She sat at the table’s head with eyes downcast and black brows furrowed. Her thin body wilted over her knees, her shins creating a shield to protect her vital organs. The corners of her lips sagged unnaturally – as if weights had hung from each end for many months, and now her muscles knew no reprieve. A kind of helpless innocence reflected in her face, yet the receding edge of her hairline and the dark shadows clouding her eyes aged her. It was hard for me to say whether she was 16 or 35. Either way, she had an inviting innocence about her, like that of a hatchling fallen from a nearby nest.
Dr. Lee, the attending physician, introduced each individual at the table: the patient’s father, the psychologist, the resident, myself, and Jenn. “We are all here to talk about what to do, Jenn,” Dr. Lee said. A few moments of silence passed.
“Well, I do have a solution,” Jenn said. “I want him to give me a pill so that I can kill myself if I need to,” nodding to her father across the table. Her father sat unmoved, like he had heard these words many times before. His tired eyes looked first to his daughter, then drifted to Dr. Lee across the table. I couldn’t tell whether he pled silently for help…or for permission.
“Why would we give you something that you could kill yourself with?” Dr. Lee asked.
Jenn fingered through her flowered green notebook, as if the pages had her answer.
“I wouldn’t kill myself. I just need it.” A childlike whine crept into her voice, the evidence of her innocent demeanor contrasting sharply with her bold request. “If you gave it to me,” she pled, “I wouldn’t have to suffer through these horrible thoughts of how I am going to kill myself. I would know I would have the pill if I needed to…” her face contorted and she retreated further into herself, flipping again through her notebook.
Jenn started again, hesitantly, as if admitting a great secret. “I think of all these horrible ways to die,” her voice cracked. “And it is torture. It’s like waiting in line to be burned alive. If you gave me a pill, I wouldn’t have to suffer with these thoughts.”
“You know we can’t do that,” Dr. Lee said.
“Well then, I want to die.”
Silence.
“I am wondering why you need us to give you a pill. You are very astute; I am sure you could find drugs on the street,” said Dr. Lee, challenging Jenn’s logic.
“It’s not that easy,” said Jenn.
Circular conversation continued as we discussed her problems with medication adherence, logistics for delaying her PhD program, and the possibility of starting electroconvulsive therapy (ECT). Through Dr. Lee’s masterful dance of strategic negotiation, a request for pills was tempered to a promise of cordless headphones. In exchange, the team got something we wanted: a signature from Jenn to rescind her 72-hour notice, which formally announced her intention to leave inpatient psychiatric treatment against medical advice, as well as a promise scrawled on scrap paper that she’d take her morning meds.
Up until then, I had always thought of depression as a chronic illness that many people lived with and died with, but never died from. It’s not that I was oblivious to the number of suicides happening each day; too often, I would wake up to read that another young person had taken their life. I would think about all the terrible happenings in someone’s life that led them to feel that suicide was the only option. And while I knew it was often a person’s circumstances in the context of depression that led to such devastating outcomes, I felt troubled by the thought that if only circumstances had been different, suicide could always be prevented.
At the end of the day, we arrived back to the workroom to finish notes. I opened Jenn’s chart, scrolling to the day’s assessment and plan. Italics jumped off the page—Major depressive disorder, severe (SAx3; Borderline Personality Disorder; Eating Disorder. She had trialed and failed every treatment for depression in the books: sampling SSRIs, dialectical behavioral therapy, cognitive therapy, second and third-line medications. She had been in and out of the hospital for suicide attempts and severe dips in her depression many times over the last fifteen years, and she now was on month four as an inpatient. Yet, somehow, in between these hospitalizations, she had managed to get her bachelor’s, then her master’s, hold a job in consulting, and now was deferring a PhD.
It was hard for me to imagine that the person curled up in the plastic chair pleading for death pills was this same accomplished woman. I felt medicine was failing her. She had tried the newest plan, ECT, before with temporary success—now it felt like her last hope.
As I left the unit at the end of the day, I passed Jenn in the hallway. She strode steadily with a determined step, wearing her new green headphones atop her head; she was looking dourly towards the floor as she powered up and down the straightaways of the E-shaped ward. I waited for the elevator to rise to Floor 8. “Caution: Patients at risk of elopement!” read the sign inside the elevator. I finally left the building, greeted by a sun that leveled the goosebumps on my arms. The chilled confinement of the psychiatric ward contrasted sharply with the warm, bustling streets. I hopped on my bike to head home.
After one week of ECT treatments, our team began to celebrate success behind closed doors. In ten years, Jenn had never made it this far in adhering to a treatment plan. I began noticing a change in her at our morning meetings. The darkness under her eyes had improved and her incessant fidgeting had quieted. I sensed hope within her for the first time. She would never admit to it, but I needed to believe, for myself, that this hope would soon take root in her mind.
The next day I was greeted by the resident as I stepped into the workroom. “Jenn didn’t go to ECT this morning,” the resident said with an intonation of defeat. “I don’t know what to do with her. She does this every time; it’s self-sabotage.” The resident’s frustration rallied in me a naive optimism. This treatment was her only hope. We called a team meeting.
“Well, we can’t keep her forever,” Dr. Lee said. “The truth is, she will probably kill herself one day.” The sac around my heart turned to lead, dropping into my gut like stone. It was true. Was it true?
I was warned once by a cancer surgeon that doctors should never consider themselves to be God-gifted Healers. “Doctors merely interfere in the patient’s own illness path; they do not determine it,” he said to me. From his perspective, if a patient got better, it was because of the patient, not the doctor. This mindset was critical for sustaining him through the deaths of many of his patients. To him, if a surgeon was a Healer, every patient’s death meant failure on the physician’s part. I took issue with his view. I worried such a mindset would distance the physician from being fully present with patients. It felt like ambivalence for the sake of self-protection. I reflected on my optimistic medical school admissions essay, “what greater gift than that of healing hands.” To heal others is why I came to medical school in the first place. Didn’t doctors do more than just interfere in a patient’s illness path?
The full meaning of his warning did not hit me until my experience with Jenn. Was I so naïve to think that after years of psychotherapy with Dr. Lee, my morning conversations with Jenn would result in her turnaround? And if so, was it my own God complex as healer that fed my optimism for her improvement? Or was it selfless hope for a young person to get better?
That day, we held another family meeting with Jenn, her father, and Dr. Lee. Behind the scenes, Dr. Lee and I talked through strategies of how we might keep her as an inpatient through one more week of ECT. We debated threatening to take away Jenn’s privilege of outpatient therapy with Dr. Lee. I pushed against this option, remembering a conversation where Jenn relayed to me her fears about being alone and unsupported after leaving the hospital.
Sitting around the table this time, Jenn looked different. She sat upright with her elbows on the counter and her eyes, though not making contact with anyone, resting firmly above shoulder height. Her green notebook sat closed, and she held her fingers interlaced quietly.
I opened the conversation to allow Jenn to share her thoughts and plan. The conversation quickly nosedived, with Jenn getting upset by the thought of staying inpatient any longer. I stopped. I waited until her gaze hit mine. “Jenn, I care about you,” I said. “We care about you. I am honestly scared that if you go home, you will hurt yourself. I see you doing better here.”
“I know.” Her body softened.
I never thought I’d see her leave the unit, but I did. It was not as joyous as it had been with other patients who had graduated back into free society from the ward. I felt more fear than optimism when Jenn left. I shook hands with Jenn before she left, a learned professional code in psychiatry, but I wanted to give her a hug.
My relationship with Jenn has made me grapple with the therapeutic role of hope in medicine. I was forced to acknowledge aloud for myself and for Jenn that thoughts of suicide would be there when she went home and may never go away. We brought into the open the unspoken fear: that once she left the safety chamber of the hospital, the possibility of death was real. Yet at the same time, my role as a care provider was to keep alive the possibility of hope in a path towards healing. When I met Jenn, she had refused all possibilities of hope, asking for a pill to end her life. However, I kept my eyes open to signs of growing hope deep within her. Importantly too, I never lost hope for her recovery or in my ability to impact her life in some positive way. My time with Jenn taught me that finding this hope is critical not only for fostering the possibility of healing for the patient, but also for sustaining a physician’s empathy.
I did not have the ability to cure Jenn of depression. Physicians cannot always stop a cancer from returning. Suicide is sometimes an unpredictable consequence of mental illness. These truths are hard to stare in the face, yet denying them—as the cancer doctor warned—is to toy with a dangerous God complex. What sustains me, however, is not this bleak acknowledgement of my limitations, but rather, a recognition that healing can happen without a cure. Physicians have the ability to keep lit a hopeful path for patients when they are too overwhelmed by darkness to remember that it’s there. In helping patients see paths of hope, and in walking alongside them as they travel into an unknowing future, no ending is a failure and no therapeutic relationship is without meaning.
Alexis Chaet-Lopez is a fourth year medical student at the University of Pennsylvania. In order to protect patient anonymity, all names in this story have been changed.
