When a Patient Wants to Die

What if he asked me to help end his life?

George was dying. I did  not expect him to last more than a few weeks. The esophageal cancer had spread to his liver and to his lymphatic system, mutated and spread beyond the reach of all known treatments. His esophagus was narrowed to the point where solid foods were impossible to swallow and he was starving. The impact of the cancer on his digestive system had resulted in intractable nausea. None of the four anti-nausea medications he was taking had made a difference. Every day was miserable. All pleasure was gone from his life and he was simply waiting to die.

He signed up for hospice care to ease his passing. He was too weak to come to the office so I went to his home to see him. He was a shell of the man he once was. He was once obese but was no longer. He had lost over 100 pounds, his clothes hung loose and his face was drawn.

During the hour I was in his home we discussed many things. He asked me many unanswerable questions-, wondering what caused the cancer, what would have happened if the specialist he had seen had made the diagnosis earlier when he first had trouble swallowing. He asked how long it would take for him to die. Having provided care to many hospice patients over the years I told him that only a foolish doctor would deign to predict a time of death. Death comes when it comes. Sometimes in comes in days, other times it comes in weeks. All I could promise was that I would be there for him, that he would not suffer.

Waiting can become the hardest part of dying. Once the inevitability of death has been accepted, when the goodbyes are said and the prayers have been made there is nothing else to do but wait, to watch each change in symptoms and wonder what it means, to wonder if the final countdown clock has started to tick or if it is just another meaningless change. 

For many patients and families the waiting is unbearable. As the suffering increases and the end approaches it is natural to ask, “Can we just do something to end it?”

Because physician assisted suicide has been illegal in California I have never had to directly answer the question. This could change at any moment, as the governor has signed a bill that would legalize the practice. When the law is implemented it will be legal for me to give patients like George a lethal dose of medication. The question of "When?" will become answerable and the agonizing days of waiting avoided. Family and friends could know the time and place and plan accordingly. Everyone would feel a sense of control.

And my role as a physician would change forever.

For patient's like George  it seems straightforward. He had at most a month or two to live, and his suffering was real. Why not provide definitive closure for such patients? What is the harm in providing a quick and easy passing?

George's case provides an answer to these questions. Under the law as written, George would have been a candidate for assisted suicide 4 months ago, when he was first diagnosed with the aggressive cancer. If he had not elected to attempt treatment his life expectancy would have been less than 6 months and he would have met the conditions of the law. Any doctor could have ended his life any time he wanted. He could have been given a large dose of morphine or other medications and the months of suffering avoided.

He also would have avoided hundreds of conversations with friends and family, including the spiritual conversations he had with me and others. A professed atheist, he specifically asked for prayer and if I would advise him spiritually as he went through the process of dealing with his disease. That 4 month process changed him. He became a different man with a different perspective. I would not have wanted to take that from him, nor should anyone.

Many will say that it should be the patient’s choice. In a godless world where man is the ultimate arbiter of his fate this makes sense. If there are no enduring consequences, if there is no ultimate meaning in life, if there is nothing good that comes from suffering, these choice advocates are right.

But we do not live in a godless world and man is not god, as much as many may wish that we were. Death reminds us of that.

As a Christian physician I will not play the role of God, I will not help a patient end his life. What I will do is relieve his suffering. I will aggressively treat his pain without reservation, even if that requires middle of the night visits. I will come to his home to pray for him, sit with him and comfort him, and do all I can to facilitate a death that is filled with dignity and comfort, knowing that each moment, even the ones filled with pain, provides an opportunity for love, reflection and faith.

- Bart

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A Little Boy's Birthday, A Mother's Suicide

On their birthdays, nine year-old little boys should not come home from school and find their mother dead. John did.

I met John when he was in his early twenties. My church had decided to rent a large home in a local neighborhood and open it up to young men who were homeless and needed a fresh start. My best friend was put in charge of the ministry and he invited me to come along and help. I cooked and cleaned and supervised the house when he was gone. I was only 19 but I was committed and responsible. I was also ill equipped and unprepared for men like John.

John was down on his luck, jobless and out of money when someone from the church happened to meet him. The home had just opened and the church member thought we could help John get back on his feet so he brought him by. We sat down with John, told him the house rules and agreed to let him stay. It did not take long for me to learn John’s story and discover how difficult his past had been and how challenging the road ahead was going to be.

On John’s 9th birthday he had come home from school and found his mother in the garage, hanging by her neck from the rafters. She had committed suicide. Happy Birthday John. The remainder of John’s childhood involved temporary homes and terrible insecurity. He did not receive the counseling and love he needed and his young life was filled with more emotional pain than he could handle. When he became a teen he took solace in drugs and they ravaged his body. His gaunt, pale and pock-marked face declared to the world that he was someone who was unhealthy both inside and out. He lacked social skills, job skills and self-discipline.

John was a talker and we spent many late evenings together in conversation. Whenever we talked about the future, about what he would need to do to make a life for himself, he would turn the conversation to the tragedy of his past. It was as if he was saying that it was impossible for someone with his past to ever succeed in life, as if what his mother had done had sealed his destiny. It seemed he thought he was supposed to fail and that as a result any effort he made to succeed, any attempt at normalcy, every job interview and each day of sobriety, was to be praised and celebrated. He craved the unconditional love that he had been denied as a child.

Unfortunately for John, each small step forward was typically accompanied by a stumble or a fall. It was difficult to give him the praise he desired and desperately needed as it would have required us to ignore behaviors that were harmful. He needed so much more than we were able to give. Eventually he left, unable to keep a job our follow the rules. I do not know if he ever turned his life around.

Looking back, I think our church leadership was naïve in its approach to the ministry. It was as if they believed that all troubled young men needed was a place to live and Jesus. The thinking seemed to be that if they had a bed to sleep in, food to eat and a Bible to read that all would be okay. There was no talk of providing professional counseling or 12-step programs, no concept of the years it would take for someone like John to change and grow. We had good hearts and intentions but lacked the training and expertise.

In spite of our inadequacies it was not the church’s fault that John did not succeed. We did give him a chance he otherwise would not have had. He was given some good advice and an opportunity to change yet because of his troubled past he was unwilling or unable to listen to and receive the counsel of others. In spite of the reality that all of his choices had resulted in disastrous outcomes he continued to make his choices alone, refused to submit to the leadership of others. He could not fully trust others and trusting himself was futile. He needed so much more than we could give and needed to do so much more than he was willing.

I will never forget John and the lessons he taught me. I have encountered many “Johns” in my 20 years of practice, men and women with terrible pasts who face terrible futures. I still struggle to find a way to encourage them to get the help they need and still mourn when I see them make bad decisions. Whenever I counsel people like John I am reminded of how crucial love and direction are early in life, how children need to be taught to be healthy. Without a healthy foundation a healthy life is hard to build.

-          Bart

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