted suicide. In March 2012, the MMS President, Dr. Lynda Young, testified before the Joint Committee[3] and did not mince her words. Allowing physicians to participate in assisted suicide, she stated, “…would cause more harm than good,” and she argued that “…physician-assisted suicide is fundamentally incompatible with the physician’s role as healer.” Instead, Dr. Young asserted, the physician’s role should be to ensure that the terminally ill patient “…continue[s] to receive emotional support, comfort care, adequate pain control, respect for patient autonomy, and good communication.”
With considerable ambivalence, I agree with Dr. Young. In my view, terminally ill but mentally competent patients should be at liberty not only to refuse further medical treatment, but also to end their own lives — for example, by refusing to accept liquid or solid food. Contrary to a widespread belief, voluntary refusal of food and fluids does not result in an agonizing or painful death, according to a2003 report in the New England Journal of Medicine.[4] Indeed, medical ethicist Dr. Cynthia Geppert informs me that voluntary refusal of food and drink is now considered an accepted approach to dying in palliative care.
As Dr. Thomas Szasz has argued in his book, Fatal Freedom: The Ethics and Politics of Suicide,[5] a liberty is not the same as a right, because the latter entails a reciprocal obligation on someone else’s part. (If I have a right to free speech, the state has a reciprocal obligation to protect that right.) Moreover, the liberty to commit suicide does not entail the “right” to have one’s physician prescribe a lethal dose of medication. Indeed, Dr. Szasz believes that “physician-assisted suicide” is really a euphemism for “medical killing” — more technically, “heterohomicide” on the part of the physician.
While I disagree with Dr. Szasz on many issues in psychiatry, I think his analysis here is essentially correct. Physician-actuated heterohomicide, in my view, is “fundamentally incompatible with the physician’s role as healer.” I believe that permitting physicians to write prescriptions for lethal drugs will eventually erode the trust that all patients should place in their physicians. More than a euphemism, “physician-assisted suicide” may be a contradiction in terms. And in my view, the very concept violates both the implicit ethical contract between physician and patient, and that between the physician and society.
To be clear: None of this means that physicians should collude in the cruel and unnecessary prolongation of dying, as is often seen in hospital settings. As physician and ethicist Dr. Fred Rosner has argued,[6] “To prolong life is a [commandment], to prolong dying is not.” Thus, in the Jewish medicoethical tradition, “removing impediments to death” is sometimes acceptable — that is, discontinuing treatments that needlessly prolong the dying of a suffering, terminally ill patient, but without actively bringing about the patient’s death. (The distinction between “letting” someone die and “making” someone die was supported in the 1997 US Supreme Court case of Vacco v Quill,[7]which upheld New York State’s ban on assisted suicide.)
But what about those suffering, terminally ill, mentally competent patients who will not choose to end their lives by refusing food and drink and instead seek out “assistance” from healthcare professionals? Again, I do not believe that medical professionals should participate in assisting a patient’s suicide. But I sometimes wonder whether society ought to permit somebody to do so.
For lack of a better term, let’s call such a hypothetical individual a “thanatician.” Let’s posit that carefully trained and closely monitored thanaticians would be permitted to provide medically screened, dying patients the same type of lethal medication now prescribed by physicians in Oregon and Washington — under essentially the same restrictions and safeguards.
But wait: Isn’t this proposal a cop-out? Doesn’t it merely place the moral issue of assisted suicide in the lap of the nonphysician, allowing the dying patient’s physician to shuffle off with a clear conscience? Even worse: Would the use of such death-dealing personnel amount to abandonment of the patient, as Dr. Geppert recently suggested to me?
Still other questions arise. As my colleague Dr. James L. Knoll has suggested, might not the training, monitoring, and supervising of thanaticians create more problems and headaches than it would solve? Finally, doesn’t the very notion of “thanaticians” suggest that we have lost faith in what Dr. Knoll rightly calls “the intensely personal journey” of doctor and patient?
I, too, struggle with these questions and find no easy answers. I suspect that at present, the best approach to the dying patient is through the skills of the palliative care physician. Palliative sedation, for many terminally ill patients, may be a viable alternative to managing suffering without ending life. Moreover, a careful psychiatric assessment of patients requesting physician-assisted death is always indicated, because major depression may distort the patient’s judgment as death approaches.
How we deal with terminally ill patients is a painful topic that I never discussed with my mother, who was fortunate enough to have excellent home hospice care in her final days. But I believe this is a discussion we urgently need to have.
Acknowledgment: I wish to thank Cynthia M.A. Geppert, MD, PhD, and James L. Knoll IV, MD, for their valuable comments on earlier drafts of this article. The views presented here, however, are solely my own.
WAGblog: Dum Spiro Spero 