"Anatomy of a Good Death"
Thomas was a 65-year-old retiree who had battled lung cancer for over a year. He had received the usual medical treatment of radiation and chemotherapy, but the cancer had metastasized and had spread to other organs in his body. He had lost more than 60 pounds, had no appetite, and could barely breathe without the aid of an oxygen tank. He had decided to end his suffering. He wanted to die.
His hospice nurse, Anna, suggested he have his wife Elizabeth contact the office of Compassion in Dying, a small, nonprofit, charitable organization in Seattle. Compassion in Dying was organized in 1993 after the failure of a state initiative that would have allowed physician assisted death. Most of the group were members of the Hemlock Society dedicated to the promotion of information, counseling, and emotional support to terminally ill patients and their families. Compassion’s basic premise is that terminally ill patients who seek to end their suffering by a hastened death should not die alone. At the time of Elizabeth’s call, I had been a volunteer with Compassion for two years. My interest in this work was rooted in my career in estate planning and assisting families in preparing for the contingency of death.
At Elizabeth’s request, an information kit was mailed with a detailed outline of Compassion’s services and a copy of their guidelines and safeguards. Included was an explanation of what was required to accumulate the necessary drugs and an outline of the protocol Compassion suggests for a hastened death. The following statement accompanied the material:
This means of hastening death should be considered only by adult persons who are terminally ill and mentally competent. Persons considering ending their lives for emotional or other reasons are urged to seek help from a Crisis Clinic, counseling center, mental health professional, clergy, or other sources of crisis assistance.
At the same time, a request form that detailed the information about Thomas’s condition was completed by Compassion’s office staff and forwarded to the Case Management Coordinator for further review. I was asked to follow up with a telephone call to make certain they had received the material and answer any questions they might have. I spoke with Elizabeth who told me they had reviewed the material and asked if I would come for a personal visit. Since one of the requirements outlined in Compassion’s guidelines is a verification of the primary physician’s diagnosis, I explained a member of our medical staff who would examine Thomas would accompany me.
Thomas and his wife lived in a small, attractive home on Whidbey Island, about an hour and a half northwest of Seattle, a trip that included a ferry ride. When we arrived, Elizabeth who introduced us to Anna, the hospice nurse greeted us. Thomas was in a wheelchair, his face partially covered with the mask of an oxygen tank. He was a tall slender man, his appearance drawn and pale. He explained to us that he was at the stage of his illness where it was progressively difficult to breathe; he had no appetite, and felt weaker each day. Despite his obvious discomfort, he exhibited a sharp mind and a keen sense of humor.
He said that he had read and understood the requirements outlined in Compassion’s guidelines and safeguards. He assured us that he met all of them and that his personal physician had already prescribed half the necessary medication and that he would be able to obtain the balance within a week. When I asked him when he anticipated a hastened death, he said sometime within the next two months.
While our physician examined Thomas, I asked Elizabeth how she felt about Thomas’s plans. She made it clear that he had her total support and, while it was terrible to think of his loss, it was worse to watch him waste away to an inevitable death. “We are keenly aware of what the final stages of lung cancer can be like, and he has made up his mind to choose when the end will come. I will not stand by and watch him suffer.”
Anna confirmed Thomas’s commitment to continue with his plans, and, when our physician completed his exam, he carefully reviewed with her the procedures outlined in Compassion’s guidelines and safeguards, as well as the administration of the required medications. When we said goodbye to Thomas, his farewell comment was that he wished he could buy the doctor and me a drink.
I came away from that first visit genuinely touched by Thomas as a man who cared for and loved his family. He had made it clear that his greatest concern was for the welfare of his wife and daughter. He did not want them to stand by helplessly and watch him go through a slow, painful death. His honesty, his sincerity, and his ability to maintain a sense of humor in the midst of his obvious pain moved me. There was something genuine and authentic about him. I liked him and left with the sense that it would be a privilege to assist him in this most important decision.
Two days later our physician submitted the following report to the Compassion office:
I visited with Thomas on September 24, 1995. The patient has
Medical records documenting the diagnosis of lung cancer, first diagnosed
In July 1994. He has lost 62 pounds in the last 15 months, has documented metastases to skull, right shoulder, and right leg (femur). He has had chemotherapy and radiation therapy. He now requires continuous narcotics for pain relief, and is eating very little. He has decided against any further chemotherapy. He is very mentally competent, and not depressed. He is fully aware of the consequences of his decisions. In my opinion, he is terminal with no more than 1-2 months to live.
I kept in close contact with Thomas and Elizabeth in the days that followed. I became very fond of them both, and I began to look forward to our frequent telephone visits. I also kept in touch with Anna, his hospice nurse, and it was she who informed me that Thomas had requested we both be present when the time came to hasten his death.
On Monday, October 9, I received an urgent telephone call from Anna telling me that Thomas had experienced a particularly bad weekend. She asked that I call his wife as soon as possible. When I reached Elizabeth, she told me that Thomas had endured a great deal of pain over the previous two days and had made up his mind that his condition had become unbearable. When I spoke to him, he could barely talk and asked if Anna and I could be with him on Thursday. By this time his physician, who was aware of Thomas’s plans, had prescribed a sufficient supply of the necessary drugs to effect a hastened death.
I Immediately called our Case Management Coordinator who closely monitors all patient relations. She told me that since neither Anna nor I had ever assisted a dying patient, it would be necessary to have an experienced case manager in attendance. Because of the short notice, I had some difficulty but was finally able to make arrangements for Sarah to assist me. I called Elizabeth and told her we would arrive to assist Thomas at 10:30 Thursday morning.
When Sarah and I arrived, Thomas was asleep. Anna had already prepared the medications and arranged everything on a tray. She had even included flowers. Elizabeth was making coffee and, when I asked how she was, she replied, “Don’t ask, it only makes me cry.” I introduced Sarah and we decided to let Thomas sleep. Elizabeth said her daughter Mimi had called and wanted to be in attendance. Sarah and Anna reviewed the instructions outlined in the Compassion protocol, which detailed the administration of the necessary drugs. There was an air of tension and apprehension with what we were about to do.
Mimi arrived as we made final preparations. I reminded them all that what we were about to do was an act of compassion done out of concern for Thomas and that nothing would be done without his expressed wish. By the time we were ready to wake Thomas, I felt we all shared a strong sense of commitment.
Thomas was confined to a small bedroom adjacent to the master bedroom. When we awakened him and introduced Sarah, he thanked us for our assistance. I reminded him again that he need only tell us if he had changed his decision. He was clear and adamant in his determination to proceed.
I was stunned by his appearance. In the short time since my last visit, he evidenced severe physical deterioration. He fought for every breath and could barely summon the energy to sit up. I could only compare his appearance to published pictures of Auschwitz prisoners. Despite his obvious weakened physical condition, he still maintained a remarkable mental presence and his wonderful sense of humor. He grinned and said; “Today is the day. Just tell me what to do.”
I noted by the clock at his bedside that it was 11:20. The protocol called first for Thomas to eat a small portion of food to be certain he had something on his stomach. Mimi had prepared some toast, and as Thomas slowly ate it, he turned to his wife with a sudden urgency and said that he had forgotten to give his favorite pair of sunglasses to one of his friends. Elizabeth replied that she would see to his request, with the added comment, “This man is a few heartbeats from meeting his Maker and he’s worried about a pair of damned sunglasses.” She then told us that Thomas had invited some of his Navy buddies to be with him a few days before. He had given then all his clothes and said his final good-byes.
At 11:45 Anna gave Thomas some additional medications. Compassion’s guidelines are very precise about the fact that patients must be able to ingest all of the medications by themselves. While Thomas took the pills with the aid of a glass of an orange juice substitute, he remarked that the astronauts took Tang to the moon, so he could take it on his way to heaven. While he seemed to be the most relaxed person in the room, the rest of us experienced our individual anxieties.
Anna had prepared the last of the prescribed medications in a cereal bowl. At 11:55 Sarah mixed these ingredients with a small amount of applesauce. She explained that it was important for Thomas to ingest the mixture quickly so that he would not fall asleep before he consumed the entire amount.
Elizabeth had prepared a quantity of vodka suggested in the protocol to help speed up the effect of the drugs. When Anna had made certain Thomas was seated in a comfortable, upright position, Sarah gave him the mixture with a spoon and instructed him to eat it very quickly. She cautioned him that it would be very bitter and not to linger over the taste. Thomas ate quickly and in obvious distaste. When he finished, he was given the vodka cocktail to help wash down the mixture. It was twelve noon.
We were all pleased the procedure had gone so well. Thomas again expressed his appreciation for our counsel and assistance. We were all somewhat shocked when he said he wanted to smoke a final cigarette. Mimi reached in the table drawer and produced a pack of cigarettes and a lighter. I asked for the lighter and told him I would consider it a privilege to be allowed to light it for him. With the cigarette in one hand and his vodka cocktail in the other, he leaned back with a gentle smile on his face and quietly prepared to take his final leap into eternity.
Sarah sat beside the bed and carefully monitored Thomas’s condition. When he said he was sleepy, she withdrew the cigarette and cocktail and helped him lie back in a comfortable position. He closed his eyes and whispered, “I want to rest.” Elizabeth and Mimi quietly went to the kitchen with Anna to wait. Sarah continued her vigil while I waited at the foot of the bed.
His head was laid back on the pillow, and he looked exactly like someone who was going into a peaceful sleep. After a few minutes, Sarah asked me to get the others from the kitchen. When we returned, Anna felt Thomas’s pulse and checked his heartbeat with her stethoscope. Elizabeth asked, “Is he gone?” Anna replied, “Yes.” It was 12:20.
Elizabeth and Mimi embraced. Anna busied herself by easing Thomas’s now still body into a prone position. Sarah and I simply stood in quiet wonder. I could not help but feel amazement at what had occurred. This was a death, yes, but even more, it was deliverance, liberation, a freeing from physical suffering and pain. It was a miracle, and somehow in those quiet moments, I had never felt closer to the presence of God.
We instinctively drew together in a circle, our arms around each other, and surrendered to the emotions of the moment. There were tears, but they were not tears of anguish or grief. There was no wringing of hands, but rather an extraordinary sense of accomplishment, a palpable sense of joy. Thomas had died a beautiful death, an easy death, and a good death. I was reminded of the words of Chekhov, “When we come to die God will take pity on us and we will live a life of radiant beauty. We will smile and in that knew life we shall rest. We shall rest to the sounds of angels.”
What happened next was as remarkable as what had just occurred. We adjourned to the kitchen and, in the wink of an eye, Elizabeth, Mimi, and Anna began to create a memorial celebration. They instructed Sarah and me to take seats at the table. Anna prepared an appetizer tray of humus, pita bread, and wonderful black olives. Mimi made fresh coffee and iced tea. Elizabeth served a dessert tray of fruit and cookies.
We were all famished and, with a combination of tears and laughter, we shared our thoughts and emotions. At one memorable point in this celebration of life and death, Elizabeth went to the living room and put on Thomas’s favorite record: Louis Prima’s rendition of “O Marie.” As she returned to the table, she paused and, in the direction of the small bedroom, announced. “That’s for you, Thomas.”
***********************************************************
Since this article was written Washington State passed an Initiative that resulted in enacting the Death With Dignity Act. Since then over 60 residents have used the law to hasten their death.
His hospice nurse, Anna, suggested he have his wife Elizabeth contact the office of Compassion in Dying, a small, nonprofit, charitable organization in Seattle. Compassion in Dying was organized in 1993 after the failure of a state initiative that would have allowed physician assisted death. Most of the group were members of the Hemlock Society dedicated to the promotion of information, counseling, and emotional support to terminally ill patients and their families. Compassion’s basic premise is that terminally ill patients who seek to end their suffering by a hastened death should not die alone. At the time of Elizabeth’s call, I had been a volunteer with Compassion for two years. My interest in this work was rooted in my career in estate planning and assisting families in preparing for the contingency of death.
At Elizabeth’s request, an information kit was mailed with a detailed outline of Compassion’s services and a copy of their guidelines and safeguards. Included was an explanation of what was required to accumulate the necessary drugs and an outline of the protocol Compassion suggests for a hastened death. The following statement accompanied the material:
This means of hastening death should be considered only by adult persons who are terminally ill and mentally competent. Persons considering ending their lives for emotional or other reasons are urged to seek help from a Crisis Clinic, counseling center, mental health professional, clergy, or other sources of crisis assistance.
At the same time, a request form that detailed the information about Thomas’s condition was completed by Compassion’s office staff and forwarded to the Case Management Coordinator for further review. I was asked to follow up with a telephone call to make certain they had received the material and answer any questions they might have. I spoke with Elizabeth who told me they had reviewed the material and asked if I would come for a personal visit. Since one of the requirements outlined in Compassion’s guidelines is a verification of the primary physician’s diagnosis, I explained a member of our medical staff who would examine Thomas would accompany me.
Thomas and his wife lived in a small, attractive home on Whidbey Island, about an hour and a half northwest of Seattle, a trip that included a ferry ride. When we arrived, Elizabeth who introduced us to Anna, the hospice nurse greeted us. Thomas was in a wheelchair, his face partially covered with the mask of an oxygen tank. He was a tall slender man, his appearance drawn and pale. He explained to us that he was at the stage of his illness where it was progressively difficult to breathe; he had no appetite, and felt weaker each day. Despite his obvious discomfort, he exhibited a sharp mind and a keen sense of humor.
He said that he had read and understood the requirements outlined in Compassion’s guidelines and safeguards. He assured us that he met all of them and that his personal physician had already prescribed half the necessary medication and that he would be able to obtain the balance within a week. When I asked him when he anticipated a hastened death, he said sometime within the next two months.
While our physician examined Thomas, I asked Elizabeth how she felt about Thomas’s plans. She made it clear that he had her total support and, while it was terrible to think of his loss, it was worse to watch him waste away to an inevitable death. “We are keenly aware of what the final stages of lung cancer can be like, and he has made up his mind to choose when the end will come. I will not stand by and watch him suffer.”
Anna confirmed Thomas’s commitment to continue with his plans, and, when our physician completed his exam, he carefully reviewed with her the procedures outlined in Compassion’s guidelines and safeguards, as well as the administration of the required medications. When we said goodbye to Thomas, his farewell comment was that he wished he could buy the doctor and me a drink.
I came away from that first visit genuinely touched by Thomas as a man who cared for and loved his family. He had made it clear that his greatest concern was for the welfare of his wife and daughter. He did not want them to stand by helplessly and watch him go through a slow, painful death. His honesty, his sincerity, and his ability to maintain a sense of humor in the midst of his obvious pain moved me. There was something genuine and authentic about him. I liked him and left with the sense that it would be a privilege to assist him in this most important decision.
Two days later our physician submitted the following report to the Compassion office:
I visited with Thomas on September 24, 1995. The patient has
Medical records documenting the diagnosis of lung cancer, first diagnosed
In July 1994. He has lost 62 pounds in the last 15 months, has documented metastases to skull, right shoulder, and right leg (femur). He has had chemotherapy and radiation therapy. He now requires continuous narcotics for pain relief, and is eating very little. He has decided against any further chemotherapy. He is very mentally competent, and not depressed. He is fully aware of the consequences of his decisions. In my opinion, he is terminal with no more than 1-2 months to live.
I kept in close contact with Thomas and Elizabeth in the days that followed. I became very fond of them both, and I began to look forward to our frequent telephone visits. I also kept in touch with Anna, his hospice nurse, and it was she who informed me that Thomas had requested we both be present when the time came to hasten his death.
On Monday, October 9, I received an urgent telephone call from Anna telling me that Thomas had experienced a particularly bad weekend. She asked that I call his wife as soon as possible. When I reached Elizabeth, she told me that Thomas had endured a great deal of pain over the previous two days and had made up his mind that his condition had become unbearable. When I spoke to him, he could barely talk and asked if Anna and I could be with him on Thursday. By this time his physician, who was aware of Thomas’s plans, had prescribed a sufficient supply of the necessary drugs to effect a hastened death.
I Immediately called our Case Management Coordinator who closely monitors all patient relations. She told me that since neither Anna nor I had ever assisted a dying patient, it would be necessary to have an experienced case manager in attendance. Because of the short notice, I had some difficulty but was finally able to make arrangements for Sarah to assist me. I called Elizabeth and told her we would arrive to assist Thomas at 10:30 Thursday morning.
When Sarah and I arrived, Thomas was asleep. Anna had already prepared the medications and arranged everything on a tray. She had even included flowers. Elizabeth was making coffee and, when I asked how she was, she replied, “Don’t ask, it only makes me cry.” I introduced Sarah and we decided to let Thomas sleep. Elizabeth said her daughter Mimi had called and wanted to be in attendance. Sarah and Anna reviewed the instructions outlined in the Compassion protocol, which detailed the administration of the necessary drugs. There was an air of tension and apprehension with what we were about to do.
Mimi arrived as we made final preparations. I reminded them all that what we were about to do was an act of compassion done out of concern for Thomas and that nothing would be done without his expressed wish. By the time we were ready to wake Thomas, I felt we all shared a strong sense of commitment.
Thomas was confined to a small bedroom adjacent to the master bedroom. When we awakened him and introduced Sarah, he thanked us for our assistance. I reminded him again that he need only tell us if he had changed his decision. He was clear and adamant in his determination to proceed.
I was stunned by his appearance. In the short time since my last visit, he evidenced severe physical deterioration. He fought for every breath and could barely summon the energy to sit up. I could only compare his appearance to published pictures of Auschwitz prisoners. Despite his obvious weakened physical condition, he still maintained a remarkable mental presence and his wonderful sense of humor. He grinned and said; “Today is the day. Just tell me what to do.”
I noted by the clock at his bedside that it was 11:20. The protocol called first for Thomas to eat a small portion of food to be certain he had something on his stomach. Mimi had prepared some toast, and as Thomas slowly ate it, he turned to his wife with a sudden urgency and said that he had forgotten to give his favorite pair of sunglasses to one of his friends. Elizabeth replied that she would see to his request, with the added comment, “This man is a few heartbeats from meeting his Maker and he’s worried about a pair of damned sunglasses.” She then told us that Thomas had invited some of his Navy buddies to be with him a few days before. He had given then all his clothes and said his final good-byes.
At 11:45 Anna gave Thomas some additional medications. Compassion’s guidelines are very precise about the fact that patients must be able to ingest all of the medications by themselves. While Thomas took the pills with the aid of a glass of an orange juice substitute, he remarked that the astronauts took Tang to the moon, so he could take it on his way to heaven. While he seemed to be the most relaxed person in the room, the rest of us experienced our individual anxieties.
Anna had prepared the last of the prescribed medications in a cereal bowl. At 11:55 Sarah mixed these ingredients with a small amount of applesauce. She explained that it was important for Thomas to ingest the mixture quickly so that he would not fall asleep before he consumed the entire amount.
Elizabeth had prepared a quantity of vodka suggested in the protocol to help speed up the effect of the drugs. When Anna had made certain Thomas was seated in a comfortable, upright position, Sarah gave him the mixture with a spoon and instructed him to eat it very quickly. She cautioned him that it would be very bitter and not to linger over the taste. Thomas ate quickly and in obvious distaste. When he finished, he was given the vodka cocktail to help wash down the mixture. It was twelve noon.
We were all pleased the procedure had gone so well. Thomas again expressed his appreciation for our counsel and assistance. We were all somewhat shocked when he said he wanted to smoke a final cigarette. Mimi reached in the table drawer and produced a pack of cigarettes and a lighter. I asked for the lighter and told him I would consider it a privilege to be allowed to light it for him. With the cigarette in one hand and his vodka cocktail in the other, he leaned back with a gentle smile on his face and quietly prepared to take his final leap into eternity.
Sarah sat beside the bed and carefully monitored Thomas’s condition. When he said he was sleepy, she withdrew the cigarette and cocktail and helped him lie back in a comfortable position. He closed his eyes and whispered, “I want to rest.” Elizabeth and Mimi quietly went to the kitchen with Anna to wait. Sarah continued her vigil while I waited at the foot of the bed.
His head was laid back on the pillow, and he looked exactly like someone who was going into a peaceful sleep. After a few minutes, Sarah asked me to get the others from the kitchen. When we returned, Anna felt Thomas’s pulse and checked his heartbeat with her stethoscope. Elizabeth asked, “Is he gone?” Anna replied, “Yes.” It was 12:20.
Elizabeth and Mimi embraced. Anna busied herself by easing Thomas’s now still body into a prone position. Sarah and I simply stood in quiet wonder. I could not help but feel amazement at what had occurred. This was a death, yes, but even more, it was deliverance, liberation, a freeing from physical suffering and pain. It was a miracle, and somehow in those quiet moments, I had never felt closer to the presence of God.
We instinctively drew together in a circle, our arms around each other, and surrendered to the emotions of the moment. There were tears, but they were not tears of anguish or grief. There was no wringing of hands, but rather an extraordinary sense of accomplishment, a palpable sense of joy. Thomas had died a beautiful death, an easy death, and a good death. I was reminded of the words of Chekhov, “When we come to die God will take pity on us and we will live a life of radiant beauty. We will smile and in that knew life we shall rest. We shall rest to the sounds of angels.”
What happened next was as remarkable as what had just occurred. We adjourned to the kitchen and, in the wink of an eye, Elizabeth, Mimi, and Anna began to create a memorial celebration. They instructed Sarah and me to take seats at the table. Anna prepared an appetizer tray of humus, pita bread, and wonderful black olives. Mimi made fresh coffee and iced tea. Elizabeth served a dessert tray of fruit and cookies.
We were all famished and, with a combination of tears and laughter, we shared our thoughts and emotions. At one memorable point in this celebration of life and death, Elizabeth went to the living room and put on Thomas’s favorite record: Louis Prima’s rendition of “O Marie.” As she returned to the table, she paused and, in the direction of the small bedroom, announced. “That’s for you, Thomas.”
***********************************************************
Since this article was written Washington State passed an Initiative that resulted in enacting the Death With Dignity Act. Since then over 60 residents have used the law to hasten their death.
