Terminal Optimism, Terminal Hope

It was only a few months before I read “Life Sentence” (1) that I found out about “Ellen’s” death. It was a coincidence, when following up on another patient at a residential facility, that I learned she had committed suicide. I was aghast; I immediately pulled her chart and called her mother. Ellen had jumped off the top of a parking garage at a prominent hospital in her community. Probably emaciated and hearing voices, she succumbed to her terminal illness. I did not understand how this, her suicide, was possible.

Upon further reflection, I understood that my somber amazement came as an outgrowth of unyielding optimism and hope for this patient’s future. Although I had not treated her in many years, I had treated her for several years in the past. Although I completely understood the severity, gravity, and prognosis of her illnesses, I remained ever hopeful—a new antipsychotic; a new combination of antipsychotic, antidepressant, and mood stabilizer; maybe add a benzodiazepine; another residential program more well versed with difficult patients; a different day program better equipped to manage severely and chronically ill, but highly intelligent, patients; and finally, a different psychiatrist, better equipped pharmacologically and psychotherapeutically.

I now realize this was almost delusional—denial in its most appropriate use, at least a fantasy, a rescue fantasy? Without doubt, but I came to realize that perhaps I had been a victim of my own optimism and hopefulness about the ability of a psychiatrist to ease the ills of a psychiatric patient. Within psychiatric discussions, suicide is mentioned in the context of prognosis and morbidity and mortality. It is not discussed in the context of a medically defined terminal illness, like cancer, for which there are lab tests, a multitude of scans, multiple regimens of chemotherapy, possible surgery, radiation of all types, and well-known patient survival rates at 5 and 10 years out. There are no stages of acceptance, no pain management, no hospice.

In psychiatry we face terminal illness, almost without knowing it. We acknowledge it, perhaps use the defense of denial or fantasy. In my case, terminal optimism; my inability to accept that nothing else can be done would be my inclination with oncological illness, even more so with psychiatric illness, for which there are few statistics, predictors (except the usual risk factors that are present in all too many patients), and long-term outcome studies. We are at an extreme disadvantage, a colossal and unfathomable stacking of the odds. We face terminal illness and may not even know it, or we face terminal illness and convince ourselves that it is not terminal, that an optimistic outlook, full of hope, with appropriate state-of-the-art treatment will overcome the odds. Alas, although we know the predictors, risk factors, and some statistics about outcome, we, at least I, never think it will happen. Oncologists are not this naive; they know the endpoint of malignant illness. We do not even know when the malignancy will strike; at what point does a psychiatric illness become malignant, at what point does the confluence of illness, severity, and circumstance change illness from chronic to lethal?

I hope that I do not lose my “terminal” optimism and hope for successful treatment of severely ill patients. However, the cold reality of death has withered my sails a bit. The seascape is rough watered when it appears calm, the sky is blue with dark clouds on the horizon. I now understand that it is imperative to acknowledge terminal psychiatric illness despite optimism for its amelioration and cure.