A Medical Economics Web Exclusive

One patient died. The other still wants to

A "routine" house call turned into a potential crime scene involving one of medicine’s thorniest ethical issues.

By David E. Hyde, MD
Family Practitioner/Yellow Springs, OH

My on-call weekend three years ago had been quiet until I received a page. It was Joyce, a home health nurse, calling from the Carpenters’ home (I’m not using real names). Elise Carpenter had passed away. Could I come to the house right away?

Elise and her husband Jack, both in their 80s, had been pillars of our community for decades. Almost everyone in our town of 4,000 knew them. It was sundown as I drove out to their home in the country. I pulled into the Carpenters’ driveway and was greeted by Joyce, the Carpenters’ two grown sons, their wives, a home health aide, and a groundskeeper. They thanked me for coming on a Saturday night and escorted me to the bedroom.

I quickly realized that I had not been told the whole story. Elise was sitting in a chair in the middle of the room. She was dead. A few feet away, her husband Jack lay quietly in the master bed. He was alive, but in a coma.

Then Joyce and the others explained what had happened. The Carpenters both had Parkinson’s disease and hated how dependent they’d become. For almost a year, they’d talked of taking their own lives. I never knew they’d expressed such ideas, but their sons and daughters-in-law did. They also knew that Jack and Elise intended to commit suicide that day, although they never explained to me exactly how they knew that.

That morning, Jack and Elise placed a large carbon dioxide canister in the middle of their bedroom, fixed plastic snorkels to it, and placed the opposite ends into their mouths. They pushed two chairs together and sat. A plastic garbage bag went over both their heads. Then they waited. It’s hard to imagine what was going through their minds at that time.

Their family and the other members of the household spent their Saturday at a neighbor’s house. I suspect they didn’t want to know too much. They explained to me that they didn’t want to participate. But out of respect for their parents’ wishes, they didn’t want to interfere either.

After deciding that a reasonable amount of time had passed, the family and aides returned to the house. They found that Elise had succeeded in her suicide attempt. Jack had not. They left Elise in the chair, and placed a comatose Jack into the bed. They cleared away the instruments of death. Then they called me.

"I cannot sign the death certificate in this situation," I told them. "We have to call the coroner."

Joyce dialed 911 and explained the situation. Soon after, police cars filled the driveway. Sheriff’s deputies placed yellow crime-scene tape all around the house, and announced that none of us could leave. Consternation mounted in the faces of everyone there. For a moment, I wondered whether I’d receive the family’s wrath for bringing this upon them, but nobody seemed to be thinking in those terms.

The deputy sheriff in charge had all of us gather in one room. He explained that the house was a possible crime scene. We’d each be asked to provide a statement, and could call our lawyers if we wished. No one wanted to do that.

The last person to enter the room was coroner Bill Rivers, a young man only a few years out of family practice residency. He urged us to send Jack to the emergency department. The family objected, since it would clearly violate Jack’s wishes. At this point, I wasn’t really sure what the appropriate course was. I had never encountered a situation anything like this.

The coroner persisted. Jack needed medical attention, he told us, noting that each of us was now potentially culpable if Jack should die. The family relented, and an ambulance took Jack to the hospital.

Now the burden of Jack’s disposition shifted to Pete, the emergency physician, who consulted the deputy prosecutor. He echoed the coroner’s admonition that we must give Jack every chance of recovery. Jack was admitted to my service.

He survived the ordeal with no sign of injury, hypoxic or otherwise. Within two days, he was back to normal. Then I had to decide where he would go upon discharge. I requested a psychological consultation. This revealed that Jack was neither psychotic nor incompetent. At the same time, he still wanted to die and could argue the point persuasively.

I was still at an impasse. What would happen if I sent him home, and to what extent would I be responsible? Was it even possible or legal for me to keep him from going home? I requested a meeting of the hospital’s ethics committee.

Someone on the committee suggested that Jack spend some time on the rehabilitation unit. He was already at risk for falls due to his Parkinson’s, quite apart from any self-destructive tendencies. It proved to be a great idea. Jack accepted it, and in the days that followed, he stopped talking about suicide. The psychologists and I concluded that Jack might be less of a suicide risk, since the suicide idea was originally Elise’s.

Jack returned home. But he refused to slow down to accommodate the Parkinson’s, despite his stay on the rehabilitation unit. To this day, he still refuses to. For a time, he experienced frequent falls, followed by trips to the emergency department, where his scalp was sutured. Ultimately his sons arranged for nursing home placement. He continued to fall and cut his scalp. It happened often enough that my partner and I would suture him right in his nursing home bed rather than send him to the emergency department.

The prosecutor deliberated for months before deciding not to file any charges in Elise’s death.

Now Jack has become sedentary enough that he rarely falls. He recently said to me, "You know my medical condition pretty well. How am I likely to die?"

We talked about various possibilities. "How can I speed up the process?" he asked.

Jack hadn’t lost his ability to catch me off guard. He also hadn’t lost his ability to force me to examine important issues in life. After further discussion, I said that whatever happens, I didn’t want him to repeat the events of three years ago. Although he remembered that adventure, he was quite surprised when I told him how much trouble it had caused everyone involved.

Either it didn’t impress him at the time, or he forgot.

I’ll never forget.

David Hyde. One patient died. The other still wants to.

Medical Economics

2001;5.