My Pal, Cal

My next column in The Everett Herald.

Last month I got an email from an old friend. Its subject was “My plans.”  

Fresh out of residency, I met him when I arrived in Oregon to begin my surgical career. Also a surgeon in town and, therefore, a future competitor, he and his wife nevertheless welcomed me and my wife, invited us to dinner, after which, as easily as if we’d known each other forever, we became pals, the four of us. Laughed, dined, traveled. Had sleepovers, even. 

Judy and I moved to Everett thirty-seven years ago, but we’ve stayed in frequent touch, they visiting here and we there. We attended each of their children’s weddings. Our scheduled trip together to the Oregon coast last winter was scrapped after his wife got into a terrible auto accident. Her recovery was arduous.  

Eleven years older than me, he’d attended college at the arch-rival of mine. The first intercollegiate baseball game, in 1859, was between our two schools. “We” won, 73 – 32. Referred to as “The biggest little game in America,” the football rivalry is the oldest in Division III, fourth-oldest in the US. He captained lacrosse; I played rugby. We were in the same fraternity in our respective schools, laughingly shared the ridiculously complex, secret handshake. We both served as military doctors; he outranked and outlasted me. 

The email arrived on a Thursday. The plan to which its title referred was suicide. Saturday.  

In my surgical practice, I’ve dealt with death, in and out of the OR. On a couple of occasions, I’d been the one to turn off a ventilator; have counseled families when the inevitable was approaching. And I watched the grim, relentless decline of my mother and grandmother as their vibrant humanity was cruelly peeled away, layer by layer, by Alzheimer’s Disease. Along with my family, I sat beside my dad as he died; was with my cousin when her mom breathed her last. 

I’ve told myself that if I knew I was heading to the final station, especially with dementia, I’d jump off the train before it got there. Until now, though, the idea of assisted suicide had been an abstraction. Suddenly, it was immediate, and I had thoughts. Like, what would he (anyone) be thinking at the moment of drinking the potion?  

Next evening, as in better times, we talked on the phone. He sounded good, relaxed. We recalled the fun we’d had, I told him how grateful I was for his friendship, how important it’d had been for me, the young guy, to work with him in the operating room on those rare occasions when it happened. How sorry I was it had come to this, that I respected his decision and considered it courageous. Asked how his wife was doing, he said, “She’s fine. Looking forward to it.” Typical.  

“It’s been a wonderful week,” he said. “Each day, family was here, with tears and laughter. It’s like I got to attend my memorial service. I don’t know why everyone doesn’t do it this way.” He wrote his own obituary.  

Debilitated and disabled with unrelenting back pain, dependent on supplemental oxygen because of progressive, untreatable lung disease, he’d become unable to get out of bed. Until his intractable spine made it impossible, he, a lover of golf, had a dream job after retiring, traveling the Northwest reviewing golf courses for a magazine.  Now, bedridden and air-hungry even on oxygen, frustration and humiliation were constant. His pain medicines made him feel unlike himself. In hospice care for months, he was tired. And ready. 

On Saturday evening, he and his wife in Oregon, we here, all we could do was drink a toast, and, with sadness and smiles, honor him.  

Last week we had lunch with his wife. He’d waited till the afternoon, she told us, in order to see the kids of friends play their consolation game in the Little League World Series. They watched part of “Forrest Gump.” Prior to the final cocktail, he took two prescribed pills. When he felt he was getting sleepy, his wife mixed the drink, per protocol, handed it to her husband, and climbed into bed next to him. 

As she snuggled into his shoulder, he said “I love you.” Not long after, he stopped breathing. She waited for a while, she said, to be sure. I wondered how she decided it was time to get up, and what it felt like when she did. 

Should Be Good

Trailer

Having much admired Booth Gardner when he was governor of my state, and having been and remaining an advocate for the law in Washington, I'm looking forward to seeing this.

Profoundly affected by his Parkinson's Disease, Governor Gardner campaigned heroically and effectively (and successfully) for "Death With Dignity." His popularity in the state, and his lifelong credibility as a thoughtful and honest man no doubt made a difference.

Heart Like A Stone

A nearby woman is the first in Washington State to avail herself of the newly-passed "death with dignity" law. Here's a quote from the article:

One opponent of the law called Fleming's death a "sad day" and criticized her choice as "egotistical... It's saying: 'I want to go out of life on my own terms, even though the vast majority of us accept the natural conclusion of our lives,' " said Chris Carlson, of the Coalition Against Assisted Suicide...

Egotistical.

EGOTISTICAL! Of all the words to describe the act, that's not one that would have come to my mind. (Looking around a bit on the intertubes, I see it is, in fact, not unique to this person: in a particularly poorly written and grievously edited tract discussing psychology of suicide, the word is mis-equated with "egoistic" and other psychobabble that hardly applies to terminal illness.)

During the campaign against the initiative, the opposition mostly focused on "slippery slope" arguments: it'll be abused; it'll be forced on people to save health care dollars; families will talk their old ones into offing themselves to get the inheritance before it's used up. Self-indulgence wasn't brought up. At least not in reference to the dying.

With good reason: it's deeply offensive, heartless, and condescending. At the very least. And, of course, it's the imposition of a religious ethic on others by people who have no business doing so. Like opposition to same-sex marriage, except that in the latter case, no one dies. In each case, the act does no harm to the protesters, is exquisitely personal, and has only religious or sky-is-falling arguments to be made against it. (The Washington law, like the one in Oregon, has safeguards -- too many, if anything -- against treatable depression and premature invocation.) These are people suffering with terminal illness. Terminal. Suffering. Unable to be experienced (much less judged) by any but the sufferer, the woman's act was, in my view, one of bravery and, in a strange way, of ultimate optimism. Affirming of her humanity.

I don't discount the sincerity of those who oppose assisted suicide, some of my fellow physicians (none of whom can be made to participate) among them. But when I read the above sentences, I thought, is that what it's really been about? Taking a tiny bit of control over the otherwise uncontrollable and intolerable is egotistical? Not by my definition.

"...even though the vast majority of us accept the natural conclusion of our lives." Huh? Natural conclusion? Don't the majority see doctors, take meds, go to hospitals, have operations? What the hell is a "natural conclusion?"

I've not heard of the speaker, but it seems he/she is a spokesperson for an activist group, so I assume it's representative. Of something. Is it a sensible argument in any way? "[M]y own terms." Yes! Of course!! And your point is what, exactly? When I saw the word "egotistical" my reaction was revulsion at the clueless insensitivity, the faux superiority, the EGOTISM. When I read the rest of the quote, I found it laughable.

In a "god help us here we go again" sort of way.
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Death With Dignity

Many years ago, a patient on whom I'd previously operated for breast cancer came to see me, with her adult daughter. She'd recently been diagnosed with pancreatic cancer, and she'd decided not to have any sort of treatment. None of her current doctors, she said, were ones with whom she felt comfortable sharing her concerns, her desire. At some level, I was touched that she trusted me with her request: making personal connections, establishing trust with my patients was something I valued. What she asked was that I provide her, over time, with enough narcotics and sedatives that, should she choose to do so, she'd be able to take her own life.

In my state, Washington, there's a ballot measure allowing physicians, under very specific conditions, to provide lethal doses of medicines to certain small subgroups of terminally ill patients. Based on a law in place in Oregon for ten years, studies of which have not revealed abuse (and, in fact, a rather low incidence of use), the proposition has, of course, provoked strong opposition. Officially, the state medical association opposes it, and claims its membership overwhelmingly share that view. The fact is that a little over half of the members, myself included, favor it. I realize it's a very difficult issue. And yet, in virtually every hospital in the country, it happens all the time, in ways not very different from what the bill proposes.

I've written about this, if tangentially, on my other blog, too. There are no easy or universal answers. And that's the point. At the time of approaching death, doctors are often at a loss: death, by definition, is a failure for those whose job it is to heal. And yet the job isn't over; we can't turn away. It's generally accepted that a person ought to have the right to refuse care for themselves. Withdrawal of "active" (for lack of a better word) care is a regular occurrence, both in the situation where an alert and cogent patient requests it, and where family does so, for a patient no longer able to decide for him- or herself. It's the former situation -- a mentally clear patient -- to which the "death with dignity" laws apply.

In hospitals, in addition to withdrawal of care, drugs are given for comfort -- narcotics -- wherein the main goal is relief of pain but with the understanding -- because it's part and parcel of the effect -- that the arrival of death will be accelerated. Sometimes there's a sort of dance around that fact, and most certainly there's a need to be certain everyone -- all care-givers and family -- understand and agree. It happens, and to some extent it's extra-legal. It's not euthanasia, it's comfort care. But it's no secret what's happening.

"Death with Dignity" laws take that concept and make it above board, and out of the hospital. I understand how some recoil from it; the law allows not only for doctors to refuse to participate, but also that hospitals have a right to prevent their staff from doing it as well. As it should. But in my view, people have a right, in one of the most difficult, personal, momentous and fraught times of their lives, to make decisions for themselves. To make their own decisions about their own suffering. Not all doctors, of course, would feel right about being drawn in to providing the means. Nor would they have to.

As I read the bill (linked above), I was struck by the stringency of it, and by the complexity of the requirements upon the doctors involved. In fact, it could be -- not to put too fine a point on it -- a pain in the ass. And yet, the airwaves are filled with disinformation and dire warnings: it can be carried out even if the person is depressed (it can't: when depression is suspected, mental health referrals must be made), it can be foisted upon the most vulnerable (I don't see how it can), the sufferer need not notify anyone of his/her decision (that's true: but the law requires that the caregivers encourage it, and document same.)

The subject is difficult and painful. I could write volumes on it; in a way, not to do so is to treat it too simply (if needed, I can enlarge upon my thoughts in comments.) I fully sympathize with those who oppose it; but I don't sympathize with the idea of preventing others, who disagree, from having the option. Realizing it sounds a little flip: if you don't believe in "death with dignity," don't avail yourself of it; nothing forces it on anyone. And don't judge the suffering of others, and how they choose to deal with it.

[For a thoughtful panel discussion of the Oregon experience, read this. It's worth it if for no other reason than to remember, in this political season, that difficult issues can be discussed respectfully by people who disagree with one another.]