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Introspections   |    
Lloyd Benjamin, M.D.
Am J Psychiatry 2007;164:868-869. doi:10.1176/appi.ajp.164.6.868
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Perhaps I was told about this in my geriatric psychiatry fellowship and simply wasn’t listening. But I honestly can’t think of a time that I ever heard or discussed the obvious concept that we not only work to promote patients’ health but will likely experience their decline, even their death. This particular day, it was as though it was only now dawning on me that our quest for patients’ improved health is at loggerheads with devolution. As clinicians, how truly emotionally prepared are we? Given that decline is so inherently a part of living and growing older, only sheer denial could have blinded me to it. But as in other instances, the blindfolds can be lifted by a patient, on this occasion, “Ms. E,” age 91, someone I had treated for a number of years, returning for follow-up.

She could not come in right away after her husband passed away from Alzheimer’s disease because she contracted pneumonia soon thereafter and was hospitalized for a few weeks. Her daughter tells me this when she calls to reschedule the appointment.

“Yes. It’s been quite an ordeal,” she says, sighing.

I extend my condolences.

“Thank you,” she says, and we reschedule her mother’s appointment. Since then, Ms. E has been moved out of her apartment to skilled nursing, and it’s unclear if she will ever return to assisted living.

When Ms. E arrives, she is quite bronchitic and walks slowly to the office, her daughter neatly folding her hands in her lap, nodding slightly and remaining in the waiting room. Yes, she says, her husband’s death has been a tremendous loss, although she also reasons that “He’s in a better place.” Nonetheless, she admits that his death hasn’t fully sunken in just yet, and she’s not sure how she’ll be when it does. While she is speaking, I also find myself reflecting on how I first came to meet her.

She was first hospitalized about 6 years previously due to being very depressed and paranoid. Her daughter soon gave a history of bipolar disorder, and after beginning to take medications, Ms. E eventually brightened and after a few weeks was able to return home. Over the years, she appeared to fare only so well, never again becoming psychotic, but her depression recurred several times. Her pulmonary status also worsened quite a bit, with a number of bouts of pneumonia, and her husband became demented. They eventually needed to move from their apartment to separate living: she to assisted living and he to skilled nursing. She would visit him each day but found his increasing volatility and amnesia quite distressing. Sometimes she considered that not visiting with him each day might make it feel less overwhelming, but then her guilt about not seeing him was equally painful. Because of a degree of vascular disease, Ms. E also became a small bit cognitively impaired, although never to the extent of not being able to care for herself.

On this visit, some years later, she appears much more frail, more kyphotic and weary. She slumps in her seat, tilting and resting her head in her left hand, mostly silent, and lost in a sad reverie. Sometimes she glances up when asked a question, speaking just slightly, and then fades back into a somber glance away, only her wheezing lingering. After some time, I invite her daughter back to meet with us and soon the daughter has slumped a bit in her seat, exuding the same melancholy as Ms. E herself. She starts to tear up and tells me of how worried the family was that Ms. E had just given up after her husband’s passing.

“Right, Mom?” she asks her mother.

“What?” says Ms. E uncertainly, raising her gaze again. “I couldn’t hear you.”

Ms. E is also hard of hearing. Her daughter speaks a bit more loudly, now sitting more forward on the couch, gently reaching to hold her mother’s hand.

“I told the doctor that we were worried about you, that maybe you were giving up. That we didn’t want you to give up.”

“No, no. I’m not giving up. I just don’t like it there. They don’t even help you,” says Ms. E with some irritation.

But then she drifts off again into thoughts that we cannot be privy to, gazing at the floor passively with a somber note, not so dissimilar from the time she was paranoid. Her daughter and I talk a bit more, and I also recommend increasing Ms. E’s antidepressant. When I look up from writing the prescription, her daughter is still leaning forward, softly rubbing her mother’s hand, carefully studying her face, and hoping that she will not disappear. “Please don’t leave me,” she seems to be saying.

After they have left, I notice that the label on her chart has fallen off, having lost its gumminess over the years. I try a few times to affix it back on, but it will not stay put. But I find the box of new labels and paste one on her chart and, like a determined first grader with a new box of crayons, slowly write her name on it. The label sticks this time, but I feel no more than small relief, only a sadness. Perhaps I will succeed in helping her over this depression as in the past, but it is clearer to me now that in my quest to help her acutely, it has been all too easy to overlook the necessary finality. We have certainly been working together, but we are also biding our time, waiting until the last stride of this mortal race is complete. Much like the label on her chart, Ms. E will fall away in time. I will have to watch, and I will also have to eventually let go. How ready will I be?

+Address correspondence and reprint requests to Dr. Benjamin, Department of Psychiatry, UCDMC, 2230 Stockton Blvd., Sacramento, CA 95817; lloben@earthlink.net (e-mail).




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