The Gift: When a Patient Chooses to Die

"If I hand a man a baseball bat, I don't know if he'll hit singles with it or hit somebody over the head." Dr. Chalazian's voice on the telephone sounded defensive, but I tried not to project my interpretation onto someone I'd never seen.

"I'll be coming there on Sunday," I said. "It would be good if you could help with the morphine."

"This is a small town." Now I could tell he was angry. "If I give my patient a bottle of sleepers and he takes them all at once, that's not my fault. If I give him a prescription for a bottle that has 200 milligrams of morphine sulfate in it for you to inject into his vein, I'm involved. And I can't be—won't be. If the word got out that I helped kill Willis Strong, I might have to leave my practice."

He paused. "I'll make sure he has plenty of his sleeping pills on hand."

"Will you sign the death certificate?"

"Sure. I won't even know you were there."

He didn't hang up on me, but the conversation was over and we said goodbye, knowing we wouldn't be talking to each other again.

I thought: "To meet the schedule I've worked out with the Strong family, it's now up to me to write the morphine prescription for Willis and take it in to be filled." It was not something I'd be able to do again for another patient. I knew one pharmacy in the city where I ought to be able to pull it off. I went there.

* * *

This story is true, but I have concealed identities other than my own. My patient's name was not Willis Strong, but it should have been. He owned the only hardware store in his little college town of 2,000 permanent residents, 50 miles south of the medical center where I taught and practiced neurology. A big, bluff type of man who met strangers with comfort, he sold a lot of shelving and gave out a lot of how-to advice to weekend carpenters and plumbers.

My specialty in neurology was amyotrophic lateral sclerosis. In my small ALS clinic, I saw 20 or more new patients every year. Our established patients rarely missed their follow-up visits, despite the effort it often took to get them to the medical center—and despite knowing that I could not do for patients what all of us wanted: make them well.

I had known Willis for four years. His case was unusual because his breathing failed when his limbs and voice were still strong. Within a few months, he was wearing a cuirass respirator, a plastic shell that made him look as if he were under attack by a giant turtle as it intermittently sucked on his chest wall, making him take deeper breaths. He wore the chest shell all night and at times during the day. He even went on vacation with his respirator, to his fishing camp in the Adirondacks. It was available to give him relief from the labor of drawing breath. No complaints.

After more than a year with the cuirass, however, Willis needed a tracheostomy and supported ventilation. The positive-pressure ventilator was cumbersome, but he was still able to do a great deal for himself. He stopped going to work and, although he could speak understandably with the aid of a one-way valve in the ventilator tubing, he preferred to communicate by handwritten notes. We found out, through frequent attempts, that he could not be without mechanical ventilation for more than a minute without becoming severely short of breath. Moreover, swallowing had become difficult. He choked on liquids. Dr. Chalazian had arranged for him to have a nasogastric tube put down. Still no complaints.

There is a last straw for everybody. It differs from person to person. With Willis, it was that his legs began to give way. He could no longer get out of bed and onto a bedside commode without help. His...