Jane

The Death with Dignity law signed into effect in Washington did not seem especially relevant to my practice once enacted. I was at best, ambivalent about this law despite a life-time belief that all of us have the existential right to suicide.  I don’t think it is a sin. I don’t think it should be illegal. The majority of people who talk about it in my experience, later change their minds. In fact, believing we have a right to it, I have rarely met a person for whom I thought all the alternative options had played out. When my patients committed suicide, I regarded it as a failure—one on their part, not hanging in there, finding some alternative option—and one on my part ie not recognizing some sign, offering some advice, or making some referral that could have changed the momentum behind this decision. It clearly identified a lack of connection, something dear to my heart and motivation as a doctor.

A physician’s participation under the Death with Dignity law is of course, voluntary. When I was first approached by a patient on hospice to consider this—he made a formal request of it with me in my office. I contacted a social worker to re-learn the requirements and steps. I walked him through this only to find quickly that he would not be able to fulfill the terms for it.  His need for a second opinion (done to confirm my impression that he would not live six more months, one of the requirements) could not be met as he became too ill to travel while living over an hour away. He died on hospice within a month or two. Bullet dodged. However, as I reflected on his request, he was the poster child both for the law and my own “existential right” belief: he had pancreatic cancer with both pain and the wasting away end-point.

I would come to provide opinions and learn the process as outlined by the law but I never had a patient actually use the option. I prescribed the medication three times and came to the conclusion that many people asking for the medication simply wanted to have a sense of control in their ending.

Nancy would test me severely on my orientation to suicide and death with dignity—and I relate my experience with her given the article on Euthanasia in Canada.

Nancy, "doctor shopped” her way to me after several years and doctors failed to provide the connection she was seeking.  Nancy had “fibromyalgia.” I have always found this diagnosis as only a description or a presentation of symptoms as the likely causes for it were and are largely not understood.  In my mind, the causes are likely multiple, and complex given our overall understanding of chronic disease and its effects on the mind. Most doctors in my lifetime have focussed on the behavior of their patients with this diagnosis and the assumption that it was a disease of the mind is common.

I am sympathetic with such patients; I offer an open mind to the possibilities and dialogue as I had no treatment option that stood out as especially useful  I tried to be friendly, interactive, and supportive with Nancy who left me with a favorable impression as I got to know her. . Regardless of the reason and its effect on her psychological outlook, she needed to be heard and I needed to think through the differential diagnosis and options for her.  I came up with nothing. I did establish a connection.

My most remembered moment seeing Nancy after we met was on my way to work one morning. I saw her in a wheelchair moving on the sidewalk of the street my clinic was on. Her apartment was in fact, next door to the clinic. The wheelchair: going through her records and after a neurological exam, I could find no reason for her to use it. But use it she had, for years. The suggestion for physical therapy seemed to be insulting (she was out of shape given her dependence on the wheel chair) and the equilibrium between patient and doctor was eventually in balance despite her resistance to this and other offered suggestions..

Nancy arrived to my office alert and energized one day. As we spoke, she made clear she had important news and a request.

“Doc, I am planning to kill myself.”

“What exactly does that mean and do you have a plan to do it?”

“Yes, I have given this a lot of thought and reached out to the Hemlock Society in Seattle. I reached out to my brother who has money. They are in support of what I want to do which is, starve myself.”

I involuntarily laughed. “Do you know how hard that is to do?”

“Well, I know it will be hard but I will have in-home assistance doing this and am asking for your help.”

I went out on a limb, “Did you see Little Big Man?  The chief in the end declares it is a good day to die, lies down and the rain wakes him up and back to the village he went.”

This elicited no response. I realized I was a bit shocked if not panicked. What was my responsibility here—-to report her? Get a psychiatric  evaluation?

I made clear that she did not meet criteria for the death with dignity act—I had no reason to think she would not live for years to come. I could not aid in her suicide by giving her lethal medications. She understood all that. She simply seemed to want, if not my blessing, my support going through a difficult process.

It was not in me to support her without reservations. She agreed to get an evaluation in our mental health clinic, as one would do if Death with Dignity applied. And I suggested I would wait and see how she did. When was she going to start her process? It turned out, she was going to start soon as her brother had agreed to pay for an in-home nurse the following week.

Her psychological evaluation was done quickly. She was not thought to be clinically depressed and the therapist saw no psychological reason to interfere with her plan. I expected that but had hoped for something more.

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She started her process. It preoccupied me. I knew her to be a determined woman and one I did not know with any depth. I did a home visit. There, I learned a couple things. She had advocates for her “suicide” who were willing to engage me on my stinginess re medication. Looking at her library and living room, I marveled at how many educational lectures we shared through Great Courses and books. She was pleasant but all business about her intentions—and mine.

I kept getting requests for meds; opiates for pain, skin lotions, anti nausea medication.

I consulted the company lawyer. “She’s within her legal rights to do what she is doing. If you prescribe to her, be thoughtful about why and in what dosages. We don’t want you on the front page of the paper…..”

Great.  I had a sleepless night thinking about her.

I had diarrhea.

Seeing or calling twenty odd patients a day, she was always in the back of my thoughts, intruding with this question of her choice and asking for my help to fulfill that choice.

I called a friend, a psychiatrist. He reviewed her record and then my discomfort and offered advice that could have come from the lawyer: “The law allows her to make this choice. You don’t control her or her choice. If you are uncomfortable, stop checking in with her. Move on.”

I did just that. My work was heavy and each day a number of needs were there to be filled. I felt better. A friend of Nancy’s called—she was a nurse—and reported that she retained the support though after a conversation, the brother was getting impatient. How long does it take for a person to starve to death? The nurse commiserated with me as she was also unhappy with the course this was taking.

I got a call from one of her advocates. She had fallen out of bed and was too weak to get up. The advocates were apparently prohibited from mobilizing her. They called 911. For a moment, I wondered, “Am I going to get a call from some medical authority asking me what the hell was going on in that apartment?”  The advocate, in relating what happened noted that she told the medical technicians that she did not want to go to the hospital, was on hospice, and simply needed help getting back into bed. I had had her sign a POLST form which was easily seen on her refrigerator which would have given them confidence. The advocate then, the day after her fall, asked me prescribe pain medication.

I had started from a position of non-involvement as related to medications, especially those that could bee used to overdose. Both the Lawyer and Psychiatrist and told me that prudent prescribing for symptoms I believed to be present was morally and legally supportable. The Hemlock Society advocates gave me input that I was only increasing her suffering with my attitude and after her fall, I allowed that small amounts of medication would be prescribed for pain. Their complaint about the small supply was met with my response that they were next door; refills were not a burden.

Weeks went by and I stopped thinking about her. One morning, a death certificate landed on my desk. It was Nancy’s.  She actually did it. Now, how to sign off on this?  She had no terminal illness, was not depressed, and to my knowledge, did not overdose. What could I certify as to the cause of death? I called the coroner and explained that I had not seen her that last month and was not sure what she died from. I would have loved an autopsy!  He was having none of it as no criminal activity was suggested. He provided me with a code for the statistical tracking of causes of death: death by self imposed starvation. I used the code and never heard a word about Nancy again.

Like most generalists I have had patients commit suicide. Usually, one wonders about what was missed at the last appointment that might have headed this off.  With time, the ability to advocate for an intervention when the conversation seems straightforward has faded as our current system in Washington is one that allows great autonomy to patients. To merit involuntary admission for being, “a danger to oneself or others,” the bar is very high: holding the loaded gun while making the threat, walking in front of moving cars, eating toxic materials…….Nancy was the only patient in my career to choose a slow voluntary method of death, one that I did not believe she could actually complete, and one that required a minimal level of participation from me. It remains one of the most painful patient interactions I have ever had.