Abstract
In the state of Washington, the second state, following Oregon, to pass legislation allowing physician assisted suicide, Hal's choice to take pills to end his life is referred to as the Death with Dignity Act, or DWD. Hal had made it clear that when his time came, he wanted to take the pills before he became dependent for his daily care. In contrast, a death in hospice is allowed to occur “naturally,” with nothing hastening the process or intervention to prevent death occurring when the “time comes.” While I can't give advice to my patients and have a neutral stance whether a patient chooses the DWD option or not, I have seen my patients struggle while contemplating this route at the end of their lives. I always have the hope that if we manage symptoms well, helping caregivers feel confident and patients move through the dying process comfortably, that the medications won't be used. Being my patients' advocate, though, I am saddened for some. The DWD law requires many steps to be completed prior to someone receiving the prescription that they take to end their life. Physicians who have provided medical care, knowing these patients for years while living with a chronic condition, have the right to refuse at the end of the disease trajectory to be those physicians that attest to a patient's eligibility for the DWD medications (i.e., the two physicians needed to make a statement that a patient is both terminally ill and competent to choose DWD). This means additional waiting for medical appointments with other physicians. A qualified patient must wait at least 15 days between their first and second oral request for the medications. The attending physician must wait at least 48 hours between the date the patient signs the written request and writing the prescription for the medications.
These are safeguards that can mean time is literally running out.
Like in Joe's case: Joe stated “I want to be done, I want to be gone. It will happen soon enough!” in response to my question when I asked him what his goals were. I knew he was pursuing the DWD option, and had conversations with his physicians about this. His adult son was in the room while we had this discussion, heard Joe's comment and blurted out, “You don't mean that, Dad—think about all the things you'd miss.” He went on to describe the disastrous prediction of the world's end by the Mayan calendar, coming up to that date soon, and how they all wanted to see the outcome, and listed several other “important” events that Joe would miss.
Joe caught my eye and I said offhandedly, “You don't seem too interested in all that.” He shared a knowing smile and waved goodbye. His son became even more animated as he saw the hand motion, and began yet another set of worldly concerns that should be important to his dad and the many reasons he should want to go on living. Joe seemed progressively subdued, and I watched his son squirm in the conversation, then try lightening things up. It'd be easier to talk about last week's football scores; though the unspoken words hung in the air.
I replay my last visit with Joe often. Joe's heart couldn't handle the increased fluid collecting in his abdomen anymore, his belly enlarged and his legs became hugely swollen. Just sitting up in bed was a tremendous struggle. (Joe wanted to remain at home to die and expressly stated no more hospital trips.) Joe told me he knew he wasn't doing well and wouldn't last long. While trying to get to the bathroom, he became so short of breath that he collapsed back on the bed, breathing in heaving gulps as his face and chest became purple colored with the effort. He gasped “Help me;” as quickly as possible I gave him a dose of morphine to ease his respiratory distress. There were minutes, seeming like hours, that Joe couldn't breathe; I was uncertain if he would again. Etched into my memory is the look of terror in his eyes and those strangled words: “Help me.” A while later, when he could talk again, he remarked he'd hoped to have his pills to get this over with. I knew he was talking about the DWD medications. But Joe, like others I have cared for, didn't realize the time required to actually have the prescription in hand, nor the “red tape.” Joe ran out of time. People debate the ethics of the DWD law. Personally, I don't know if I would take a lethal dose of pills to have my life end prematurely. But I want people to have that option if they choose. I am a little horrified that Joe, who wanted to avoid the desperate breathing and fully dependent state he ended his days in, was unable to obtain the prescription, because the two doctors who knew him best were arch enemies of the DWD law, refusing to participate in any way and so creating the delay of awaiting additional physician appointments.
But as I looked around Joe's bedroom, I didn't see either of his doctors watching this grim battle.
Only a week later, I listened as my patient Hal told me, pointing to a soft gray and pink paper bag on top of his refrigerator, that he planned to take his “magic pills” on Friday. He said the one thing he would miss was his friends; he couldn't quite imagine not seeing them again. When Friday arrived, his three close friends were there for lunch; they took a number of pictures together with smiling, laughing faces. They didn't all agree that Hal should take the pills, but they supported his decision to end his life the way he chose. A little before 1 pm he announced, “I might as well do this” and took his medicine. They tell me he commented simply that he didn't like the taste, but quietly went to sleep within 10 minutes. And 10 minutes later he stopped breathing. I received the call that they thought he was “gone.” When I came to the apartment I met the “three amigos” as they were affectionately referred to. Though Hal had worried about how his friends would do (forever being the caretaker), I heard them laugh while sharing stories and shedding some tears, but I also saw a captivating camaraderie, with Hal in the center of the room, lying on his favorite easy chair, utterly at peace.
I thought to myself, “Graceful, right to the end.” And I believe Hal got his wish: death…with dignity.