Like his father, his name was Angel. In the sunny critical care room, his dad crowded by dialysis apparatus, infusion pumps, and ventilator tubing, the namesake son had found the furthest corner, where he perched precariously on an institutional recliner. He seemed younger than his 27 years, unruly bangs sliding over brows, bright eyes shining with tears and reddening as we spoke. He lost composure several times but quickly reassembled his features; the struggle for normalcy futile. He was alone, but described a large scattered family, spread — as many immigrant families are — over several continents. He was far too young, it seemed to me, to be here.

“My dad,” he began, “he was okay when I was little … ” Gleaning through the timeline, his father had suffered erratic beliefs and paranoias for several decades, often of a religious persuasion, but had been able to hold down odd jobs and evade significant trouble for many years. The relationship between the patient and his wife was understandably strained and could not be sustained, their union brief. Extended family implicitly seemed to understand the patient's limitations and supported him as they could, even while they themselves wrestled toward the American dream. When the patient intuited a break from the conventional world, and parenting became too much, he dismissed his son to the far-away custody of his mom. The patient too moved several hundreds of miles away, suddenly and mercurially, propelled by voices and imperatives unheard by most. He drifted through rooming houses, eventually suffering a stroke, and this ironically became a stabilizing force in his life, as he now was obliged to receive medical care and attention. During rehabilitation, the patient reached out to his son — from whom he had become (unsurprisingly) estranged — as he convalesced. For a time, the patient steadied enough to offer counsel and educational guidance to his now teenaged namesake, and their relationship grew. Once discharged from the stroke program, however, medications faded and mental illness again got the upper hand. The patient wandered further this time, off continent, engaging in a pilgrimage of sorts as he meandered south to north. His travels were erratic and unpredictable, but snippets of information intermittently reached family. Never seeming to find what he sought, eventually he straggled back to the east coast, and here loved ones again tended to him, sensing worsening disease. It wasn't until the delusions compelled him to grievous crime that the patient again, satirically, received medical care, this time involuntarily as he was committed to the state psychiatric hospital. Individuals afflicted with serious mental illness suffer, relative to the general population, a greater frequency and severity of comorbidities and chronic illnesses, and they have more difficulty accessing and retaining care (Bahorik et al., Reference Bahorik, Satre and Kline-Simon2017). Consequentially, their life span is often compromised, sometimes by as much as 15–20 years (Misra and Ganzini, Reference Misra and Ganzini2006). Minorities and immigrants access mental health support even less often, despite equal or greater need, as barriers such as insurance, finances, language, and cultural perceptions limit care (Derr, Reference Derr2016). Those with serious mental illness are more susceptible to encounters with the criminal system, further impairing their ability to maintain stability and wellness (Steadman et al., Reference Steadman, Osher and Robbins2009). At least, some of these parameters are likely reflected in the drop in life expectancy noted in the US since 2014 (Woolf and Schoomaker, Reference Woolf and Schoomaker2019), as well as the 34% rise in suicide rates in working-aged adults documented in recent years (Peterson et al., Reference Peterson, Stone and Marsh2016).

The son was weeping openly now, as the layers of suffering summarizing his father's life were splayed open, raw, and tender in their entirety. The demons, literal, and figurative, his father had battled and eluded filled the room, and in the silence punctuated by alerts and alarms, the anguish was immense. This oft estranged son had flown across the country on a moment's notice and was now expected to make critical decisions for a man who had suffered dire cardiac compromise, a man he had not seen in years. The son alluded briefly to his own fears, referencing struggles in school and work, as he too strived to care and provide for loved ones. The weight of mental illness hung heavily in the room, the gravity of time and opportunity lost. This family's suffering seemed boundless — too much — and yet the son gripped my hand firmly, reassuring me with a tearful but wry smile “don't worry about me … I'm an old soul.”

The text the next day was brief: “son has decided to withdraw, can you come?” — but the clinic was busy and off-site; I couldn't make it in time. The nurses told me that the son, previously wavering, had now seemed certain and calm, and that his father had gently died almost immediately after extubation. Silently, I implored the angels — wherever they may be — to watch over him.