Life had never been easy for Suzanne Marks, and neither was her eventual death. Born in 1943, severe chronic depression began in her teens. Along with depression came suicidal and paranoid ideation, delusions, hallucinations and chronic serious eating disorders necessitating ongoing psychiatric monitoring and treatment.
Her personal life was filled with stress and sorrow. Married at age 19 while in college, she was divorced about 10 years later. Attempting to begin anew, she moved from New England to Louisiana where her parents lived. Three years later, both parents and a younger brother perished in a plane crash. Her eating problems became uncontrollable; at age 36, she weighed in excess of 300 pounds. All efforts to control her weight gain had failed.
In apparent desperation to try anything, she was referred to Dr. Kenneth B. Jones, a general surgeon who performed a horizontal gastroplasty in attempts to limit her digestive capacity.
Suzanne initially lost weight. She could not maintain this loss, however, because the opening !n her stomach became enlarged. Three years after her surgery, she again weighed in excess of 300 pounds. Revision surgery was deemed appropriate and was performed in 1982. Although she once again lost significant weight she began developing chronic nausea and vomiting after each meal. Neurological symptoms, such as dizziness and blurred vision, also progressed. She was diagnosed as suffering from Wernicke's encephalopathy (a deteriorating neurological disorder caused by thiamine deficiency). Her depression deepened, and she expressed that she had "no desire to live." Although all other treating physicians noted that her physical problems apparently were in large part psychologically driven and her vomiting possibly self induced, a psychiatric consult offered the opinion that her symptoms were more likely caused by her surgeries.
Suzanne was considered a difficult patient at best and frequently characterized in her records as uncooperative and manipulative. Although she sought out medical intervention, she accused doctors who tried to enhance her digestive functioning of "trying to make her fat again." Physically and psychologically, Suzanne continued to deteriorate and the remainder of her life was spent in and out of treatment facilities including nursing homes. In 1995, at age 52, Suzanne Marks died of cardiopulmonary arrest
In 1986, Ms. Marks had filed a malpractice complaint against Dr. Jones in which she alleged that he failed to provide her with an adequate regimen for her vitamin and caloric needs, and that he failed to properly respond adequately to her persistent nausea and vomiting. Even after her death, litigation against him continued with her daughters substituted as parties.
After trial in 1996, the court found in favor of Dr. Jones deeming that he did not breach any reasonable standard of care. Charging bias of the court, the daughters appealed the decision, charging among other things that footnotes in the trial court's opinion manifested a loss of objectivity.
Holding: The verdict was upheld. There was no failure of the court to remain objective. Moreover, standards of care were not clearly breached. The court also found that many, if not all of Ms. Mark's problems were caused by her obsessiveness with her weight and her noncompliance with medical directives, including self-induced vomiting which may have caused her vitamin deficiencies. The court made no mention of the undue risks Dr. Jones may have undertaken in performing drastic type surgery on a patient with her degree of psychiatric dysfunction.
| Samuel Klagsbrun, M.D. Chief Executive Officer Four Winds Hospital |
Dr. Klagsbrun comments: During the intervening years of this patient's gradual demise after her original surgery, she was suicidal, induced self vomiting endlessly, did not cooperate with any of her doctors, and had multiple psychiatric hospitalizations, including one long stay in a state hospital. Suzanne occasionally had some contact with Dr. Jones, was told by other doctors that they would not treat her because of her manipulativeness. She isolated herself, and she died alone.
But like a phoenix from the ashes, her estranged daughters, with whom she apparently had little contact of any consequence—since they do not appear any place in the charts as supporters or as caretakers—continued a lawsuit against Dr. Jones. Yes, the promise of money creates its own form of posthumous "love."
Ironically, the management of Ms. Marks should not have been the responsibility of Dr. Jones or any of the surgeons or primary care physicians who took care of her. For any patient who is as mentally ill as Suzanne Marks, a psychiatrist as a pivot person for the treatment is the optimal approach.
Now that elective cosmetic surgery offers a variety of newer procedures, surgeons are becoming increasingly aware about the need to closely involve psychiatry in the process. This is especially important because the motivation behind these procedures is often tinged with an obsessional or depressive illness. These same psychological frailties will predictably complicate the post-surgery management. The psychiatrically ill patient may show poor compliance with aftercare instructions or may alienate the doctor with missed appointments and vague, chronic symptoms.
All over the country, treatment units with a specialty in psychiatric patients with complicated medical needs might have provided better management. Why wasn't the psychiatric care scrutinized? It's all too easy to focus on a surgical procedure, so easy to define, and so easy to blame. This misses the mark of where treatment responsibility ought to have been scrutinized. Did Ms. Marks get the psychiatric care which could have saved her life?
Surgical procedure where the stomach is sewn to limit the digestion and absorption of food.
