Lessons from Randy-How to deal with regret

On his most recent visit he was quite cheerful, sporting that wry smile of his that had been absent on many of his previous visits. He said he was doing quite well and even made a couple of jokes. But he quickly added "under the circumstances," in which he alluded to the many burdens that he was saddled with, including heart disease, disabling back pain, anxiety, the loss of his beloved dog, financial troubles, and a rocky marriage.

His two most pressing concerns on this day were his medical bills-to the tune of $800 per month, even with insurance-and his chronic pain. He was always honest and upfront, and always very respectful. In short, he was a nice guy who was down on his luck. His health challenges were many.

MEDICATIONS WERE HELPING

He was on an antidepressant, and also used lorazepam for his panic attacks, which were coming more frequently. What started as 20 pills to last a few months soon grew into a pill a day, then 2 a day, and most recently, 3 a day. I closely monitored him, bringing him back every month to check his progress. I was indeed encouraged. Much as I disliked the idea of him being on lorazepam, he wasn't experiencing side effects, and clearly it was helping him get through his otherwise miserable life. And that was why he kept returning, to get a little pep talk and a medication renewal.

Randy was also seeing a pain specialist for his chronic back pain, but he didn't like him at all. At one point, he complained, "He's not a nice person. He doesn't listen to me-just renews my medication and won't consider other options, says it's 'my way or the highway.' " He had run the gamut of medications, from entry-level narcotics all the way up the food chain. I gave him names of other specialists, but Randy dragged his feet. At each visit, he off-handedly asked if I could prescribe his pain medications, but I stood my ground, stating that I was not a pain specialist.

A couple of days after last week's visit, I noticed he was already back on my schedule. Then he was off the schedule, then back on, and I wondered what it was he wanted. He never showed up for his appointment.

A few days later, a tap on my exam room door heralded the distressing news. Randy had committed suicide. His daughter's voice quavered on the phone as she told me how she and her brother had found him in the bathroom, the victim of a gunshot wound.

Having been touched by the specter of suicide 3 times in my own family, I was particularly sensitive to its stigma. I didn't have much in the way of comfort to offer her, just an understanding voice across the phone lines that I knew would be far too inadequate to salve her misery.

As I hung up the phone, I sat there a moment, collecting my thoughts. Images of Randy at his many visits hurtled at me faster than I could analyze them, seeking clues that he was desperate enough to take this drastic final step. But I saw no clues, just a broken man. Sometimes, he would just stare at the floor and list his troubles in a dull monotone.

On our visits together, I always tried to offer encouragement. I often became frustrated with him because he was loath to follow up on my suggestions to find a new pain specialist, one with whom he could connect a little better. At times, I sat and listened as he reminisced about happier moments in his life. I even prayed with him, and he was genuinely thankful for this gesture of intimacy and concern.