Treatment Failure; The Thin Man update

The Thin Man.

I am terribly sad about this....I learned at work a few weeks back that the medical examiners office (from a state about 12 hours drive from us) called one of our social workers, then spoke with the MD.  My wonderful, brilliant, humorous and handsome patient is dead.  I try really hard not to cry at work, but when I got in my car, I cried. 
In my line of work, what happened to him is referred to as  "Folie a deux", and it's pretty rare. In other words, he and his wife shared their insanity.  To illustrate: she ONLY came to see him on day of discharge to pick him up, and even then brought a VERY well know PhD and friend with her. She was afraid we would lock her up, she didn't know "the rules" of what you must say to get admitted to a psych hospital. He had prevented her admission to our hospital years before, with a convincing argument with the ER doc.
But, here's the word on the unit about it......she drove him to a hospital. She went into the ER and said her husband was in the car, and not well. No doubt the ER nurses and techs ran out to the car....and found a very dead man. In fact the ME reports he had probably been dead between 8-12 hours. Probably from starvation and dehydration.  This is a very painful way to die. There was no need for this to happen. This is what we call "total treatment failure". In psych, we don't normally have a lot of deaths. Yes, an occasional suicide, or sometimes even natural causes. But this????  It breaks my heart.
His siblings from around the globe actually called us, when they couldn't get him on the phone. Not the police, not his internist, and of course they had already spoken with his wife....who wouldn't ever put him on the phone. His social worker did call the police, who did do a "safety check".  That means they forced his wife to have him to come to the door so they could see he was there and alive.
His wife failed him.
His sisters and brothers failed him.
His friends failed him.
Our society failed him.
His world failed him.
I failed him.
I have always thought we should have a mechanism in place to "follow up" with our patients. I always write our phone number on the discharge instructions and say "please call if you have any questions, ask for me, I'll try to address your concerns, because it's so much easier than an ER visit".  Many patients have indeed called. I think we should make that phone call. But I have never pushed for this to happen.
Say a prayer tonight for "The Thin Man".
While your at it, say one for me. 

The Thin Man

It's rare after so many years of doing the same thing to stumble upon something new....well, not new, but a new version.
What do you do with a 50 something year old man, who is quite tall, maybe 6'3".....and weighs........128 lbs????  Not kiddin you! And that was with his clothes on...so maybe closer to the 124 mark.  He does not have anorexia, which is usually the only time you see someone this cachectic in psych. As a matter of fact, in moments of "awakening" he is a delightful man, funny, warm, brilliant.....and starving to death.  How it got this far is almost beyond me. But not quite, you see his wife will not come visit him, nor will she call the staff to see how he's doing. She's apparently afraid we'll keep her, obviously unaware of our "one family member at a time" policy. 
During his moments of lucid thought (he had one entire day over the weekend) he has tried to eat whatever is not nailed down. I had to stop him. Re-feeding a starving body has its own unique set of complications.

We do get calls from his siblings around the globe telling us what to do and not to do. I didn't have the heart, even after the 25th phone call to tell sis, 1). We are not new at this. 2). Have you SEEN your brother lately?  He wouldn't let me take a picture, but let me tell you, some of the survivors of Dachau looked healthier! I think the "standing by and watching someone die" was already covered by his wife, so we've crossed that treatment approach off our to do list.

I have twice had the pleasure of  bathing the Thin Man, so I've seen his body up close and personal. 2 amazing things. 1). His skin is (so far) intact. Kinda odd considering his nutritional status in not "up to par", and his bones stick out way farther than any other tissue. 2).  You could easily teach an anatomy class with this guy as a living example/skeleton. You can count each bone all 206 of them.

So exactly what is the matter with this man, you may ask? Here's my 25 cent diagnosis: he has a major depression, with psychotic features.  He has delusions (here we go again) vs. hallucinations. He chose not to (or could not) get help or have his depression treated, so typical of men! It progressed along it's merry way and invited some psychotic thinking to join in.  Fortunately his last healthy neuropathway was lonely and picked up the phone to schedule a check up with his internist (who, btw has called 3 times a week to see how he's doing), who booted his butt (gently, hence the still intact skin) into an ambulance and off to the hospital.

I like this guy. I wish I could tell you more about him....he has had a fascinating life so far.....but seriously, all that HIPPA stuff is real, and was around YEARS before the stupid HIPPA laws, which really have nothing to do with privacy BTW.  That's another soapbox story.