A New Physician's Personal Experience with the End of Life Option Act

My grandfather lost his central vision to macular degeneration and used a talking watch as one of his adaptations. On the hour, a chirpy monotone voice announced: “It's four o'clock p.m.,” for example. After he died I didn't run into that technology again until one of the first patients I met in internship was counting down the last minutes of his life.

On my second day of internship, I spent a day with home hospice. I set out with Molly, ^* the nurse who guided me through the day. She had a list of home visits to complete, but there was a patient who was having symptoms requiring urgent attention. His large vascular soft tissue sarcoma had started bleeding every time he made any physical effort. Early that morning he bled after a bowel movement, and his family called Molly for wound care. They were terrified, but to Molly it was routine. “Let's just go see him first and take care of this,” she said.

Molly gave me a brief history of Mr. Smith. Almost as an aside, she mentioned that he was one of the few patients she knew who had been prescribed medications under the End of Life Option Act (EoLOA), legalizing physician-assisted dying in California. The law was again in effect after being briefly overturned. I graduated from medical school in Tennessee, where physician-assisted dying is a topic of discussion in ethics seminars the way that the “Trolley Problem” ^† is; none of us is actually driving that trolley. Similarly, Molly discussed Mr. Smith and the EoLOA as a point of interest, not as something we might confront that day.

We pulled up in Molly's van and stepped out into the staticky early July heat. Molly collected her wound care supplies, and I grabbed my stethoscope and draped it around my neck as if I had some business walking into a dying stranger's home. The patient's wife and daughter already knew Molly, and they greeted her with hugs and concern. Molly introduced me: “This is the doctor. She's observing me today.” I shook Mrs. Smith's hand and tried to quiet the internal dissonance that surfaced hearing “the doctor” to refer to me on my second day of internship.

Molly and I went into the dark bedroom where Mr. Smith was lying with his small dog curled up next to him. Blood soaked the dressing covering the tumor in the middle of his chest. My hands hung dumbly by my side, my stethoscope still uselessly around my neck while Molly held pressure before expertly changing the dressing. The bleeding had stopped, and I sat down at the family table while Molly finished tending to Mr. Smith's wound.

The room where we sat was piled high with powerful medications—antiemetics, benzodiazepines, and opiates—interspersed with family tchotchkes. We jumped back and forth between small talk and the intricacies of Mr. Smith's illness. Mrs. Smith and her daughter told me what a chore it was for Mr. Smith to leave his bed, how they feared that he would bleed any time he turned his body or tried to sit up. “He doesn't want to bleed to death,” his daughter told me. “He can't keep doing this.” She explained the conflict in their family surrounding EoLOA. Mrs. Smith and her daughter supported Mr. Smith's decision to end his life at the time of his choosing, but other family members opposed it. It was a moot conflict for the time that the law was off the books, but now the choice was back on the table.

We sat for a few moments in silence until Molly rejoined us at the table. “He says he wants to take his medications right now,” she told us.

Mrs. Smith's face was still. “I kind of thought he might.”

The family and Molly started making preparations while I sat in place, wondering whether they were talking about what I thought they were talking about. Did he just decide he's going to die? Like, now? Mrs. Smith brought out a paper pharmacy bag containing two bottles and set them out on the kitchen counter.

“How do we do this? Do I make it for him?” The logistics of the lethal “shake” were more complicated than I had considered. Mr. Smith had to self-administer the medicine so that his death was not deemed euthanasia or homicide. It was allowed, though, for his wife and his daughter to aid in the preparation.

Before the medications came the phone calls. “Dad wants to say goodbye,” Mr. Smith's daughter said to each of her siblings. She put them on speaker phone while her dad said, “I love you” to his children one by one. His daughter kept reassuring her siblings, “The doctor is here, too.” I didn't understand how my presence could provide any security when I felt so inexpert.

“This is the right thing,” Mrs. Smith said aloud. I stole glances at Molly, who was texting and making her own phone calls to her supervisors. This road was as uncharted for her in practice as it was for me. She debated whether staying in the house might be legally suspect, ultimately deciding that she should be there in case Mr. Smith bled or had intractable nausea or other symptoms.

Mr. Smith was instructed to take an antiemetic 30 minutes before swallowing the fatal medication mixture. After the nausea pill, Mr. Smith pressed a button on his watch: “It is eleven-oh-four a.m.” it chimed. Thirty minutes to go. “It is eleven-oh-nine a.m. … It is eleven-seventeen a.m. …” As soon as his watch chimed 11:34, Mr. Smith swallowed his medication cocktail. His family could stand by his side, but they were not allowed to help him drink. Molly and I stayed outside the room. Soon his wife and daughter came out to tell us that Mr. Smith was asleep and calm. His breathing sounded mostly regular though with a few pauses and subsequent gasps. Molly told the family and me that it could be anywhere from minutes to a few hours. She said we could give the family some time to be with him and that they could call us when he had passed away.

“I guess we have to get lunch,” she said. So that's what we did. “Was that … did that feel normal to you?” I asked her. She shook her head no. We ate our lunches in relative silence until the phone buzzed. She saw it was Mrs. Smith calling. “Hi, honey,” she said. “We're on our way.”

When we stepped back into the house it felt still and quiet. “I'm so sorry,” I said. Molly stepped into the bedroom to pronounce Mr. Smith, and then she called me in. The dog was still curled up at the foot of the bed. Mr. Smith's mouth was open, and his hands were folded over his chest just below his tumor. Molly wanted to clean him up before the funeral home came to collect his body. She asked me to help her turn him to one side. I wasn't used to touching dead bodies yet, and putting my hands on Mr. Smith was jarring. I had just spoken to him an hour ago. Later I thought about what it meant for me as a physician to be present as this action plan unfolded. Maybe my mere presence was the same as participation. Maybe my being in the house meant I condoned Mr. Smith's choice. I wasn't sure if I did, or if it even mattered.

Now, even after just over a year of residency, I've spent the last moments, hours, or days of life with many patients. I've stood by the bedside as the QRS complex snaked out on the monitor until an alarm sounds. Asystole. Mr. Smith didn't look like those people. He had looked ill and frightened when we met him, but not imminent. His breathing was regular when we entered his home. He was alert. He wasn't one of the patients about whom I would have exchanged a knowing glance with the nurse: just a couple of hours to go. When I saw him next, he was deceased. On purpose.

When my family talks about my grandfather's death, we talk about how grateful we are that he died at home surrounded by those of us who loved him fiercely. “It couldn't have gone better,” we say. But then I think about my grandfather's last words to me before he stopped talking. He held my hand and said, “I hope there's not an afterlife. I can't go through this again.” I think he meant that he couldn't go through life again, but maybe he meant he couldn't go through dying again. I know how I experienced his last weeks and days, but I have no idea how they felt for him. Maybe it could have gone better. Maybe he would have wanted the control to count down to his last moments with the chime of a watch, too.