Did I help Bobby kill himself?

A patient's death taught this young doctor a valuable lesson about controlled substances.

By Jasmine D. Kelley-England, MD
Internist/Tucson

I walked warily down the hospital hallway towards the ICU. Only 18 months out of residency, and what was in store for me? Malpractice? Joblessness? Maybe jail?

My patient's family was waiting for me. Maybe their attorney and my medical director too? I feared that I'd soon face the wrath of the medical and legal communities, and I had little defense. Bobby Garrison was about to die, and I was responsible. (All names have been changed.)

The call had come late last night from the ICU nurse. "Mr. Garrison's family wants to see you."

Garrison had been at the clinic two days earlier. He'd been clean-shaven for the first time since we'd met. He had a wide smile and winked when I entered the room. "Hey doc!" he called cheerfully.

A scan of his chart showed chronic low back pain, and two lumbar laminectomies. He'd been taking pain meds for more years than I'd been an MD. That day his vitals had been normal; he'd come in only to refill a script. After the initial courtesies, Garrison's campaign for an increase in pain meds had begun.

"I'm in constant pain," he asserted, his cheerful demeanor suddenly lost in a spasm. "Them T3s ain't doin' a thing." Note to self: 90 pills a month for the past 10 months; never missed a refill; codeine on the last urine drug screen.

Buried somewhere beneath my sarcasm and disenchantment was a trace of my first-year med student compassion. Well, maybe he really is hurting. He's going to physical therapy, and the latest MRI showed degenerative changes. What did they teach us in residency? Always believe the patient?

"Let's switch you to something long-acting," I said, while writing a script for sustained-release oxycodone. "Thanks, doc," he answered. "Now what about them sleeping pills?"

Back to the present. I gulped another breath of hospital air and glanced at the room—a middle-aged man was standing at the bedside, and an older woman was seated, clutching her handbag and staring at the television. Lying in bed was my patient, motionless and intubated. He had a darkness around the eyes that shadowed his face and hinted at his prognosis.

I mustered up a bit of confidence and entered the room. "Dr. Kelley?" the man asked. He didn't look ready to strike, which was reassuring. "Lloyd Garrison," he said, extending his hand politely, "and this is my mother and Bobby's. She found him, you know, not breathing."

Rather than avoid the subject I was certain would end my career, I confronted it head on. "I'm so sorry, Mr. Garrison, Mrs. Garrison. This must be so difficult for you both. Well, it appears that he overdosed on medications I'd prescribed for his pain."

I paused to let that sink in before going on to "He may not make it." Lloyd shifted uneasily and began to shake his head slowly. Here it comes, I thought, the incontestable accusation of guilt.

"Bobby's been struggling for so long, doc, always looking for an out," Lloyd said. "We knew it might come to this eventually. He's been through bottles of pills before, but never this bad. He did it all—alcohol, drugs, you name it—especially since his divorce."

I glanced at their mother, who was nodding and crying, searching her handbag for a tissue. "I really wanted to talk to you about all this, Dr Kelley. Bobby here—he don't want none of this," he stammered. Lloyd clutched at the ventilator tubing and began to grow tearful himself. "We went through this with Dad not long ago." Handing him a box of tissues, I said, "He was so cheerful when I saw him two days ago. Have things been bothering him more than usual lately?"

"Bobby's not the type to come out and admit a problem like that," Lloyd said, "but since his divorce he ain't been doing nothin' but popping pills and sleeping all day."

"I'm so sorry. I had no idea," I said hurriedly.

"It's not your fault, doc," Lloyd cut me off. "It was Bobby's decision, you know. I know him too well." I nodded uncomfortably and we said our goodbyes. Orders were written. By morning Bobby was extubated, and by noon he was dead.

I never received the lashing I'd expected, and I've come to realize that Bobby had, on his own, made the fatal decision to take a month's worth of narcotics and sedatives in less than 24 hours. But could I have saved his life when I'd seen him last by asking a few simple questions? Should I have asked, "How've you been feeling lately—really?" and "Do you ever take these pills I give you not just for the pain, but to escape?" I might have also screened more carefully for alcohol dependence.

After that experience, I'm much more guarded about prescribing narcotics. I tell my patients why: I'm no pain expert, but I know that there is pain, and then there's pain. Fractures, cancer, recent surgery—there's no question that they call for treatment with narcotics. But a nagging backache? Not if it means sending a depressed man to self-treatment and certain death.

My new policy has led to battles in the clinic and I've probably lost a few patients to more indulgent physicians. But controlled substances must be controlled by someone, and that responsibility should fall upon the prescriber. We must do everything possible to ensure that at-risk patients are recognized, channeled to the proper behavioral help, and protected—from themselves.

 

Jasmine Kelley-England. Did I help Bobby kill himself?. Medical Economics 2002;17:79.