May I Die?

The plight of Brittany Maynard has brought public attention again to the issue of patient control of his or her destiny, particularly as it relates to the timing and management of one’s own death. This lovely and bright 29 year old woman has faced her mortality after being given the diagnosis of unresectable glioblastoma multiforme that has displayed a relentlessly aggressive course. She has been informed about the expected decline in her health with the high likelihood of appreciable suffering. She and her family moved to Oregon, one of the few states that allow medically directed self determination of the end of one’s life when there is futility and suffering. She has chosen to die on November 1, 2014, after her husband’s birthday. Her choice to avoid debilitating therapies has provided her with the opportunity to travel and enjoy her family and do other things that have brought some measure of joy to a life too soon to end.

I relate Brittany’s courageous decision because a patient of mine came to me recently for a candid discussion regarding her own remaining time. She also had concluded, as Brittany did, that therapy for her third cancer, at age 81, would be too caustic and that any added months to her life not worth the suffering. She came to me to ask my permission to end her life in the comfort of her family at a time of her choosing.

Pat has been a patient of mine for 13 years, first presenting with Stage 3 breast cancer that required combination chemotherapy, radiation therapy and hormonal therapies. This disease lay fallow for the ensuing years.

Two years later she was found to have a form of lung cancer that is considered to be relatively nonaggressive and which usually remains limited to lung tissue. She underwent surgery and when there was local recurrence she was placed on Tarceva, a pill that blocks a cell surface receptor thus inhibiting a growth signal for the lung cancer. She has been taking it for the past 7 years with excellent control and minimal side effects.

Although courageous in her efforts to live with cancer, she has had immense fortitude withstanding 15 back surgeries that were required for severe scoliosis and disc disease. She has spent many months over the past decade in a recovery mode and her mobility has been severely restricted. Pain is a constant in her life.

Despite these immense medical burdens, she has faithfully come to see me every six months with a smile on her face and with her incredibly helpful aide by her side. I always looked forward to seeing her and I was grateful her cancer problems were under control and not a dominant issue in her life. Until her most recent visit.

I knew she had a problem after receiving a call from her asking my recommendation for a gynecologic oncologist at Columbia, where I work. She explained that a tumor had been discovered in her pelvis, thought to be ovarian, and she wanted her care here. I did not know what transpired until her visit with me.

She had a proper cancer operation for presumed metastatic ovarian cancer but the pathology was most consistent with metastatic breast cancer. This is not completely surprising, since there is a low risk of late relapse in this form of cancer.

She was offered oral chemotherapy in Connecticut where she lives, but after a few days she felt it was intolerable and chose to stop it. She considered other forms of therapy but after careful thought, she concluded that she preferred no further therapy because her current good quality of life allows her to enjoy her family and friends, much like the choice Brittany made.

Pat seemed embarrassed when she told me her decision. She thought I would not approve. It suddenly became quite clear to me that she had come to see me to ask my permission to end her life on her own terms. She told me she had enough of a certain medication that would be lethal if taken but she was afraid she would fall asleep too quickly and not finish the task. It was clear she had given a lot of careful thought to the process. She was informed about the organization called Compassion and Choices which has a presence in Connecticut and which is an advocate for self determined death with dignity. She had not yet reached out to them but awaited my response.

I told her that I completely understood the reasons for her deliberative decision and that I supported it. I knew the last decade of her life had been very constricted by her medical maladies and that pain has been a daily component. She rightfully could see no utility in attempting to prolong her life at the cost of more suffering. The only issue became how to end her life in peace.

I suggested she reach out to Compassion and Choices to see what resources they could provide. I also mentioned Home Hospice and morphine. She already was using oral morphine at night to control pain. I reminded her that it was a great drug for pain, respiratory distress and anxiety and it has eased the passing of innumerable patients at the end of life. I told her this form of dying can be very peaceful and comforting to loved ones as well as the patient.

This visit was almost unique in my experience since most patients are focused on life at any cost. I had great admiration for Pat as she so thoughtfully presented her ideas. I was honored to think she had such respect for me that my concurrence was important to her. I said good bye and kissed her, assuming this would be the last visit. She then asked, “When will my next visit be?” I was very surprised, but the twinkle in her eye told me her answer. She was buttressed by my approval of her decision. There will be no other visit.