RP's dilemna

I saw RP yesterday. Perhaps I saw his wife? I don't know. RP is a patient of mine who was just brilliant. He isn't now. He has Alzheimer's. He is interesting because he has always known. Most of the people (probably at least 90% - no one has ever studied this) don't know that they have something wrong with their thinking when they have Alzheimer's. The ability to sensor our own thinking processes is one of the first things that usually goes. There is a lack of insight. Anyway, RP has always maintained that. I've had several Alzheimer's patients who know that they have it. He lives at home with his wife. He is estranged from his children. He has no siblings. His wife is having a difficult time because there are too many delusions. He thinks that she is trying to control him. He rarely thinks that she is his wife, he mostly doesn't recognize her. He wakes her in the middle of the night, because he doesn't really know time that well. He woke her up at 1:00am one night and wanted to talk to her about why she had stolen all of his things. He isn't physically violent with her. Sometimes she is afraid that he will be, because he is very verbally abusive and incredibly angry. He never was an angry man. She said that she knows he isn't "R". She knows that he is someone else, but she still gets shook up. She is tired. She thinks now that maybe she can't continue to care for him at home, and that she has to consider placing him in "a home". I sent the home health people to her house about three or four months ago. I sent the social worker and the psych nurses out there. I thought it was time for him to be "in a home" about six months ago, but I knew then she wasn't ready. I was hoping that she was ready about three months ago. The people who went to her home told her that it was time, but she couldn't. She is going to start to look into the details of how to get that done now. It isn't simple. There are serious economic issues. They aren't rich and nursing homes are very expensive. I've been through this sort of thing many times. Then there was a twist to the story. RP keeps asking her to help him commit suicide. She said she can't. I think she said she "can't". Maybe she said she "won't"? Anyway, she said "not for him". I couldn't understand her very well since her words weren't coming out and since she was trying to keep the crying on the inside. It wasn't really staying on the inside, she was just trying. RP wasn't talking the whole visit. He was just sitting there kind of nodding and listening. Then, when she brought this up, he said, "I thought of maybe stealing someone's airplane." (He was a pilot and a flying instructor.) He has also considered a car accident, but a plane accident is more effective. "You don't want to crash a car and then end up worse than you already are" is what he said. They don't own guns. She doesn't believe in guns. All of this information he has in his head. He doesn't know what day it is, or what year it is, but he knew all of this. I guess he doesn't know how to get on the internet and look up the hemlock society or figure out the doseage for an overdose of tylenol. Anyway, she won't (?can't) help him. She isn't Catholic. She is a kind of agnostic. She believes in the "universe". She believes that suicide is ethical. It's ethical for her. I really didn't say anything. I couldn't really say anything. I told her about a patient I had taken care of about fifteen years ago in Rochester. He was quadraplegic and he could just operate an electric wheelchair. He couldn't feed himself or transfer himself or pick up anything. So he would sneak out in his electric wheelchair about three or four times a year and try to rush out into traffic to get run over by a car. He wanted to commit suicide, he just couldn't DO it. He had no hands to do it with. RP is like him, but he has the hands - he lacks the brains.