A patient’s final decision

The woman, an artist visiting from Holland, was tall with dark hair and creamy skin. Although she had just turned 40 and seemed to be in otherwise good health, she had unexplained anemia.

At first I reassured her with benign possibilities -- laboratory error, her menstrual period, an unbalanced diet. At the same time, I also suggested a further work-up. She refused.

A month later, when she began to feel nauseated and tired with crampy abdominal pain, she agreed to a CT scan of the abdomen. It revealed a stone-sized density on the left side of her pancreas.

She later recalled the moment before seeing the scan as her final moment of freedom before being branded, defined by the diagnosis, as a young life in peril. From that moment forward, she was unable to think of herself without reference to her condition and how it polluted her life.

After the needle biopsy proved cancer, I sent her to a surgeon who offered a shred of hope -- an operation with a 10% chance of a cure when combined with chemotherapy. But the last illusion of her good health was punctured by his knife; the 10-hour operation was followed by a long painful recovery stretching over several weeks.

Afterward, she and I held to the slim chance of a cure. She hurried to show her latest art work at a local gallery, at the same time receiving chemotherapy. The medication made her vomit, and when she became dehydrated she carried intravenous fluids with her. She was a striking sight in my office waiting room, leaning against her IV pole as if it were a cane while talking on her cellphone to friends.

It wasn’t long before her cancer returned. A CT scan four months later showed that the parent tumor was gone but had spread its progeny throughout the abdomen, tiny seeds attaching to the peritoneal lining, where they quickly grew into hard little balls.

When the cancer spread to the bone and the pain began to intensify, she began to talk about dying.

I gave her morphine to make her comfortable. The drug lowers blood pressure even as it relieves advanced suffering. I tended to use high doses when a patient’s life was all about pain, when he or she was lethargic from the effects of cancer and oblivious to all but the suffering.

Such doses were difficult to justify for her, because she was still wide awake and had some quality to her life. I saw my role as helping to keep her alive long enough to say her goodbyes, not hastening her death with a comfort medicine.

But for this patient, that wasn’t enough.

In Holland, active euthanasia is legal, which means that a dying patient can ask a physician to inject him or her with a deadly drug. This process gives the physician a new power, choosing the exact moment and the cause of a patient’s death. It also requires that the physician decide when a patient’s quality of life has been so compromised that death is in all ways preferable.

When I received a phone call from her informing me that she was canceling her next appointment and returning to Holland, I at first felt rejected. Yet I also knew there was nothing more that I could do for her. I wished her well and she thanked me.

She did not seem to be depressed, but she’d clearly decided that the pain and weakness had overwhelmed whatever joy she had left. I was relieved to see her make her own choice, but I wasn’t comfortable with her plans.

I had been trained to preserve life at all costs -- and to relieve suffering at all costs. Sometimes the two goals were in conflict. It was easy for me not to help her end her life, because in the U.S. in most cases, physician-assisted suicide isn’t permitted.

Even if the law changes, I will still be ambivalent. Active euthanasia seems to go against my Hippocratic oath. In this case, I was especially concerned that the patient had made such a final decision while her life still had satisfactions.

Two weeks later I received another phone call, from her sister, relaying the subsequent events:

She admitted herself to a small hospital outside of Amsterdam. Her parents arranged for a small party at her bedside. Her oldest and closest friends were there. A CD player played her favorite jazz.

She drank champagne, ate fresh lobster, and for dessert had a large, freshly baked sugar cookie from the bakery she had gone to since age 3.

After her friends left, her parents contacted the nursing station where her family physician had been waiting. Her sister said he was kind. I wondered whether he reassessed her for depression at the end or asked if she wanted to reconsider.

I’m sure that her parents were sobbing. I heard that they stayed in the room as she curled up in the fetal position.

The woman wasn’t the kind to waver. Illness had taken control away, had dictated the terms of her life for many months; she regained control by choosing the circumstances of her death.

There are times when a doctor needs to be flexible about giving control to a patient. She taught me to be more comfortable in accepting a patient’s decision to make life and death choices without my direct guidance.

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Marc Siegel is an associate professor of medicine at New York University School of Medicine. He can be reached at marc@doctorsiegel.com.