Suicide in Neurology

I heard about Dana Colby’s* death first thing Monday morning.  It was suicide, her friend Olive assured me when I spoke to her on the phone.  Olive had helped her plan it.  They had done a lot of research into the subject, looking up pills and other methods on websites devoted to the topic.

“It’s a lot harder than you’d think,” Olive told me.  “We asked some of her doctors about it, but all they’d say was that well, she could starve herself, or eventually she’d get an aspiration pneumonia and die that way.

  What kind of options are those?” 

Dana Colby began having trouble remembering things a couple of years ago.  She’d always been a very put-together kind of woman.  Not remembering to get everything on the grocery list would previously have been unimaginable.   

She was also an anxious person, who could be easily flustered.  The first time she came in for cognitive testing, she left shortly afterwards because she found the testing too stressful.   The tests did show cognitive difficulties, but it was unclear just how much of this trouble resulted from her panicking throughout the tests.  Such problems are sometimes referred to as "pseudo-dementia." 

When I sat with a team of neuropsychologists, nurses, students and a senior physician to discuss her case, we had a diagnostic dilemma that is not uncommon in our field of work—were Ms. Colby’s cognitive problems limiting her ability to go about her daily life?

  This is the thin and often blurry line between a dementia and mild cognitive impairment

She was certainly no longer driving—but she had voluntarily given that up due to her perception that she was starting to have more trouble.  She never had an accident, never had anyone else so much as make a negative comment about her ability to drive.

  She was also no longer doing finances, but again, this was based on her own concern.  So was she truly unable, or were these decisions just based on the hypervigilance of the anxious and perfectionistic?

The same could be said of a lot of the cognitive changes she’d experienced.  Sometimes people forget things, but then they get flustered about forgetting things, and so they forget more things, which makes them more anxious…  it’s the proverbial nasty spiral.  How much of Ms. Colby’s cognitive changes were due to anxiety, and how much were due to something else, like Alzheimer’s disease?

It didn’t help that Ms. Colby’s father had Alzheimer’s disease.  She had sworn, her friend told me, that she would never allow her children to watch her decline the way that she had watched her father.  I think that I had explained to her that most  Alzheimer’s isn’t inherited in the kind of fashion that worried her, but would she have heard me? 

Ms. Colby talked about her decision with her friend, who she had known since they were girls.

  She talked about her decision with her son and daughter.  They offered support.  It was her life, after all, and the decision not to live with something like Alzheimer’s seemed understandable enough.

“I think we’re going to see a lot of this,” Olive said,  “as our generation gets older.  We’ve all seen what happened to our parents.  Why can’t the medical establishment give us more options?”

Maybe that’s why Ms. Colby never told me her plans… I was part of the medical establishment, and would presumably have tried to stop her.  There’s something to that.  If I am told that a patient has active suicidal plans, and I let them go off and commit suicide, society can judge me as being partially responsible for that patient’s death.  I could face some severe consequences, with a lawsuit being just the beginning. 

But I also believe that it’s the patient’s life, and they should be able to do what they want.  I trained in Oregon, where (in very specified circumstances), physician assisted suicide is a viable option, something which I happen to agree with.  I wouldn’t pursue that route personally, I think, but I believe that it’s a right for those who want to do so. 

Still, Ms. Colby’s death felt a bit like a betrayal.  Being a physician has allowed me to hear some of the most intimate and personal parts of other people’s lives—maybe I fooled myself into thinking people were telling me everything, rather than the truth, which is that people come with agendas, with secrets—after all, they are people.  They have a right not to tell me things, even if they could have done so safely.  Ultimately, this decision wasn't about me.

Or was it?  People are also prone to mistakes.  Would Ms. Colby have made the decision to kill herself if she could have heard, even through the false certainties supported by her crippling anxiety, that maybe she didn’t have Alzheimer’s at all?  Would her friends have supported her if they knew she might be motivated by fear and fear itself? 

Those are hypotheticals.  In my heart, I really believe she did have the disease.  I can’t be absolutely sure—the brain never came to autopsy, and we never did lab tests that would have more conclusively shown evidence of Alzheimer’s. 

Even if Alzheimer’s was present, though, I’ve got mixed feelings about suicide in this disease.   I know plenty of people with Alzheimer’s, most, who still enjoy their life, and their loved ones enjoy being around them, despite the disease.  Getting a diagnosis of Alzheimer’s changed their life—it didn’t end it.  

That’s not to trivialize the terribleness of Alzheimer's disease.  I hate Alzheimer's disease and what it does to people, to the point that I dedicated my life to working to end it and its kind.  But fearing it to the extent of suicide feels like giving Alzheimer’s undue power, even while I know for some it’s the only way they feel they can keep that power and control for themselves.

If this was Alzheimer’s, did Ms. Colby’s death represent a kind of victory?  The ability to see to it that she died how she wanted, before the disease robbed her of her will and ability to do so?  I like to imagine there’s such a silver lining to this black cloud.  I’m not sure if I’m just imagining it or not.

*All names and potentially identifying information in this article have been changed to protect confidentiality of everyone involved. Quotations have been paraphrased.

Continue Reading