Old Books, Warm Cookies, and Death With Dignity

• death and dying
• Death with Dignity
• family medicine, patient-physician relationship
• physician-assisted suicide

Mary was my patient for one night, the night of her death. Our earthly relationship was brief, but as any family physician will tell you, quality relationships transcend time. That night still shows up in my soul.

Earlier that day, I was finishing up in clinic when my preceptor walked by.

A brief “hello.” And then, “Eric, what’s your experience with Death with Dignity?”

Remembering our didactic session from last week, I responded, “It allows terminally ill Oregonians to end their lives through the voluntary self-administration of a lethal dose of medication, expressly prescribed by a physician for that purpose.”¹

“Yes. Would you like to make a house call tonight?”

Hm, I thought house calls were a thing of the past, and having gone to medical school outside of Oregon, I thought Death with Dignity was something relegated to my undergraduate bioethics course. I never thought I’d have a chance to make a house call. Furthermore, 6 months into my intern year, I still had never been present for a death before. Never. But this is part of the “Calling,” that spirit of family medicine that drives us to show up for our patients, however they need it.

I felt something bubbling up from the part of me that has no words, compelling me, “Yes, I’m there.”

The man who opened the door was bathed in the warmth of incandescent bulbs, wearing a fuzzy cotton robe. Cheerful was not the right word for his demeanor, but he was, in a way, happy to see us. He was my patient’s second husband. Doting, silver-haired, gentle. Chatty and pleasant. He was Mr Rogers meets Rick Steves. He had been there since before the diagnosis of metastatic ovarian cancer. He had been there to help raise her children (they’re now his children, too). He had been there for the trip to Venice, and to Spain, and to China, and more.

He had been there to collect the old books with musty covers and antique film cameras displayed on shelves in their mid-century home. A wooden Möbius strip with dark finish, shaped like an infinity symbol, hung above the Eames era fireplace. On and on and on.

He led us to the living room where, sitting on a pull-out cot covered in plush pillows and a quilt of family photos, with her daughter by her side, was Mary.

A retired special-education teacher, Mary had dedicated her life to a “Calling:” she showed up and loved others at their most vulnerable. She welcomed my preceptor and me into her home like we were there for dinner, like we had sat in her living room a million times before, across the decades. A buffet of home-cooked desserts was offered. I took a few Hershey’s Kisses from the tray on the glass-covered coffee table, made from the helm of her father’s old sailboat, and began to nervously form a ball of tin foil the size of a marble that grew and grew as the night unfolded.

She asked about how our days had gone. She asked if we do this often. She asked how old I was. She asked why I was here. She asked how anyone could do what we do and not become horribly depressed. She was grateful for our services, though. She made this whole situation feel so normal: when people are ready to die, the doctor shows up to help them move on from suffering. It’s that simple, it seems; she put me at ease. If our patient wasn’t afraid, why should I be? She insisted we eat the home-baked desserts in the kitchen. She cracked jokes like we went to college together. She was so warm, and she was ready to die.

A tragic reality for patients with metastatic ovarian cancer begins when it bites onto their peritoneum and grows like wicked ivy. Then, fluid fills the abdominal cavity, incubating their organs in a broth of floating cancer cells and proteins that should really be kept within blood vessels. That makes it hard to have a breath capacity and blood pressure compatible with enjoying activities such as playing with grandchildren, making a pot roast, getting up to go to the bathroom, or breathing comfortably at rest.

Did you know a belly can swell so big it makes it hard to keep down food or fluid? With little fluid and no food intake, Mary had been living off the nourishment stored in the swelling of her legs and belly for, literally, weeks. No more dessert. No more fresh pasta in oil and basil at the small, cozy cafe overlooking the Grand Canal. No more Thanksgiving pot roasts. How long can one take that hell? Why keep suffering?

Oregon law attempts to give answers, under strict, specific circumstances, to patients who ask themselves those very questions. Our patient tonight had her answers.

Mary was able to answer those questions in the comfort of her own home. It was a palace of love, filled with all those campy trinkets, well-dusted cameras, musty old books, spunky knickknacks, yellowed photos, warm cookies and soft brownies, the black furnace, a funky wooden drawer shaped like a conga lady that I couldn’t open no matter what instructions she gave me, the Möbius strip that went to infinite, a doting husband, and an attentive daughter.

All love.

It was time to help Mary make her answer. Out of my preceptor’s black bag came the government-issued medications (sedatives and heart-stopping medications in doses adequate to put down a large mammal) and instructions for mixing. Bitter, white powders and tap water stirred in a glass of Mary’s choosing; we turned the kitchen sink into an apothecary. I looked at my preceptor as we mixed the powders; I felt the force of past practitioners, all of those who made house calls in the snow to be present with their mortal patients as they approached the threshold where they were to pass. This is the Calling. The honor. The unique, often routine privilege in a profession that vacillates between the banality of prescribing metformin and the intimacy of attending a death.

We poured the concoction into a large syringe, to be administered rectally, and brought it to her bedside in the living room.

“Will this hurt?” “Not at all.”

“How long does it take?” “Quickly for most.”

“How do I do this?” “We hold the syringe, but you must push the plunger.”

“Do you have any prepared last words?” “Nope, I’ve said my good-byes to everyone.”

“Feel free to keep eating desserts after I push this thing! I see you’re a big fan of the Hershey Kisses but please, eat a brownie!”

“Are you sure you want to do this? You can still say no.”

“Hell yes! I’ve been waiting long enough.”

She pressed the plunger, became light-headed, and drifted off into an opioid-benzo-coated dream.

And that was that.

Except it wasn’t. Mary didn’t die for another few hours. While she lay in her peaceful state, breathing silently, more and more shallow, we waited. Mary’s husband had gone to bed; he did not want to be present again until she had passed. Her daughter, a lovely presence in her own right, went out for a cigarette. My attending read the New York Times Book Review. I sat on the couch and explored the room, my eyes crawling over every inch of this palace of love, filled with reminders of why we all keep on living, and also, filled with one big reminder that living, inevitably, will end for us all.

Since I began this career, I’ve been obsessed with my own questions: What is my role as a physician in the lives of my patients? How am I going to practice that role? How do I follow my Calling? The answers to these questions will, if I’m lucky, stretch across the decades of my own life, changing in unexpected ways, so long as I keep my mind open to the possibilities for growth, beauty, and love...all I know is that these answers won’t end until I do. Until that time comes, I just try to answer these questions every day, in every way that I show up to practice this ubiquitously intimate profession, whether it’s to prescribe metformin or bear witness to the end of another human being’s life.

Mary passed away that night around midnight. Her husband and daughter thanked us for our time and our care. My preceptor and I packed up and drove home. I showered, brushed my teeth and went to bed after setting my alarm for 6:00 AM. I had to be on the wards the next day.

• Received for publication September 5, 2022.
• Revision received December 11, 2022.
• Accepted for publication December 13, 2022.

• © 2023 Annals of Family Medicine, Inc.