Dr Jill McIlraith
For a doctor, suicide of a patient interrupts the therapeutic relationship like no other death. There is no recovery, no chance to rescue the unique partnership of the doctor and that patient: only a cauldron of questions and emotions.
Doctors are used to death. Usually it is expected, slightly cushioned by its approach as part of a journey, sometimes taking years, with increasing frailty and senility or with bumps of chemotherapy or surgery along the way. Holding the patient’s hand on that road is what we do.
But sudden death catches us unawares, like an abrupt full stop. Fatal accidents are right up there in forcing doctors to confront the loss of a patient. But a patient taking their own life is the worst. It is often a pivotal moment for a doctor, churning up grief, anger, sadness and critical thoughts as we get caught by the same ripples that rock families, friends and workmates.
Between the extremes of regarding a suicide as the ultimate failure as a doctor or the ultimate autonomous decision for the patient, lies a spider web of emotions, events and reflections. There is none of the preparation, the advanced care planning so trendy now as part of the dying process. We don’t get to have any of the conversations about what the patient and their family would most cherish as death approaches, what their wishes are about the big and little things and about the nitty-gritty of life coming to its end.
Suicide stops all that.
It causes us as doctors to question our interactions with that patient and ask what we could have done differently. Had we missed something that could have changed events? Why we were not given the chance to help—and is it inappropriate that I should feel angry and deprived by such a lost opportunity? Or it that just hubris on my part? Am I wrong, or unprofessional, to be focused on my emotions and needs, when I should be thinking of what it was like for the patient in the days and hours leading to them taking their own life?
A doctor’s sense of purpose and value is based on the assumption that patients want to be well and that our role is to mitigate the distress and dis-ease that, although part of the human condition, detract from health and happiness. Life may not live up to expectations, it may be filled with harmful contradictions of unhealthy lifestyles and addictions, but as doctors our underlying principle is that it is precious. Life is worth living.
Suicide calls that basic assumption into question.
Recently a patient I had looked after for 20 years abruptly changed doctors and then days later triggered a series of events that led to her death. We had been through many ups and downs together and I thought she had found a measure of stability and happiness. On several occasions she had thanked me for being there for her and our last consultation, some months before, gave no hint of what was to come.
As I wrote a lengthy report for the coroner, I searched for explanations. Should her changing doctors have alerted me to her unraveling? Should I have phoned her when the transfer request arrived? (I didn’t; I was caught between wanting to know why and respecting her right to change doctors without having to justify it and possibly feel harassed.) I do not usually personalise it when patients change doctors, but this time my curiosity was mixed with a sense of rejection and I needed time to process my feelings. Events overtook those reflections and I was left dealing with the core conundrum: does respect for patient autonomy mean accepting that for some patients suicide may be a legitimate path? Was ending her life her right or my failure?
Dr Jill McIlraith: Jill McIlraith is a general practitioner who wanted to be policewoman or a vet, but who instead worked as journalist and then went to medical school as a mature student. Writing and animals continue to be a source of comfort and sanity.
Suicide Prevention Line 0508 TAUTOKO (0508 82 88 65)