DYING WISH
A pioneering doctor in medically-assisted dying recounts with compassion and honesty the first patient she helped to end his life
It is the morning of Harvey’s death. Normal life is happening all around me, but nothing about today will be normal. It’s June 16, 2016, the day Harvey has chosen to die. This event is all about Harvey, but it’s momentous for everyone involved. I drive slowly, but the trip to Harvey’s home passes quickly. I pull up along the kerb next to Harvey’s house, close enough to have arrived, far enough that no one from inside can tell I’m here yet. I notice an older gentleman wearing a golf cap quietly walking his little jack russell around the neighbourhood. I take a deep breath. In medical school, the saying was “see one, do one, teach one”. But in this case, there has been no way for me to “see one”. The law changed only a few days ago. I am about to take a big, blind step.
My heart is racing. Am I truly ready?
I leave the car and stride to the front door of Harvey’s house without looking back. I let myself in and kick off my shoes when I see the disorderly array of footwear just inside the door, then I head up the carpeted steps to the open living and dining room space. I catch Norma’s eye from across the room, but before I can get over to greet her, I meet Jessica, the nurse practitioner who will assist me, standing at the top of the stairs in her scrubs and stocking feet. We smile at each other and silently shake hands. She will be responsible for starting the IV we use today, but at this particular moment, all I can think of is that I do not want the family to suspect we have never actually met. I don’t want to do anything that might remind them I have never done this before. I can tell by how Jessica greets me, with a slightly forced familiarity, that she intuitively feels the same way. I know immediately we will get along.
There are eight close family members in the house this morning, and Norma introduces me to each one. I say hello to everyone politely, aware that I represent an uncomfortable unknown and that I’m probably provoking anxiety. I ask to speak privately with Harvey for a few minutes, and I’m told he is in his bedroom at the end of the short hallway on the right, so I head there. I put down the pharmacy bag just inside the bedroom doorway, sit down in the chair next to the bed, and begin. “How was your night?” I ask. “It was what it was,” he replies. “I’m ready to go. I need this to be over today.”
Harvey does not hold back. He says what he means: No need to soften any blows. This time I’m the one who appreciates the direct speech.
The official purpose of this talk is for me to verify that Harvey is still capable of making this decision – that Harvey is clear of mind, that he still wishes 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 review the order of events. Harvey reassures me that his affairs are all in order; his funeral plans are made and already paid for, the names of his lawyer and his accountant are written out for the family to contact. He expresses some concern about those he is leaving behind. I try to reassure him that I will provide them some resources, but I match his no-nonsense attitude. I don’t lie. I agree it will be difficult for everyone. We’re both speaking with an appropriate frankness.
“Thank you for making this possible.”
I don’t recall who reached out first or when we began holding hands, but once again, he is holding mine a little longer and a little tighter than expected. He doesn’t let go when I think our conversation is over. He clearly has something on his mind. I wait, stay seated, say nothing, knowing it will come when he is ready. “You know, I’m a little scared.”
“Of course you are ... that’s OK.”
I catch myself. I want to answer him with the same degree of honesty he has offered me but I’m not entirely certain what he is referring to. Does he mean he’s scared of what he’s about to do, of some unexpected discomfort or indignity? Or is he asking for more time? Has he changed his mind about proceeding? I quickly calculate my options and choose 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 says again. He smiles, shrugs, almost apologetically.
And there I am, in an unexpected moment. I recognise that this is not a casual remark or an ordinary conversation, that it would not be acceptable to simply pat his hand or placate. No. He wants to address this, needs me to hear him, needs ... something. I feel a wave of self-doubt. What if I say the wrong thing? I am knowledgeable but still learning. He deserves more, someone who knows what they’re doing, someone who can guide him to a more settled place. Why aren’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 flies through my mind in under a second. And then I understand; I am all that he has. He has many people in his life, of course, but in this confession, he has trusted only me. So I try to rise to the occasion, try to be human, stay curious. “Tell me, what scares you most?”
We talk, take the time we need. No one is 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 very spiritual or whatever. But I do not believe this is the end. It just can’t be.”
“OK. But what if it were, Harvey?” I ask. “What would you change, do differently, or wish you’d done differently in your past?”
Our dialogue continues. I realise that expressing the question is as important as finding any answers. I listen, try to discover what he needs to explore. He continues to hold my hand. I hear his regrets – there are few – and of what he is most proud. I learn so much from Harvey. His willingness to share his innermost feelings schools me in the profundity of this work.
At some point we both fall silent. I explain that I will go speak with his family to prepare them for what to expect. I promise to return in five minutes with his loved ones, and he nods his approval, looks away. The connection has passed. I hope it has been enough.
By now I’ve reassured myself that Harvey is still eligible and capable of making this choice. I hand him the required provincial form and watch as he scratches out an unsteady version of his signature. I tuck the form away for safekeeping.
I invite Jessica in to start Harvey’s IV, then head back out to the living room. I join the family. There are two men with scotch in their hands, one woman with what I think is gin. Norma is fussing with a balled-up Kleenex in her hand. Their grown children are staring blankly. Everyone is quiet, hesitant, and looking at me for answers.
“I want to go over exactly what will happen this morning, so there are no surprises,” I begin. “And we’re doing this here in the living room so you can feel free to ask me anything. Harvey has heard all of these details before, and he knows that we are talking.”
I explain the order of events, the number of syringes, and the time for last words. We review who will stand or sit where. I ask if there is any ritual or ceremony they’d like to incorporate, and then I get down to the details. “The first medication is an anti-anxiety medication called midazolam, and it will make Harvey relax, feel pretty good, pretty sleepy. He’s already quite weak, so I expect he’ll fall quickly into a nice light sleep.
We might hear him snore; that’s one way you’ll know he’s truly comfortable.”
I have their full attention. I am trying to be as transparent and informative as I can.
“The second medication is a local anaesthetic you’ve probably heard of called lidocaine. I use
I don’t recall who reached out first or when we began holding hands ...
it to numb the vein. It may not be entirely necessary if Harvey is sleeping already, but I want to be 100 per cent certain he is comfortable. Some of the other medications can sting a bit, so I’ll use this local anaesthetic to numb his vein to be sure he won’t feel any discomfort as we proceed.”
I notice involuntary nodding from his brother, his son. I recognise relief on Norma’s face and see blank stares on the others’ ... the reality is starting to sink in.
“The third medication is the stuff we would normally give someone to go to sleep for an operation, except it’s a much larger dose. With this dose of propofol, Harvey will go from his nice light sleep down into a much deeper sleep, down into a coma, and into a deep unconscious state over the course of a couple minutes. You won’t see much except that he is still sleeping. But if you’re looking carefully, you might notice his breathing begins to space out with this medication ...”
I am using my hands now, widening them to gesture and explain what is going to happen. “His breathing will also become more shallow at this time and will most likely stop.”
I am looking around at different faces, trying to judge reactions and ensure that all are OK while they are hearing this.
I lower my voice a little. “I will of course stay with Harvey the entire time, making sure things go smoothly and comfortably, as I have promised him. And a couple of other things I should mention: I do not expect you will see any gasping or twitching or anything unsettling. My goal is to make this as comfortable and as dignified as possible. But there is a real possibility his breathing will stop before his heart does. And if that’s the case, you will likely see some colour changes, a paling of his face, maybe a bit of yellowing.
His mouth might drop open slightly. His lips may turn a bit blue. If you find yourself uncomfortable at any time, please feel free to step back, sit down, or step out. There is no medal for staying in the room. I will be focused on what I am doing, so I’ll need you to take care of yourselves in those few moments, if necessary. OK?”
Muted nods. A few people breathe out as if they hadn’t realised they were holding their breath.
“Any questions about the procedure itself or what you can expect?”
No one says anything or dares to move.
As I head back into Harvey’s room, I’m followed only by his wife and children. Harvey’s bloated, bruised, and failing body is belied by his vivid green eyes. Opening wide when I walk back into the room, watching me carefully as I line up my syringes, his eyes are full of expression, still sparkling with life, and as I pull my chair in close to his bedside, they lock tightly on my own. I wonder what he sees reflecting back from my face. I hope it reassures him that I know what I am doing, even though we are both aware I have never done this before – never even seen this done before – and so I cannot truly know.
Harvey is calm, he is smiling, and he appears certain. His love for family has been evident from the start, and they are all here with him now. Norma is sitting on a chair tucked in tightly on his right side, leaning in, her face close to his; she is smiling and crying at the same time. Harvey’s children are reaching out to touch him – his feet, his legs, his hands. We are all huddled in closely around his bed, all faces towards Harvey, everyone present, just as he asked.
The support they give him in these final moments, putting his needs above their own, feels brave to me and very loving. I ask if anyone has anything left unsaid. Harvey’s son reaches
out from beside me and places his open palm directly onto Harvey’s chest.
He repeats that he loves Harvey and thanks him for being such a great dad. Harvey reminds them all that this is what he wants and asks them not to be sad.
I take hold of Harvey’s left arm. Only after he looks me in the eye and thanks me one last time do I think to begin. When I announce I will start, I sense Jessica reach out from behind me. I didn’t realise how tense I was until she put her hand on my back.
When I feel the warmth of her palm, I realise the circle is complete, we are all connected physically, and none of us is alone. I feel myself relax as I push the first medication through the syringe.
“Maybe now is a good time to think of a great memory,” I begin, “when you were doing something you loved, maybe with someone you loved doing it with ... Go to that place now, be there, and feel that moment again ... If you feel sleepy, go ahead and close your eyes, you’ve earned it. We’re all here with you now. We’re going to stay here with you.”
Then Harvey dies exactly as he wished: being held by his children and gazing into the eyes of his wife as he begins to feel sleepy. His wife of 52 years. They connect here, forehead to forehead, whispering to each other as I continue. She holds his face in her hands, strokes his head, and tells him it’s OK. She tells him she loves him, that she will miss him, but that she is all right. She whispers inaudible words, evoking private memories, and he smiles. The intimacy of this moment is so absorbing that I struggle to focus on what I’m doing. She tells him to let go, that she is here with him, and as on most nights of his life, hers are the last words he hears as he falls asleep.
Only after the last medication is delivered do I cap and lock the IV. Only after the empty syringes are resealed within the plastic container do I reach for my stethoscope. And only after I listen for a complete 60 seconds do I announce: “He’s gone.”
Only then do his family members allow themselves to be overcome by the loss they’ve all been suffering. There are vocal sobs, tightclenched hugs, and flowing tears. This man will be sorely missed.
To my utter astonishment, there is also an immediate outpouring of gratitude for what I have just done, and for this, I’ll admit, I was unprepared.
Dr Stefanie Green pioneered physicianadministered assisted dying in Canada. Voluntary assisted dying (VAD) laws have been passed in Victoria, Western Australia, Tasmania, South Australia and Queensland, and a bill is currently being debated in the NSW Parliament.
I’m not a religious man, not even very spiritual or whatever. But I do not believe this is the end. It just can’t be