Wednesday, January 13, 2016

It's over, Debbie

It's Over, Debbie

The call came in the middle of the night. As a gynecology resident rotating through a large, private hospital, I had come to detest telephone calls, because invariably I would be up for several hours and would not feel good the next day. However, duty called, so I answered the phone. A nurse informed me that a patient was having difficulty getting rest, could I please see her. She was on 3 North. That was the gynecologic-oncology unit, not my usual duty station. As I trudged along, bumping sleepily against walls and corners and not believing I was up again, I tried to imagine what I might find at the end of my walk. Maybe an elderly woman with an anxiety reaction, or perhaps something particularly horrible.

I grabbed the chart from the nurses station on my way to the patient's room, and the nurse gave me some hurried details: a 20-year-old girl named Debbie was dying of ovarian cancer. She was having unrelenting vomiting apparently as the result of an alcohol drip administered for sedation. Hmmm, I thought. Very sad. As I approached the room I could hear loud, labored breathing. I entered and saw an emaciated, dark-haired woman who appeared much older than 20. She was receiving nasal oxygen, had an IV, and was sitting in bed suffering from what was obviously severe air hunger. The chart noted her weight at 80 pounds. A second woman, also dark-haired but of middle age, stood at her right, holding her hand. Both looked up as I entered. The room seemed filled with the patient's desperate effort to survive. Her eyes were hollow, and she had suprasternal and intercostal retractions with her rapid inspirations. She had not eaten or slept in two days. She had not responded to chemotherapy and was being given supportive care only. It was a gallows scene, a cruel mockery of her youth and unfulfilled potential. Her only words to me were, "Let's get this over with."

I retreated with my thoughts to the nurses station. The patient was tired and needed rest. I could not give her health, but I could give her rest. I asked the nurse to draw 20 mg of morphine sulfate into a syringe. Enough, I thought, to do the job. I took the syringe into the room and told the two women I was going to give Debbie something that would let her rest and to say good-bye. Debbie looked at the syringe, then laid her head on the pillow with her eyes open, watching what was left of the world. I injected the morphine intravenously and watched to see if my calculations on its effects would be correct. Within seconds her breathing slowed to a normal rate, her eyes closed, and her features softened as she seemed restful at last. The older woman stroked the hair of the now-sleeping patient. I waited for the inevitable next effect of depressing the respiratory drive. With clocklike certainty, within four minutes the breathing rate slowed even more, then became irregular, then ceased. The dark-haired woman stood erect and seemed relieved.

It's over, Debbie.

--Name withheld by request

From A Piece of My Mind, a feature in the Jan. 8, 1988, issue of JAMA (Vol 259, No. 2). Edited by Roxanne K. Young, Associate Editor.

An anonymous essay in The Journal of the American Medical Association, describing the killing of a cancer patient by a resident physician, has astonished doctors and touched off a struggle between local prosecutors and the American Medical Association, which has vowed to protect the author's identity...

The local authorities are investigating the case because both the A.M.A. and The Journal are based in Chicago. The Cook County State's Attorney's office has issued a grand jury subpoena seeking all documents in the case, and the medical association filed a motion in Cook County Circuit Court today to quash the subpoena...

The essay, entitled ''It's Over, Debbie,'' does not indicate when or where the incident took place. Some physicians question whether the incident took place at all.
The essay appeared without explanation or comment in a section reserved for personal commentary called ''A Piece of My Mind,'' and was published, over the objections of several staff members, because of the topic's importance, said Dr. George Lundberg, editor of The Journal. A Disservice to the Profession
Dr. Mark Siegler, a professor of medicine and director of the Center for Clinical Medical Ethics at the University of Chicago, said the essay did a disservice to the medical profession by giving the appearance of sanctioning the physician's behavior. ''This could change medicine profoundly and irreversibly,'' he said. ''It undermines the profession if the public believes that doctors have the power to kill people, and occasionally do.''.,..
The editors found the article disturbing from the start. ''We were blown away,'' Dr. Lundberg said. ''It simply arrived in the mail like any other manuscript. We knew immediately that this was extremely important and worthy of serious deliberation.'' ...
The Journal agreed to publish the article anonymously, a decision that breaks with scholarly tradition but that is not unheard of at The Journal...
Opponents of mercy killing say the essay only underscores their fears and arguments.
''This is a perfect example of why this kind of conduct should not be legalized,'' said Giles Scofield, legal counsel for Concern for Dying, a patient's rights group based in New York. ''Some would say there is a fine line between the withdrawal of treatment and active euthanasia. This doctor clearly crossed that line.''
Advocates of euthanasia also found the essay troubling.
''We're shocked by the speed and spontaneity with which it happened,'' said Derek Humphry, founder and director of the Hemlock Society, a Los Angeles-based group that promotes voluntary euthanasia. ''People say, 'Let's get this over with,' when the doctor comes in to draw blood. That's not a request for death.''
Some physicians say the essay points up a problem in the training of residents. ''The cold, bitter anger in the essay makes you wonder, 'What are we doing in the socialization of our doctors?' '' said Dr. Arthur Caplan, director of the Center for Biomedical Ethics at the University of Minnesota.
''There was a quick inference, an irresponsible leap and no consultation with anyone else,'' Dr. Caplan said. ''It was horrific, but it ought not cast a pall over a discussion of mercy killing.''
Dr. Siegler said he considered the case an anomaly, and called it ''a personal failing that goes beyond the system.'' But he said he feared that the appearance of sanctioning active euthanasia could change the way doctors approach their work.
''If you go to the bedside of a patient and the option of killing the patient exists, as it did in the mind of this resident, doctors will be less inclined to think of alternative medical possibilities,'' Dr. Siegler said. ''It will change the mind and attitude of even the most conscientious doctors. And patients will be afraid that their doctor may be a great believer in death with dignity when all they need is their asthma medicine.''
See below.  See Medicalization of suicide 9/18/15.  


  1. When we published, "It's Over, Debbie" in JAMA in 1988, the hullabaloo was massive. But this factual tale of a caring physician using intravenous morphine to end the horrid pain-wracked life of a young woman with terminal ovarian cancer shook a largely complacent culture. Next was Dr Timothy Quill and his disclosure in the New England Journal of Medicine in 1991 that he prescribed barbiturates at the request of a leukemia patient to allow her to end her life. Then, beginning in 1990, Dr Jack Kevorkian and his suicide machine assisted in the deaths of more than 100 patients; the right message writ large but by a deeply flawed messenger.

    On the American legal front, Oregon pioneered physician-assisted suicide by popular vote in 1997. With all of the built-in safeguards, only some 1200 people in nearly 20 years have asked for the medications to kill themselves, and nearly half of those have not even used them.

    The state of Washington followed Oregon in 2008, also by ballot initiative; then Montana, by court order; and in 2013, Vermont, by legislative action. Now, the big one: California Governor Jerry Brown, once on the Jesuit road to the Catholic priesthood, recently signed into law the End of Life Option Act. It will go into effect in 2016 in our largest state. Many more states will follow as we approach a tipping point.

    On the US federal front, Medicare tried years ago to institute payment for physicians to provide end-of-life counseling for seriously ill patients. But Sarah Palin's 2009 demagogic "Death Panels" harangue derailed that effort. At long last, the Centers for Medicare & Medicaid Services has approved payment for voluntary end-of-life counseling as part of its 2016 Medicare physician payment schedule. When you pay physicians to do something, they will do it.

    Finally, for the next driver in this phase of our metrics-crazed medical system, hospitals interested in their patient safety statistics might do well to note that much of what is chalked up as deaths related to medical error is actually occurring with the frail elderly, often in critical care units (CCUs). Many of these patients probably should not be in the CCU anyway. Maybe not even in hospitals. Most Americans say that they prefer to die at home, in the company of loved ones, not hooked up to tubes and contraptions, on meaningless and futile life support. Help your safety statistics; let the dying die at home.

  2. A week later she phoned me with a request for barbiturates for sleep. Since I knew that this was an essential ingredient in a Hemlock Society suicide, I asked her to come to the office to talk things over. She was more than willing to protect me by participating in a superficial conversation about her insomnia, but it was important to me to know how she planned to use the drugs and to be sure that she was not in despair or overwhelmed in a way that might color her judgment. In our discussion, it was apparent that she was having trouble sleeping, but it was also evident that the security of having enough barbiturates available to commit suicide when and if the time came would leave her secure enough to live fully and concentrate on the present. It was clear that she was not despondent and that in fact she was making deep, personal connections with her family and close friends. I made sure that she knew how to use the barbiturates for sleep, and also that she knew the amount needed to commit suicide. We agreed to meet regularly, and she promised to meet with me before taking her life, to ensure that all other avenues had been exhausted. I wrote the prescription with an uneasy feeling about the boundaries I was exploring — spiritual, legal, professional, and personal. Yet I also felt strongly that I was setting her free to get the most out of the time she had left, and to maintain dignity and control on her own terms until her death.

    The next several months were very intense and important for Diane. Her son stayed home from college, and they were able to be with one another and say much that had not been said earlier. Her husband did his work at home so that he and Diane could spend more time together. She spent time with her closest friends. I had her come into the hospital for a conference with our residents, at which she illustrated in a most profound and personal way the importance of informed decision making, the right to refuse treatment, and the extraordinarily personal effects of illness and interaction with the medical system. There were emotional and physical hardships as well. She had periods of intense sadness and anger. Several times she became very weak, but she received transfusions as an outpatient and responded with marked improvement of symptoms. She had two serious infections that responded surprisingly well to empirical courses of oral antibiotics. After three tumultuous months, there were two weeks of relative calm and well-being, and fantasies of a miracle began to surface. (continued)

  3. (continued)Unfortunately, we had no miracle. Bone pain, weakness, fatigue, and fevers began to dominate her life. Although the hospice workers, family members, and I tried our best to minimize the suffering and promote comfort, it was clear that the end was approaching. Diane's immediate future held what she feared the most — increasing discomfort, dependence, and hard choices between pain and sedation. She called up her closest friends and asked them to come over to say goodbye, telling them that she would be leaving soon. As we had agreed, she let me know as well. When we met, it was clear that she knew what she was doing, that she was sad and frightened to be leaving, but that she would be even more terrified to stay and suffer. In our tearful goodbye, she promised a reunion in the future at her favorite spot on the edge of Lake Geneva, with dragons swimming in the sunset.

    Two days later her husband called to say that Diane had died. She had said her final goodbyes to her husband and son that morning, and asked them to leave her alone for an hour. After an hour, which must have seemed an eternity, they found her on the couch, lying very still and covered by her favorite shawl. There was no sign of struggle. She seemed to be at peace. They called me for advice about how to proceed. When I arrived at their house, Diane indeed seemed peaceful. Her husband and son were quiet. We talked about what a remarkable person she had been. They seemed to have no doubts about the course she had chosen or about their cooperation, although the unfairness of her illness and the finality of her death were overwhelming to us all.

    I called the medical examiner to inform him that a hospice patient had died. When asked about the cause of death, I said, "acute leukemia." He said that was fine and that we should call a funeral director. Although acute leukemia was the truth, it was not the whole story. Yet any mention of suicide would have given rise to a police investigation and probably brought the arrival of an ambulance crew for resuscitation. Diane would have become a "coroner's case," and the decision to perform an autopsy would have been made at the discretion of the medical examiner. The family or I could have been subject to criminal prosecution, and I to professional review, for our roles in support of Diane's choices. Although I truly believe that the family and I gave her the best care possible, allowing her to define her limits and directions as much as possible, I am not sure the law, society, or the medical profession would agree. So I said "acute leukemia" to protect all of us, to protect Diane from an invasion into her past and her body, and to continue to shield society from the knowledge of the degree of suffering that people often undergo in the process of dying. Suffering can be lessened to some extent, but in no way eliminated or made benign, by the careful intervention of a competent, caring physician, given current social constraints...

    I wonder how many families and physicians secretly help patients over the edge into death in the face of such severe suffering. I wonder how many severely ill or dying patients secretly take their lives, dying alone in despair. I wonder whether the image of Diane's final aloneness will persist in the minds of her family, or if they will remember more the intense, meaningful months they had together before she died. I wonder whether Diane struggled in that last hour, and whether the Hemlock Society's way of death by suicide is the most benign. I wonder why Diane, who gave so much to so many of us, had to be alone for the last hour of her life. I wonder whether I will see Diane again, on the shore of Lake Geneva at sunset, with dragons swimming on the horizon.

    Quill TE. Death and dignity. A case of individualized decision making. N Engl J Med. 1991 Mar 7;324(10):691-4.

  4. It is hard not to feel compassion for this young woman who movingly explained her resolution on “I do not want to die. But I am dying. And I want to die on my own terms. Having this choice at the end of my life has become incredibly important. It has given me a sense of peace during a tumultuous time that otherwise would be dominated by fear, uncertainty and pain.”...

    "I would not tell anyone else that he or she should choose death with dignity," she said. "My question is: Who has the right to tell me that I don't deserve this choice? That I deserve to suffer for weeks or months in tremendous amounts of physical and emotional pain? Why should anyone have the right to make that choice for me?"...

    Let me be clear. Had Brittany Maynard come to me while weighing her decision to ask for my input I would’ve shared with her my ambivalence between faith and feelings. I could understand her fear of facing an unbearable future. I could empathize to the best of my ability with her desire to avoid seemingly certain horrors. Yet to her question – who has the right to tell me that I don’t deserve this choice? – I would have to answer: “Only the One who has given you the gift of life has the right to end it.” Taking the life of another is called murder. It is not because we have no right to take someone else’s life. It is because we have no right to take away life. So too, we have no right to take away our own existence from this earth.(continued)

  5. (continued)But shouldn’t we have compassion for those forced to endure future pain? My feelings beg me to consider the hardships; my faith reminds me that my concern is assuredly not greater than God’s, who is all merciful, all kind, and all loving and yet has still not decreed death.

    Suicide in the simplest sense is disagreeing with a Divine verdict for life. To the question of why? – Why should I continue to live when I am in so much pain? Why should I go on when I am only a burden to others? Why should I stay the course when the end I desire is in any event inevitable? – we can only find comfort in God’s response to Moses when asked to “show me your glory – let me understand your ways”: “Man cannot see Me and live… I will pass before you and you will see my back, but my face you shall not see” (Exodus 33:18 – 23). As mortals we can never fully grasp the why of God’s management of the universe. Yet there is one truth that often serves to give us a glimpse of His wisdom. We can never see His face; as life unfolds in its mysterious ways we are often perplexed by its seeming cruelties, bewildered by its inexplicable hardships. Yet oft times we can see “his back”; in retrospect, events take on meaning, difficulties recognizable as having had purpose...

    What needs still to be said is the danger of confusing compassion for Brittany Maynard with the kind of approval for her decision that has already made itself manifest in many circles. Assisted suicide poses a real danger to people with disabilities. Who is to say when multiple sclerosis or ALS are classified as “terminal”? Who will make the determination whether disabilities deserve death as ideal option? In the Netherlands, for instance, doctors are free to decide whether a child born with a disability should live. The government has come up with a guideline of standards and if the medical team believes that the child – or the parents – would face significant suffering, then that infant can be euthanized...

    Readers of my articles on may recollect my sharing with you the diagnosis I received in which my doctor informed me that I had a fatal illness for which there is no cure. Research on the Internet informed me that from the time of diagnosis I would have no more than six months to live. That happened almost three years ago. With great thanks to God and in almost all certainty as response to my prayers and the prayers of countless others, I feel fine today and hopefully look forward to the proverbial 120 years of life.

    All that is but another way of saying that suicide is wrong for yet another reason: It does not end suffering; it ends hope. It fails to admit the possibility for recovery, for medical miracles, for divine intervention.

  6. Reported in the "New York Times," Nov. 22, 1994

    and "National Public Radio," June 7, 1996:

    A Canadian farmer was convicted of second-degree murder in the death of his disabled daughter, causing debate among Canadians about mercy killing.

    Tracy Latimer, age 12, was in near-constant pain since birth due to severe cerebral palsy. She never learned to walk, talk, feed herself, or even sit up. She suffered from daily seizures and frequent vomiting. As her illness progressed her muscles were constantly dislocating her limbs, twisting her spine like a pretzel. Her pelvis was contorted and her hip had been dislodged for a year. Tracey's parents, Robert and Laura Latimer were involved in constant 24-hour care.

    With the feeling that he was doing what was right, Mr. Latimer put his daughter into the cab of a pickup truck on the family farm and piped exhaust fumes into it.

    He told the police that he was ready to stop the engine if she started crying, but she fell quietly to sleep. "My priority was to put her out of her pain," he said. The Latimers were known as especially loving and attentive parents to their daughter during her brief lifetime...

    Rabbi Tzvi Meklenberg (19th century Europe) writes in Haktav vi-Hakaballah:

    The seemingly repetitive nature of the verse in Genesis 9:5: "From the hand of every man; from the hand of every man who is his brother will I demand the life of man," refers to two types of murder:

    1) to the detriment of the victim ("from the hand of every man"), such as for revenge, money, etc.

    2) for the benefit of the victim ("from the hand of every man who is his brother"), when he is in great pain and would rather die than live.

    The Torah does not differentiate based on motive and reasons.

    By referring to the two ways in which one person might take another's life, the Torah does not differentiate based on motive and reasons. Both are equally prohibited.

    It is forbidden to cause the dying to die quickly, such as one who is moribund over a long time and cannot die, it is forbidden to move him so that he may die.But if there is something that delays his death, such as a nearby woodchopper making a noise, or there is salt on his tongue, and these prevent his speedy death, one can remove them, for this does not involve any action at all, but rather the removal of the preventive agent. (Rabbi Moses Isserles - Code of Jewish Law YD 339:1)

    The jury's decision to convict the Canadian farmer of murder is consistent with Jewish law.

    The only situation in which one is allowed to kill another person is when the other is a potential murderer, whereby such killing one might save one's own life or the life of another innocent person.

    The Torah defines this potential murderer as a rodef (pursuer), and therefore he forfeits his life. But killing someone who is not a threat to the life of another is ... murder.

  7. On October 6th 2015, Governor Jerry Brown signed a controversial “Death-With-Dignity” law into effect effectively marking one of the worst decisions by the state of California since outlawing Frisbee tossing at the beach without explicit lifeguard permission. This legislation was based on a similar law passed over 20 years ago in Oregon allowing for physicians to prescribe lethal medications to terminally ill patients, one which the Federal Government has taken issue with and one that as a religious Jew and a physician I am forced to take issue with myself.

    All of my colleagues went to medical school with different aspirations. But whether it was to ambitiously cure cancer or serve as a humble small town doc, not a single person I know went through the trials and tribulations of medical training to participate in physician-assisted suicide. The ancient and original code of physician-hood attributed to Hippocrates over two thousand years ago states, “Nor shall any man’s entreaty prevail upon me to administer poison to anyone.” For folks that aren’t history buffs, an updated version – The AMA’s Code of Medical Ethics – reads, “Physician assisted suicide is fundamentally incompatible with the physician’s role as healer.”...

    Addressing a patient’s wishes regarding declining aggressive care – involving intubation and resuscitation – is different than prescribing a lethal pill with the intent of hastening a patient’s demise. Alleviating pain and suffering and physician-assisted suicide are light years apart. One is providing care and the other is actively promoting death.

    As a psychiatrist, I am particularly concerned with the language of such laws requiring that a patient be deemed “mentally competent” to ask a physician to prescribe lethal medications. Would such competence be determined by a forensic psychiatrist? A court of law? Or a physician the patient had just met who happened to feel exempt from their profession’s official ethical code? In the past week, I have already been approached regarding a paranoid and psychotic woman who is “traveling to California to get euthanized because there isn’t any reason to live.” I can tell you she isn’t competent but who’s to say what would happen in California? “Mentally competent” is too subjective a term which is tremendously dangerous when life is on the line.(continued)

  8. (continued)From a Jewish perspective, physician-assisted suicide is a tragedy because life is a precious gift. The Torah teaches us, “I have set before you life and death, the blessing and the curse, you shall choose life so that you and your descendants will live” (Deuteronomy 30:19). Our Creator wants us to do the best we can with what we’ve been given. Chronic pain and illness are not an easy thing to live through; nor are they an indication that one should throw away the life they’ve been given...

    While the “Death-With-Dignity” legislation generally applies to “terminally ill patients” who will die within six months, such predictions are often premature with the limited tools available to modern physicians. I’ve witnessed miraculous recoveries myself in the hallowed halls of Harvard Med School and the Talmud is clear that giving up hope is not an option, teaching us the story of King Hezekiah’s own battle with “terminal illness” and stating, “even if a sharp sword is resting on your neck, you shouldn’t give up on divine mercy,” (Talmud Berachot 10A).

    Not that we need a reminder, but Maimonides is clear that both killing and suicide are absolutely forbidden, “Whoever causes the loss of a soul is considered as if he destroyed the entire world,” (The Laws of Murder and Protecting Life 1:16). As Rabbi Yitzchok Breitowitz – a Harvard-trained lawyer and an expert in the field of Jewish Ethics – once wrote, “Because all human beings are formed in the image of the Divine, all life is regarded as being of infinite value regardless of its duration or quality. As all mathematicians realize, infinity cannot be halved. If and when some human life is deemed to be less valuable than others, then life as a whole has gone from being infinite to being relative and the lives of us have become cheapened and debased.”

  9. Reported on Sept. 30, 1997

    Dr. Jack Kevorkian assisted in the suicide of a Colorado multiple sclerosis patient whose body was discovered in a motel room.

    A letter released by the office of Kevorkian's lawyer stated that Kari Miller, 54, of Englewood, Colorado, left a note saying she could no longer sit or lie down because of the excruciating pain, and could hardly walk. Her body was found at a Red Roof Inn in a suburb of Detroit.

    "The pain I was forced to live with and what the MS had done to me became intolerable," she wrote. MS "had robbed me of all my dignity and my zest for life."...

    The fact that the patient is in unremitting pain and pleads for assistance in ending his life does not change the law. Anyone who kills a dying person is liable to the death penalty as a common murderer.

    Active euthanasia, by means of an overt act to hasten death is prohibited, even if the patient is suffering great pain and discomfort, as explained by the following Talmudic and Rabbinic sources:

    One who is in a dying condition is regarded as a living person in all respects. (Talmud - Smachot 1:1)

    One may not close the eyes of a dying person ... Rabbi Meir would say: "It is to be compared to a sputtering candle which is extinguished as soon a person touches it - so too, whoever closes the eyes of a dying person is compared to have taken the soul." (Talmud - Smachot 1:4)

    Even the removal of a pillow when a person is in death throes, thereby hastening death, is forbidden. (Rabbi Moses Isserles, Code of Jewish Law)

    It is permitted to administer morphine, etc., to a dying person when necessary to relieve pain, even when though there is a known risk of hastening the [patient's] death, provided that the sole intention of the therapy is to relieve pain and suffering. This is only true if each injection, in and of itself, is not certain to shorten the patient's life, rather the cumulative effect may be life-shortening. However, in a case where even one injection of morphine might cause spontaneous respiration to cease, it is forbidden to administer this drug, even if he is in serious pain, unless the patient will be mechanically respirated. (Rabbi Shlomo Zalman Auerbach, quoted in Nishmat Avraham, Vol. 2, Yoreh Deah 339:4)

    Life, be it for 120 years, or a split second, is of infinite value - mystical, and unfathomable. Therefore the quality of life at any one moment does not alter its infinite value.