Voices: Death with Dignity

Death with Dignity | Michael L. Pearl, MD, FACOG, FACS

Some patients influence our lives in ways we never expect.

In July, 1989, I was a brand new chief resident, learning to manage an extremely busy and complicated gynecologic oncology service. With four active gynecologic oncologists, lengths of stay averaging a week and minimal outpatient chemotherapy, our inpatient census typically numbered in the 20’s.

Michael Pearl, MD

Michael L. Pearl, MD, FACOG, FACS

I, like my fellow residents in those days, worked long hours: getting to the hospital by 4:00 a.m. to prepare for rounds, rounds from 5:30 a.m.- 6:45 a.m., OR from 7:00 a.m. until the last case was done for the day, evening rounds, and home by 10:30 p.m. if we were lucky, efficient and not on our every-third overnight call. There wasn’t much time or energy for emotional or personal care of the patients.

Enter a remarkable woman who forever altered my life. She was young, with end-stage, recurrent endometrial cancer and intractable pain. When I asked her why she was being admitted, she replied, “So I can die in peace without pain.” Alas, despite receiving enough IV morphine to deplete the hospital’s supply, we were unable to adequately control her pain. Never shall I forget coming into her room each day and hearing her ask me, “Why am I still here?”

I found myself spending as much time as possible with her, listening to her talk about her life, her pain, her desire to die in peace and her frustration with the system’s barriers against letting her make her own choices about her death. We, the system, and I, failed her on two of her three goals. She ultimately died, not without pain or in peace, and certainly not in a manner or timing of her choice.

After 23 years of debate and at least seven prior proposals, California’s Governor Jerry Brown signed the “End of Life Option Act” on Oct. 5, 2015. With his signature, California became the fifth state to allow terminally ill patients to legally choose when and how to end their lives. California joins Oregon, Washington, Vermont and Montana as the only states where terminally ill patients can receive a prescription for life-ending drugs from a physician.

In order to receive a prescription for an “aid-in-dying drug,” individuals must meet a number of criteria including state residency, attestation from two physicians that the individual has less than six months to live, mental competency, and three requests for an “aid-in-dying drug” (two oral requests, at least 15 days apart, and a written request). The act provides protection for the individual, persons present when the individual ingests the drug, and health care providers. In addition, the act states, “death resulting from the self-administration of an aid-in-dying drug is not suicide, and therefore health and insurance coverage shall not be exempted on that basis.”

Governor Brown, a former seminarian who has had his own experiences with cancer, wrote in his signing statement, “I do not know what I would do if I were dying in prolonged and excruciating pain. I am certain, however, that it would be a comfort to be able to consider the options afforded by this bill. And I wouldn’t deny that right to others.”

Opponents, including religious organizations and disability activist groups, question the morality of the act and raise the specter of abuse. Marilyn Golden, a senior policy analyst for the Berkeley-based Disability Rights Education and Defense Fund, was quoted in the LA Times as saying, “This bill is simply about protecting doctors and HMOs from liability and tells people with disabilities who face a terminal diagnosis that may prove inaccurate that there is no dignity in our lives.”

As a gynecologic oncologist and a hospice and palliative medicine specialist, I have cared for innumerable women with incurable cancer at the end of their lives over the past 25 years. While we have come far with our ability to care for our patients, we, the system and I, all too often still fail to meet our patients’ goals to “die in peace without pain” and in a manner and time of their own choosing.

As Luther F. Cobb, the California Medical Association’s president, said, “Despite the remarkable medical breakthroughs we’ve made and the world-class hospice or palliative care we can provide, it isn’t always enough. We believe it is up to the individual physician and their patient to decide voluntarily whether the End of Life Option Act is something in which they want to engage.”

Despite the passage of the “End of Life Option Act,” it is clear that the debate is far from over. The issues remain the same on each side: an individual’s right to “die with dignity” at a time and method of their own choosing versus moral opposition to assisted suicide and the specter of the potential for abuse. Resolution of this debate, as is true for other controversial social issues, is vital to our ability to mature as a society.

Michael L. Pearl, MD, FACOG, FACS, is a Professor and Director, Division of Gynecological Oncology; Vice Chairman, Research and Faculty Development and Director of Women’s Cancer Services, Cancer Center at Stony Brook University Hospital in Stony Brook, NY.