Planning The Last Breath

It was the morning of Harvey’s death. For five minutes I stood in my bedroom, staring into the abyss of my closet, considering choices and discarding them immediately. I was at a complete loss. What does one wear to a scheduled death? Wearing all black seemed
morbid. Harvey was certainly not morose. Bright colors seemed inappropriate, too festive for the family. I wanted to look professional but not cold, casual but no jeans. How could this be the hardest part of my day?

Normal life was happening all around me, but nothing about this day would be normal. It was the day Harvey had chosen to die, and the day I had agreed to assist him. This event was all about Harvey, but it was momentous for everyone involved. And here I was, stuck standing in my closet, feeling anxious, or could it be excitement? Wrapped in a towel, hair still wet, momentarily stymied by the prospect of the day’s events. I had to pick up the medication at ten, I was expected at Harvey’s home by eleven, and I suspected he would be dead before noon.

In the end, I opted for gray jeans, a black sweater, and glasses in my hair. Casual but intelligent seemed the right look to go for.

That morning, there were eight close family members in Harvey’s home, and I said hello to each of them, aware that I represented an uncomfortable unknown and that I was probably provoking anxiety. I asked to speak privately with Harvey and was told he was in his bedroom at the end of the short hallway. I put down my bag of medications just inside the bedroom doorway, sat down in the chair next to the bed, and began.

“How was your night?” I asked.

“It was what it was,” he replied. “I’m ready to go. I need this to be over today.” Harvey did not hold back. He said what he meant: No need to soften any blows. The official purpose of this talk was for me to verify that Harvey was still capable of making this decision—that he was clear of mind, that he still wished to proceed—and, if so, to obtain his final consent.

“Are you having any second thoughts?”

“No, none at all.”

“OK, then let’s go over what’s going to happen.”

I reviewed the order of events. Harvey reassured me that his affairs were all in order: His funeral plans were made and already paid for, the names of his lawyer and his accountant were written out for the family to contact. He expressed some concern about those he was leaving behind. I tried to reassure him that I would provide them with some resources.

“Thank you for making this possible.”

I don’t recall who reached out first or when we began holding hands, but he was holding mine a little longer and a little tighter than expected. He didn’t let go when I thought our conversation was over, he clearly had something on his mind. I waited, stayed seated, said nothing, knowing it would come when he was ready.

“You know, I’m a little scared.”

“Of course you are.That’s OK.”

I caught myself. I wanted to answer him with the same degree of honesty he had offered me, but I wasn’t entirely certain what he was referring to. Did he mean he was scared of what he was about to do, of some unexpected discomfort or indignity? Or was he asking for more time? Had he changed his mind about proceeding? I quickly calculated my options and chose to give him a way out. “There is no rush, you know, we can wait a few more days if you prefer. Longer, even, if you want.”

“No, no, I want to go ahead today. I’m just a little scared,” he said again. He smiled, shrugged, almost apologetically.

And there I was, in an unexpected moment. I recognized that this was not a casual remark or an ordinary conversation; it would not be acceptable to simply pat his hand or placate. No. He wanted to address this, needed me to hear him, needed something. I felt a wave of self-doubt. What if I say the wrong thing? I was still learning. He deserved more, someone who knew what they were doing, someone who could guide him to a more settled place. Why weren’t my colleagues in palliative care here—isn’t this part of what they do best? Who am I to be the one? This hesitation flew through my mind in under a second. And then I understood; I was all that he had. He had many people in his life, of course, but in this confession, he had trusted only me. I tried to rise to the occasion, tried to be human, stayed curious. “Tell me, what scares you most?”

We talked and took the time we needed. No one was in a rush.

“What do you think comes next, Dr. Green?”

“I really don’t know, Harvey. What do you think?”

“I’m not a religious man, not even spiritual or whatever. But I don’t believe this is the end. It just can’t be.”

“Okay. But what if it were, Harvey?” I asked. “What would you change, do differently, or wish you’d done differently in your past?”

Our dialogue continued. I realized that expressing the question was as important as finding any answers. I listened, tried to discover what he needed to explore. He continued to hold my hand. I heard his regrets, there were few, and of what he was most proud. I learned so much from Harvey.

***

Assisted dying in some form or another is now available in many countries. In the United States, the most common term is assisted suicide, or physician-assisted suicide, in which a person can take his or her own life with a doctor providing the medications with which to do so. This term is meant to emphasize the essential element that the death is self-administered. The medication is primarily a drink, a foul-tasting mixture of barbiturates. In Canada, we offer both the self-administered drink and another option, which involves a health care professional administering the medications. Many describe this second option as euthanasia. The term euthanasia originates from the Greek eu, meaning good or well, and thanos meaning death.

***

One of my earliest memories of someone dying happened when I was a teenager. I don’t know who was calling that Sunday morning or how she got my name. She was an elderly woman from the synagogue whose family name I recognized but whose face I couldn’t quite picture; she was asking if I had a few hours free, might I be willing to help? She didn’t elaborate except to say that someone, a man I didn’t know, had died. The funeral, she informed me, was happening at 1:00 p.m., and they needed help at his house for the shiva, the seven-day mourning period in Jewish tradition where family and friends gather to offer condolences and support. I was to meet another woman at the house of the deceased and do whatever was needed; the other woman would instruct me.

On the day of the funeral, I walked the 15 minutes to the address she gave me and wondered what I’d gotten myself into. I was not especially scared, more curious than anything, feeling useful, in fact, and rather grown-up. I knocked at the door of the modest brick home, and as promised, another woman greeted me. She instructed me on what was needed to prepare the house for the mourners soon returning from the funeral. I covered the mirrors with cloth, as was custom. I laid out a bowl of water by the entranceway for the people to wash their hands. I left the front door unlocked and plated some food for the expected guests. I didn’t notice I was alone in the house until the telephone rang; I debated whether I should answer it or not. Those were the days before everyone had an answering machine; on the eighth ring, after no one had answered, I picked it up.

“May I speak with Mr. Morris, please?” asked a woman.

“Umm, he’s not here right now.”

“It’s Dr. Beck’s office, confirming his appointment on Tuesday.”

“I’m sorry to tell you, but Mr. Morris died yesterday.”

“Oh! I see. I’m sorry, I’m very sorry to bother you. I’m very sorry for your loss.”

I didn’t have time or even the words to explain who I was. Although I remember feeling nervous when I picked up the phone, by the time I replaced the receiver, I felt different, almost powerful.

I finished the preparations as instructed, and when the first mourners began to arrive, I slipped out the side door and walked home. I must have told my mother about my day, but I don’t remember sharing it with anyone else. Looking back, I wonder if this inspired me to consider walking into other spaces that felt unusual.

When Canada legalized medical assistance in dying I found myself at a crossroads. I had been practicing medicine for over 20 years, trained as a family physician, and focused on maternity and newborn care. As a maternity doctor, I prepared women and their families for birth and the profound transition that a new baby would bring to their lives, and I delivered their babies and helped them through those first chaotic months. But with the new law, I changed course, learning everything I could about this emerging field so that I could support people with their final wishes and their transition at the other end of life.

At both “deliveries,” as I call them, I am invited into a most intimate moment in people’s lives. Although some choose to die alone, the majority of my patients are surrounded by loved ones. I’ve witnessed their extraordinary final conversations, the whispered words of love between husbands and wives, the tearful goodbyes of mothers and children, the final advice between grandparents and grandchildren. I’ve seen people attend their own living wakes where friends and family gather to toast them before they go. When a person knows the hour and date of their death, they can plan their final words and actions with profound intention.

What if you could decide, at the end of your life, exactly when and where your death would happen? What if, instead of dying alone, in the middle of the night, in a hospital bed, you could be at home at a time of your choosing? You could decide who would be in the room with you, holding your hand or embracing you as you left this Earth. And what if a doctor could help ensure that your death was comfortable, peaceful, and dignified? You might never look at death the same way again.

***

I knew from the first moment I met Ed, he was an eccentric man. When he opened the door to his apartment, I was struck by the variety of handmade jewelry on his body: a row of bracelets, several necklaces, and multiple earrings. A small statue of the Buddha surrounded by various colored crystals sat on the floor behind him, and a strong smell of incense wafted out of the completely unfurnished space. I had been offering assisted deaths—providing medication and helping people to end their lives—for several months by then, and I had met some fascinating individuals, the courageous pioneers and the truly desperate, but still, Ed stood out. I got to know Ed and his story over several months while visiting him in various residences, or sometimes in the hospital, in Victoria, British Columbia. At 68, Ed was proud to say he had never held a job and had “lived the life of a free spirit.” He told me he had seen the world, chased his dreams, and had few, if any, regrets.

Like more than 65 percent of the people I work with, Ed had terminal metastatic cancer. His cancer had developed over four years, and never once had he consented to active medical treatment—avoiding chemotherapy, surgery, and radiation. His disease had progressed as expected and now was causing symptoms he couldn’t avoid. Ed’s pain was reasonably controlled, but his increasing need for narcotics, his deep fatigue, and his frequent, urgent trips to the restroom were severely limiting his ability to move around independently, which made it all but impossible for him to venture outside. Life confined within four walls was not a life for Ed. He was articulate in his explanation of the loss of meaning in his everyday experience, the dwindling of sand in his hourglass. He was a true believer in reincarnation, he told me, and was eager to move on to his next life.

Ed was also the first person to tell me he wanted to die alone.

When I arrived on the day of his scheduled death, he was in a small private hospital room, and we chatted for a while first. He seemed ready, eager to proceed, tired of waiting. After a few minutes, he excused himself to go to the washroom and returned wearing a full clown suit: tie-dyed pants and T-shirt, a colorful wig, and a red nose. He told me he hadn’t been sure if he was going to use the nose or not, but in the end, he’d decided to go for it. Despite all our previous conversations, I’d never realized Ed was an amateur clown. I asked him why he’d chosen to wear the clown suit on this day, and he told me he wanted to go out laughing. He figured this was his best bet.

I called for the nurse and, as Ed was having his IV inserted, excused myself to go see his friend Maggie, whom he had asked to wait in the quiet sitting area nearby. About 10 years his junior, she was sad but coping. I wanted to explain to her what would be happening even though she wasn’t going to be in the room with us, I also mentioned that Ed had put on his clown suit.

“Oh, good,” she said, “he felt sure that would make him smile. You should tell him a joke.”

I was open to the idea but at a bit of a loss for content.

“He helped me through a tough time a while back,” Maggie explained.

“We’ve known each other for over 20 years. He taught me the basics of how to be a clown.” She smiled broadly at the memory. “We even worked a few events together. I was terrible at it, but it wasn’t really about the clowning—it was about the friendship.”

Then she told me his favorite joke.

I headed back into Ed’s room. He was resting on top of the bedsheets, quite colorfully laid out. He was ready, he told me, and the nurse confirmed that all was in order. The nurse, a middle-age man, was a veteran in his profession, and as he finished packing up his IV supplies, he paused to look me in the eye. These were still early days in assisted dying, and I wasn’t sure what might be going on in his mind. Across the bed from him, I replanted my feet, lifted my chin, and readied myself for a possible lecture about how he couldn’t condone the work I was doing. But the nurse spoke quietly and explained it was the first time he’d been involved in a case of assisted dying. He wanted to thank me for my work. He believed having this option was important, that it was long overdue, and he was glad he could contribute in some way. I exhaled. I suspected he may have witnessed many deaths over the years that he might not have described as “good,” and his brief, unexpected remarks sparked a feeling in me of relief and being supported. I thanked him for his words and work, and he left.

“Are you sure you’re ready?” I asked Ed.

“I am certainly ready,” he said. He was looking straight up at the ceiling—not nervous, not sad, but not smiling.

“All right, I will begin.”

I was standing next to the bed on Ed’s left with the medications neatly lined up on the bedside table. Eight syringes in all; the middle two were quite large and filled with a milky-white substance. I administered the first dose of medication through the IV catheter in his arm. Often, I will guide my patient to a cherished memory, if appropriate. On this occasion, I leaned over and spoke close to his ear. I asked, “Ed, why don’t cannibals ever eat clowns?”

He turned his face toward mine with a big smile, and without missing a beat, he delivered his favorite punch line: “Because they always taste a little funny.”

We were nose to nose and both grinning from ear to ear, and as he turned his head back to a comfortable position, I heard him chuckle. Then he closed his eyes and fell asleep.

Stefanie Green, M.D., clinical faculty at the University of British Columbia, is the author of This Is Assisted Dying.

From This Is Assisted Dying: A Doctor’s Story of Empowering Patients at the End of Life by Stefanie Green, MD. Copyright © 2022 by Stefanie Green. Reprinted by permission of Scribner, a Division of Simon & Schuster, Inc. All rights reserved.