An internist will never forget the dark secret his patient revealed during a routine visit — or the grim aftermath.
The patient, who had a progressive, incurable neurological condition, confided that he planned to kill himself. The patient intended to conceal the true manner and make the death look natural.
"[He planned to do it] very carefully at home so no one would know," said the internist, who remains anonymous. "[He shared] the methods he would use."
Perhaps more shocking than the patient's confession was the physician's response.
"He did not require my help to do what he planned, and I did not try to stop him," said the internist. "I reported his death as 'natural causes' and never told anyone."
The account comes from a response to Medscape's 2020 Ethics Report in which physicians were asked about their toughest ethical dilemma. Many physicians shared secrets and dilemmas that have haunted them for years. An ob/gyn for instance, wrote about struggling with whether to tell a father that his newborn baby was not his genetic child. The newborn had a blood type that made it impossible for the father to be biologically related to the infant, the anonymous doctor wrote.
"I told the wife who then informed me she had a lover," the ob-gyn said. "I never told the husband."
It's uncertain whether carrying the burden of such hidden knowledge affected the physicians involved in these cases. However, in general, secrets can weigh heavily on the minds of those who keep them and contribute to stress, said Malia Mason, PhD, a psychologist and Dean of Research at Columbia Business School in New York City. Holding onto secrets can cause depression and anxiety, research shows. The more often people think about the secret, the greater the impact, according to a recent study co-authored by Mason.
"Keeping a secret diminishes well-being," Mason said. "It makes people feel socially distant. It lowers relationship satisfaction, and it leads people to feel inauthentic. The reason that secrets do this is because people think about them all the time. The more you think about it, the more you see these consequences."
Feelings that stem from a secret depend on the content. The more immoral a secret is thought to be, the more people feel ashamed, according to a 2021 analysis of thousands of secrets by Michael L. Slepian, PhD, and Alex Koch, PhD. However, secrets more related to a person's profession are often internalized differently, the study found. The more a secret fell higher on the profession/goal-oriented dimension, the more people felt they had insight into their secret, according to the analysis. For example, having clear thinking about the secret and/or knowing how to handle it.
"The more shame participants felt from their secret, the more they indicated the secret hurt their well-being," Slepian and Koch write in the study. "The more insight participants felt they had into their secret, the less they indicated the secret hurt their well-being."
Suspicious Deaths Exposed After Investigations
The internist's account of keeping his patient's suicide a secret raises many questions, such as how the patient masked his manner of death. The internist did not share any more details about the incident.
Suicides are among the most challenging manners of deaths to certify, says James Gill, MD, a pathologist and President of the National Association of Medical Examiners. Death investigators must demonstrate intent, meaning the person caused the injury to intentionally harm themselves. Fewer than half of people who die by suicide leave a note, Gill said, so investigators can't rely on the absence or the presence of a note in making their determination.
A decedent who had cancer or a severe neurological disorder presents further challenges, said Gill, who serves as chief medical examiner for the state of Connecticut.
"These [deaths] may not be unexpected and may not be reported to the medical examiner/coroner," Gill said. "If there is no suspicion and the treating doctor is willing to sign the death certificate, the death will not come under the jurisdiction of the medical examiner."
Gill recalled a death his colleague once investigated that appeared to be natural but emerged as something else after a deeper look.
A woman with metastatic breast cancer was about to be discharged from a hospital into hospice the next morning. The night before, she had a "going away" party with friends who came to visit her in the hospital. Shortly after the friends left, the woman was found dead. Because of her condition, she could have died at any time, Gill said, but she also had a history of depression and hospital staff were suspicious. The death was reported to the medical examiner's office.
Toxicology testing found markedly elevated concentrations of phenytoin and pentobarbital, neither of which were prescribed during her hospital stay. Gill said it turned out that the woman and her friends worked at a veterinarian's office, and the medication they used to euthanize dogs was a combination of phenytoin and pentobarbital.
"The death was certified as a homicide because of the direct actions of another, but a reasonable argument could be made for suicide," Gill said.
In a similar case reported by the journal Science & Justice, a 64-year-old cardiologist was found lifeless by his wife after he collapsed near the stairs of his home. Next to his body, was a bottle of whiskey and two cups, one that appeared to be used for the alcohol and one with a yellowish liquid smelling of honey. The wife reported her husband always drank whiskey with honey before bed. The death was initially classified as natural, but after vehement protest by the family, a forensic autopsy was performed.
Prior to the autopsy, death investigators learned the decedent, who was a well-known and successful practitioner in his community, had Parkinson's disease. At times, he could not sign his prescriptions because of the increasing tremor in his hands, according to the case study. Investigators learned the patient's mother had also suffered from Parkinson's, and that her son had witnessed her decline.
The autopsy revealed only nonspecific lesions such as acute stasis of the viscera, moderate pulmonary and cerebral edema, and moderate generalized atheromatosis. Histological examinations did not yield any unusual findings.
An analysis of the beverage containers detected pentobarbital in the yellowish syrup residue of the second cup. Testing of the doctor's peripheral blood revealed the presence of a metabolite of pentobarbital, ethanol, and traces of phenobarbital. In addition, a urine analysis showed the presence of venlafaxine, an antidepressant, as well as the benzophenone of lorazepam, a sedating benzodiazepine, and metoclopramide, an antiemetic.
Lead author C. Brandt-Casadevall, MD, and colleagues write that the levels were clearly compatible with a scenario of a pentobarbital overdose with a lethal outcome.
"…It is obvious that the victim attempted to hide his suicide from his family circle," Brandt-Casadevall and colleagues write. "Thus, we obtained no evidence indicating that he might have spoken at any point of putting an end to his life. There was no written note. The victim did not wait to be alone at home. Instead, he committed his act in a routine situation: his wife was watching television late at night and he was upstairs, presumably going to sleep. Thus, he had one to two hours at his disposal, and he ingested a very fast-acting drug which would make any attempt at reanimation impossible, even after a brief period of time. This may have induced the physician in charge to believe that the cause of death was cardiac origin, a likely hypothesis given the age of the victim."
What to Do When a Terminally Ill Patient Talks Suicide
When a terminally ill patient expresses the desire to end his or her life, it's important to understand that desire is often a result of existential suffering, a sense of hopelessness, and lack of social support, says Lynn A. Jansen, PhD, a bioethicist at the University of Arizona in Tucson.
"The duty of beneficence requires that physicians attempt to provide the support and care that is needed," said Jansen. "Here, interdisciplinary teamwork is important and should be utilized. Physicians should refer patients to professionals, such as social workers, pastoral care, psychologists, etc., who are better able to address these issues."
The rate of desire for a hastened death among terminally ill patients ranges from 17% to 45%, depending on the population studied and how the desire is evaluated, according to an analysis in the Primary Care Companion to the Journal of Clinical Psychiatry. In one study, 14% of about 130 palliative care patients with cancer had a strong desire to quicken the dying process.
In addition, patients with neurologic disorders have a significantly higher suicide rate than those without neurologic disorders, a recent JAMA study found. About 1 in 150 patients diagnosed with a neurological disorder dies by suicide, the analysis determined.
A tricky point to remember is that a desire by a terminally ill patient to hasten his or her death by suicide should not be taken by itself to indicate depression, Jansen noted.
"In principle, such patients can make an autonomous decision to end their lives," she said. "However, the expression of such a desire is very often associated with depression and forms of suffering that can be effectively addressed by the healthcare team."
Physicians can also explore other avenues with the patient such as palliative care or making sure adequate pain relief is available, adds Robert Klitzman, MD, a professor of psychiatry and academic director of the Master of Science in Bioethics program at Columbia University, New York City.
"If they are saying it's because they are distressed, ethically, a doctor can and should find ways to decrease their distress," he said.
Of course, physicians who practice in the nine states (and Washington, DC) that have physician-assisted dying laws have different legal and ethical elements to consider. Physicians in these areas have no ethical duty to participate in the process, Jansen said, but they have a duty to refer patients who express a desire to pursue physician aid-in-dying to another provider who can assist them.
Physician aid-in-dying laws vary somewhat so it's important that physicians in these areas be aware of their specific statute, Klitzman said. States that currently have these laws are California, Colorado, Hawaii, Maine, New Jersey, New Mexico, Oregon, Vermont, Washington, and the District of Columbia.
"In these states, if a terminally ill patient says they don't want to live anymore, a physician would first decide if this is a result of depression or if it's a request for physician aid-in-dying," he said. "Even then, in most cases, the patient would be evaluated by not one, but two different health professionals at two different points. We want to see if it is a consistent decision that the person has made that they want physician aid-in-dying, and not just that they've had a bad day or a setback in their treatment."
In the case of the internist who told no one of his patient's suicide plan, Klitzman said he would have dug deeper into the patient's mindset.
"Not knowing anything about the patient or the doctor, I would have responded differently," he said. "I think a physician should address why a patient feels that way. They may feel their pain is unbearable, and we potentially offer more pain relief. Maybe the patient shows evidence of having depression, which may be treatable [with medication]. The patient would then feel better and be able to spend quality time with family and loved ones, make sure their affairs are in order, and have a chance to say goodbye."
Have a tough ethical dilemma you would like to share? Email Medscape reporter Alicia Gallegos at firstname.lastname@example.org.
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Cite this: The Secret I'll Take to My Grave: Doc Reveals - Medscape - Aug 25, 2021.