‘I’d Like to Choose my Own Way:’ VSED in the Non–Terminal Patient

In my palliative care clinic, I see a variety of patients and families who are faced with a life–limiting illness, and the bulk of my interaction has to do with symptom management and/or counseling around goals of care. So when a patient showed up on my schedule with the stated purpose to review advance care planning, it seemed a straightforward case. My fellow reviewed the patient’s past medical history and other relevant details (recent small stroke without residual deficits, otherwise a relatively healthy 78–year–old man) and then went into the exam room to begin the patient interview. A short while later, my fellow came out with a frown, saying “He wants to die, and he’d like our help.”

Request for a hastened end of life among the terminally ill isn’t new. Much has been written about how a conscientious and empathetic provider can explore the reasons behind such requests, to uncover the suffering (physical, spiritual, emotional) that underlies a desire to end one’s life. But this patient was different. As my social worker and I joined my fellow in the exam room, we elicited more of his story. He was an otherwise healthy, physically active older man who still worked in a consulting firm that he founded. Aside from a minor stroke and mild hypertension, he was without serious illness. He’d had a hip replaced last year, which he had tolerated well. He traveled, and enjoyed time with his children and grandchildren. Having borne witness, however, to the death of others including his first wife, he wanted to avoid the debility and loss of dignity that often preceded death, and wished to end his life “on [his] own terms.” This was not a new plan; indeed, he had researched legally acceptable means of ending one’s life for the past eight years, and was very knowledgeable about the legal precedents recently–passed physician assisted suicide. He informed us, then, of his plan to stop eating and drinking to bring about his own death, and asked if we could help guide him through this process and maintain his comfort while he approached his end of life.

Our conversation continued. Was he experiencing any debilitating physical symptoms? Aside from some mild joint pain, no. He continued to exercise at least sixty minutes day and enjoyed bike riding with his second wife. Was he depressed? He didn’t appear to be, and scored very low on the geriatric depression screening scale. Was there any spiritual distress? This he denied; though he had been raised Jewish, he was a self–described atheist and denied any spiritual concerns. Did he understand that he very likely had years left of a life of health and functional independence? Yes, he recognized that he likely did, but his recent small stroke had raised the specter of a slow but progressive and irreversible decline that he had feared for most of his adult life. He felt he had lived a long, productive and meaningful life, and wished to die “on a high note.” Had he informed his family (three grown children, second wife) about his plans? They knew in general what his wishes were, but he hadn’t yet told them that he was planning to move forward with his plan to stop eating and drinking, which he planned to implement in several months time.

My social worker asked more about what his past experience with death had been like. He discussed at length watching his father die in a nursing home some 20 years ago, and how for the years preceeding his death, his father hadn’t been able to care for himself or even recognize the people around him. He spoke, too, of his wife’s death a few years later from breast cancer. She had been on hospice, and despite this he identified that her final weeks and months of life were characterized by suffering and indignity. These experiences strongly shaped his desire to avoid such an approach to death and to maintain a certain amount of control...