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Marguerite
  1. J Carpenter
  1. Dakota Ridge Family Medicine, 2995 Baseline Road, Suite 210, Boulder, Co 80302 USA; julietindra.com

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    In the dialogue about assisted suicide, euthanasia, and palliative care, there is an often overlooked point of view. It involves opening the door in the patient to his or her own ability to let go of life.

    I had been physician to Marg for twelve years and we looked forward to our visits together. Six years earlier, the diagnosis and treatment of pernicious anaemia had led to improved mental activity and resolution of incontinence and vertigo. Shortly thereafter, she had signed a do not resuscitate (DNR) order and made it clear that she never wanted to live in any kind of nursing home or assisted living facility. She was fiercely independent, regal, courageous, and wilful. Well into her ninety first year, she lived alone.

    One day she fell; she managed to struggle to the emergency button. She was confused and incoherent. Her oxygen saturation was 67%. At the emergency room, she was diagnosed with pneumonia and admitted. The confusion was new; her speech made no sense. Magnetic resonance imaging (MRI) showed a new stroke in the occipital lobe. Afterwards she went to a nursing home for rehabilitation. She would wink at all passers by in the hall and say: “Marg go home”.

    When she left the nursing home, now unable to care for herself and administer her own medication, she was sent to assisted living at the facility where she had previously lived independently. She hated it, but refused to go to her daughter’s home to live. In less than a month, she fell again, this time tripping over the oxygen tube; she fractured her pelvis. Another admission. She wasn’t hungry anymore; even the slightest movement hurt. She sat tall in the chair after the breakfast she had just sampled. She knew who I was but could not articulate anything. Meanwhile we had started treating the heart failure and pneumonia which had developed over the preceding 24 hours.

    I leaned over and rested my temple against hers. I had already asked the usual questions: “Do you know where you are”; “What day is it”. We sat like that for a few minutes.

    Then I said: “You don’t have to go on like this”. Silence.

    “What will they do to me?”

    “Nothing you don’t want.”

    For the first time in two months, she was right there, every ounce of her concentration bringing her to this moment.

    Our conversation continued, punctuated by what would ordinarily have seemed like long pauses.

    “I don’t want to die.”

    “Are you afraid to die?”

    “No”, came her reply.

    “You won’t be able to live alone anymore. Your daughter wants you home with her. You will have to go to a nursing home first, and then to your daughters’. Would you go?”

    “Yes … This is so hard.”

    “I know. We’ll make you comfortable, give you medicine to help fix things; there is only so much we can do once the body is this old.”

    “So hard.”

    We sat a few minutes more.

    “When you don’t want to go on, you can stop eating.”

    I got up to leave, told her I loved her. She said she loved me too. About an hour later, she developed bradycardia, a very slow heartbeat, and over the next three hours died peacefully, holding her granddaughter’s hand.

    AFTERWORD

    Over the years I have been impressed by people’s ability to choose to die as if it is a choice that rises out of their spirit nature rather than their conscious volition. It often happens after the last loved one has arrived from far away to say goodbye or after some task or piece of art has been completed or, as in the case of Marguerite, where she had no other option if she were to remain true to her wishes. There is a peacefulness which surrounds death when this happens.

    As physicians we often look at issues around terminal illness in a black and white way, either attempting to save life at all costs or to medicate our patients into unconsciousness as they deal with the pain of dying, which then brings up issues of euthanasia and assisted suicide. It is not that I oppose the use of medication to ease pain. I feel there are other options for us, one of which is to help our patients to choose to let go, to give permission. When I say this I cannot lay out some formula. It is something which happens in the precious intimacy which exists between physician and patient, those moments when we look into their eyes, touch their hand, speak from the heart.

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