Hiding behind ‘free will’

THE PHONE RANG at 3 a.m. “Dr. Partovi,” the person on the line said, “I’m calling to let you know that William expired this morning.”

I’d first met William about six months earlier in May 2006 at the Venice Family Clinic after his release from a hospital where he was treated for congestive heart failure. I still remember his loud, childlike voice: “No, no ... I’m not going to the hospital!” he shrieked when I told him that I wanted to refer him to Harbor-UCLA’s cardiology clinic.

William -- I’m calling him that because medical privacy rules don’t allow me to use his real name -- was 61. Six feet tall with gray hair, he dressed in T-shirts and pants that were a little too big. He lived alone in an apartment in Brentwood and had a sister in Canada and a niece in New Jersey.

Three years earlier, he’d had a heart attack and a stroke, and he now suffered from dementia, likely as a result of the stroke. It was quickly obvious to me that William could not take care of himself anymore. He spoke like a whining toddler. He was very stubborn, and his judgment was extremely limited. “My memory’s not good,” he’d huff if he couldn’t answer a question.

But one’s inability to care for oneself is not a criterion to receive involuntary treatment for the mentally impaired. And for many mentally impaired people without family nearby to rely on for housing, food and help in managing their medical care, the result can be disastrous.

A recent study of adults with serious mental illness who were treated in eight states’ public hospitals and clinics found that they died, on average, at age 51 -- 25 years younger than the average American. The study’s lead author, Dr. Joseph Parks, director of psychiatric services for the Missouri Department of Mental Health, said that about three out of five died of preventable diseases.

William’s heart failure was very treatable, but only if he would take his medications appropriately.

I continued to see him every two weeks or so at the clinic. At first he was brought by a female friend, and then after she disappeared, by a new friend, Mike. Mike kindly made sure that William had food, checked that his bills were in order and put his medication into daily pill boxes. When, after a few months, Mike confessed that he’d met William only recently when buying one of his boats and couldn’t continue to be this involved, I understood.

I asked one of the clinic’s volunteer psychiatrists to see William, and she chatted with him for a bit during his regular clinic appointment with me.

Though he seemed to like her, he would never go to her office at the Edelman Westside Mental Health Center, a county clinic, and neither of us could make him go. I also called the county office that handles elder services -- which investigates impaired adults to learn whether they suffer from abuse, isolation or neglect -- but he kicked the social workers out. “He’s got a personality problem,” one of the social workers said to me afterward. “We can’t help him.”

William’s health deteriorated, and he landed in the emergency room with abdominal pain -- most likely angina related to his heart failure. I asked for a psychiatric consultation; if William were deemed incapable of making his own decisions, we could try to get him placed in a long-term care facility.

But the hospital psychiatrist claimed that William knew his name and where he lived -- and that he was very insistent on not being placed.

“But he can’t take care of himself, he doesn’t have food, he can’t pay his bills, he won’t take his medications,” I replied.

“It’s his free will to not take his medications.” Thus, he was deemed “fully competent.”

A woman who’d been assigned by the hospital to sit with William in his room took it upon herself to become his home health caretaker after he was released. She cleaned his apartment -- which she described as unlivably filthy -- washed his clothes, stocked the fridge. But it lasted only three days. He became so verbally abusive that she left.

Mike called a few days after that. He’d found William naked on the couch, claiming that he couldn’t find anything to wear.

I thought that he should go to Harbor-UCLA Medical Center, where I could try to get another psychiatric consultation. Mike agreed to take him, but William refused to go.

He’d still come to his now-weekly appointments at the clinic, but he stopped taking the drugs that controlled his blood pressure, cholesterol, fluid levels and agitation. He would only say, “I promise, Dr. Partovi, I’m going to do better,” like a 3-year-old promising not to hit his sister.

The next phone call came from his landlord. “William looks very sick,” she said, “but he won’t go to the hospital.”

When I called to check on William, he sounded breathless. Yet, when I mentioned the hospital, he slammed down the phone.

I called the county’s psychiatric emergency team but was told that its members couldn’t force themselves into someone’s house, and I knew William wouldn’t let them in voluntarily. The unit recommended asking the police to do a courtesy check. But the police said they weren’t allowed to force entry either.

William had gained more than 50 pounds in fluid. I begged him to go to the hospital, but he vehemently refused.

“Do you want to die?” I asked, exasperated.

“No, no, I don’t want to die,” he’d squeal in his childish voice. But he couldn’t understand that he was killing himself.

The next Monday, he came to the clinic, complaining of chest pain. The attending physician called the paramedics to take him to the hospital. He again refused to go.

“Do you know your name?” one paramedic asked. “Do you know where you are?” These are the standard questions non-psychiatrists ask to assess one’s mental state.

“The Venice Family Clinic,” William said, sing-songy.

“He’s competent,” the paramedic said. “We can’t take him if he refuses.”

A few days later, I got a call from William’s new roommate, John. He was in a panic: “Dr. Partovi, William looks horrible. He can’t get off the couch, and he’s hallucinating. He’s barely breathing!”

“Call 911,” I told him. I could hear his hesitancy in the silence. “He’s going to die on your couch if you don’t.”

John called 911, and paramedics took William to the emergency room.

“We’ll get him tuned up,” the ER physician assured me. I could hear William’s boyish cries in the background, “No, no, no!”

That night I got my last call about William. The one that came at 3 a.m.

Since the deinstitutionalization of the 1980s, when state laws protecting the right to refuse psychiatric treatment were strengthened, it has been extremely difficult to involuntarily hospitalize the mentally ill or mentally impaired. Though psychiatrists are the only ones who make legal determinations, other physicians, the police and the paramedics all know the criteria: “If the patient is at risk of harming him/herself or others ... “

But what is harm? Wasn’t William harming himself? And aren’t we allowing him to harm himself under the guise of “free will?”

There’s a homeless man in Santa Monica who sits on the same stoop all day, every day. He has matted hair down to his hips, long nails and a honeydew melon-sized hernia easily visible under his filthy clothes. He’s quite benign, but he refuses anything from me or the outreach workers I go out with. Isn’t he harming himself? Isn’t it harmful to live in the streets, not bathe, not seek a doctor’s attention for a chronic condition?

In the wake of the massacre at Virginia Tech, we’ve been repeatedly told that we all need to be able to spot the warning signs of mental illness. But it’s not rocket science. Seung-hui Cho was severely mentally ill -- and there were several attempts to “help” him by his teachers at Virginia Tech, whose efforts were thwarted.

The law allows people their free will to refuse treatment. As someone on the front lines of treating the mentally ill, I would like to see the law take better care of people like William, the homeless man with the hernia and Cho -- and, by extension, the 32 people he killed.

Perhaps the issue confronting us is not about free will at all. Perhaps it’s about our own disinclination as citizens and taxpayers to fund more treatment facilities, counselors and hospitals for the mentally ill. And perhaps “free will” is the propaganda we’ve decided to believe instead.