The following is an exclusive excerpt from the book “Uncaring: How the Culture of Medicine Kills Doctors & Patients,” which is available in audio book, ebook and hardcover. All profits from sales go to Doctors Without Borders.
This is a story about David, a colleague and friend at Kaiser Permanente who lived a beautiful life that was cut short by illness. In his final years, David and his family were faced with a difficult decision, one that raises important questions for all of us about ethics, morality, the law and the chioces we make at the end of life …
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The myths of ancient civilizations reveal that people have always been fearful of death and fascinated by the thought of immortality. In one ageless example, Hymn to Aphrodite tells of the human quest for eternal life. The Homeric poem introduces us to Tithonus, prince of Troy. He has taken a lover, Eos, the goddess of dawn. They make a handsome couple. Each morning, Eos glimmers with beauty. Her lover is himself a sight to behold: Trojan royalty with a warrior’s passion. And yet their love is cosmically unnatural. For a goddess, dating mere mortals is prohibited under divine Greco law.
So what’s a mythological couple to do? Eos, hopelessly in love, vows to do everything in her power to ensure that her relationship with Tithonus lasts forever. She whisks him away to her celestial palace, and there, with tears in her eyes, she pleads with Zeus, god of gods, to grant him immortality. Seeing that Eos truly loves Tithonus, Zeus agrees. But in her passionate haste, Eos commits an epic error. She asks that Tithonus be granted eternal life but forgets to request enteral youth for her lover, as well. As a consequence, the prince does indeed live forever, but his existence is marred by this grand mistake:
“She nourished him, keeping him in her palace with grain and ambrosia. And she gave him beautiful clothes. But when hateful old age was pressing hard on him, with all its might, and he couldn’t move his limbs, much less lift them up, then in her thûmos [roughly translated: heart, mind, and will] she thought up this plan, a very good one indeed: she put him in her chamber, and she closed the shining doors over him. From there, his voice pours out—it seems never to end—and he has no strength at all, the kind he used to have in his limbs when they could still bend.
Our hearts go out to Tithonus for his suffering. An eternity of infirmity: Could anything be more tragic? Though we might struggle to imagine the misery of living forever—unable to get out of bed or walk around freely—this ancient Greek tale is not purely mythical. The curse of Tithonus has been resurrected in modern times: not through the hubris of gods but through the actions of doctors.
The twenty-first century has granted humans access to medications and procedures that can extend life almost indefinitely. Ventilators can breathe for us, intravenous tubes and pumps can nourish us, and hemodialysis machines can filter wastes and excess water from our blood, all but replacing healthy kidneys. These present-day miracles, paired with around-the-clock nursing care, can turn any of us into Tithonus, alive but damned.
Until the second half of the twentieth century, the overwhelming majority of critically ill patients suffered from acute and urgent problems. Pneumonia and perforated intestines were far more common than chronic diseases. Although many people admitted to critical care units died, those who survived often recovered fully and lived normal, fulfilling lives.
Times have changed. Walk into any ICU, and you’ll find the majority of beds filled with frail, incapacitated patients in their eighties and nineties. Most will never be able to live without constant medical care. Many will never eat, breathe, or urinate again without machines. They’re too weak to get in or out of bed without assistance. Once discharged, they will languish and deteriorate, requiring hospital readmission within months if not weeks. Few if any will ever return to a vibrant life.
Helplessly, these patients lie in their beds as physicians, nurses, and technicians poke them with needles, drawing blood out and pushing medications in. They writhe in pain by day and endure sleepless nights. They tug at the plastic tubes extending from their mouths to their lungs and from their nose to their stomach. They are restrained and sedated. They suffer delirium, growing confused and paranoid. In the ever-distressing, noise-polluted, sick-care environment of today’s hospital, it’s not clear whether these patients are being treated or tortured. Doctors today are struggling to confront the reality that medicine can simultaneously preserve life while inflicting hell on earth.
The fact that humans can survive under such dire circumstances—or, rather, that medicine can extend their lives almost indefinitely—is considered by many to be a great scientific achievement. But like so many tragic protagonists of yore, doctors feel beset by the gifts they’ve been given. Physicians now wrestle with an ethical quandary that didn’t exist a generation ago. What should they do for patients who survive past the point that life is worth living? Indeed, modern medicine has advanced the medical frontier so far and so fast that the most pressing question isn’t whether we have the ability to keep every patient alive. Rather, the concern haunting physicians is, “Should we?”
For doctors seeking answers, the clearest (and most culturally supported) guidance on how to care for people in their final act of life comes from the American Medical Association’s Code of Medical Ethics. Here’s “Opinion 5.7”:
“It is understandable, though tragic, that some patients in extreme duress—such as those suffering from a terminal, painful, debilitating illness—may come to decide that death is preferable to life. However, permitting physicians to engage in assisted suicide would ultimately cause more harm than good. Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.
As if etched on a silver platter, these edicts prove more decorative than practical. Doctors are instructed to “save a life at any cost” and “first, do no harm,” but what should they do when these actions simply prolong pain and contradict the desires of patients? In opposition to the rigid proscriptions of doctors who lead the AMA and other medical organizations, elected officials in several states have passed Death with Dignity laws, which legalize certain forms of medically assisted death. One in five Americans now resides in a geography that allows terminally ill patients to end their lives with medical aid. In California, such a law went into effect June 9, 2016, making it legal for physicians to prescribe life-ending medications to patients who meet strict qualifications. The person must have a terminal illness with death expected in fewer than six months. Two doctors must concur the patient is of sound mind. And these individuals seeking eternal peace are required to administer their own life-ending medication without assistance from doctors or loved ones.
The week that this legislation was enacted, I received dozens of emails from physicians in our medical group. None of them wrote to ask for details on how to proceed. Rather, all of them wanted to be sure they would not be required to prescribe life-ending sedatives for their patients. The reaction reminded me of other medical-ethical issues from the past, such as performing abortions and prescribing medical marijuana under state law. For a few doctors, these actions violated personal or religious beliefs, and they felt morally bound to refuse. Most, however, just didn’t want to be directly involved. Doing so felt messy, time-consuming, and sullied. So it is with medical aid in dying.
Although it is now legal in numerous states for patients to shorten their suffering, people who are terminally ill often encounter difficulty finding a doctor willing to assist. A survey of 270 California hospitals, conducted eighteen months after implementation of the state’s End of Life Option Act, found that six in ten inpatient facilities had a policy forbidding physicians from participating, even though doctors who prescribe an aid-in-dying drug in accordance with state law are not subject to legal liability or professional retaliation of any kind. These hospital policies, which contradict state policies, leave doctors in ethically compromised positions. They must either stand idly by and watch their patients suffer or choose to challenge the rules of their hospital and the norms of physician culture. Either proves emotionally draining for doctors. They would rather not deal with these “messy” issues at all.
In the past, dying was simpler for both doctors and patients. Most people didn’t survive long enough to suffer slow, horrific deaths. Those who did expected nothing more from physicians than compassionate care on their way to salvation. Today’s doctors have difficulty knowing what’s best for their patients. And as such, it shouldn’t surprise anyone that burnout rates among critical-care specialists have soared in recent years.
The decision to end a patient’s life isn’t always uncomfortable. To explain, I want to introduce David, a physician, colleague, and friend.
David graduated from Yale Medical School six classes ahead of me. He stayed on the east coast for his residency in orthopedics while I ventured to Stanford University to train in plastic and reconstructive surgery. We both eventually accepted positions in the Permanente Medical Group in California, and that is where our paths first crossed. David’s office was in the orthopedic wing of the medical center, situated across the parking lot from the hospital’s surgery department, where I spent my days. I planned to operate on an eighteen-year-old patient with a complex hand fracture and wanted a second opinion about whether to immobilize it with a rigid plate or just insert a couple of metal wires. So I walked over to David’s office.
With the door propped open, I found him sitting behind his desk, leaning back in his chair, holding a patient’s chart above his face. From the doorway, I could see only his beard—full, rich, and rusty. I knocked. Without looking to see who was there, David stood up and began making his way over. Tall and handsome, his eyes met mine, and he welcomed me into his office with a toothsome smile. As he walked around the desk to shake my hand, I observed his right side dipping with an obvious limp. His leg swung in a circular motion like the side rod of an old steam locomotive. I did my best to pretend I hadn’t noticed. As a fellow physician, I could have asked him about it. In fact, it would have been natural for me to inquire, doctor to doctor. But there was something about David’s confidence and ease that made his imperfections seem somehow off-limits. As colleagues in different specialties, we didn’t work together often, but eight years into my practice, I suddenly became dependent on David’s surgical skill.
Early one fall, I led a team of plastic surgeons, anesthesiologists, and nurses from Kaiser Permanente to Mexico to operate on children with cleft lips and palates. Together, we procured supplies, packed them in cardboard boxes, and flew south with a pair of volunteer pilots. On our second day in the small town, I met up with an anesthesia colleague for our morning run. As we reached the main road, the sun edged up over the horizon, smearing the sky with oranges and reds. We must have been two miles from where we began, running against traffic along the shoulder of a narrow two-lane highway, when it happened. I didn’t see the truck shift into the passing lane behind me, but I heard it a split second before the driver-side mirror crashed into my right arm, fracturing it in multiple places just above the elbow.
In a panic, my running partner sprinted back to town for help. Forty minutes later, I was being helped into an airplane. The pilot hastily explained my options. Stanford University Hospital was only a couple of miles from the airport in Palo Alto he liked to use, but the University of San Diego was even closer. I shook my head at both suggestions and asked him to radio ahead for an ambulance to drive me to the Kaiser medical center where David worked. I wanted him to do my surgery.
I called from the plane and described the situation. At the emergency department entrance, David greeted me with yet another toothsome smile, one that exuded warmth and confidence. His demeanor was that of an experienced and well-trained physician, someone not easily rattled by a hideous and potentially career-ending injury like mine. He examined my arm, talked me through the procedure, ordered some X-rays.
Before he left, said something I’ll never forget: “Today is a wonderful day!” It seemed an odd choice of words, considering I was minutes away from major surgery with my arm severely fractured, my bone exposed, and my face contorted in pain. At first, I couldn’t tell if he was being sarcastic or glib or delusional. As I would come to find out over the next fifteen years, this was simply David’s outlook on life—captured in a mantra that his colleagues came to expect in delightful daily pronouncements. Like most of his patients, I found David’s optimism oddly reassuring, even contagious. I felt at ease under his care, a feeling that proved well-founded.
Two weeks after my cast was removed, I was back in the operating room, assisting with surgery. From that day forward, I smiled whenever I heard David’s full-throated laugh, and I never again doubted his rosy declaration that “today is a wonderful day.”
Throughout his career, David was regarded as a gifted surgeon and an effective physician leader with talent and ambition to spare. By the time he decided to retire, he had achieved more than most, even though he had chosen to call it quits at the relatively young age of sixty. At his retirement party, David told the crowd that he’d made two great decisions in his career. The first was going into medicine. The second was leaving it.
He relished the thought of having time to focus on two of his other passions. David was both a skilled craftsman and an animal lover. He held equal space in his heart for vintage furniture and the untamed beasts of the Serengeti. And, true to David’s demeanor, he combined his passions with exuberant creativity. Within a year of his retirement, David’s home in Santa Cruz brimmed with wild, wood-trimmed treasures. In the foyer was a Georgian armchair with the hand-chiseled feet and face of a Nile crocodile. In the living room, sat a vintage bench bordered by two elephant tusks carved out of oak. In the dining room, at both heads of the table, the faces of two perfectly textured lions emerged from the chairbacks, looking quite hungry.
After David’s retirement, we stayed in touch through mutual friends. In the years that followed, I enjoyed hearing about his growing acclaim as a woodworker and artisan. In 2017, nearly a decade after he left the medical group, I got a call from a colleague and close friend. Her voice cracked as she asked whether I’d heard the news about David. I confessed I hadn’t.
“I’m so sorry to tell you this,” she said, bracing me. “David is dead.”
She explained that he had taken his own life, passing away inside his home three days after the New Year. It felt oxymoronic at first blush: David choosing death. He was one of the liveliest and most optimistic people I’d ever met. He had the gravitational pull of Jupiter. Everyone wanted to be close to him. He radiated joyfulness and energy. David had a delightful family and a satisfying avocation. He’d enjoyed a productive medical career, followed by eight years of artistic and commercial success. Throughout his life, he garnered the near-universal respect of everyone he met.
As a fellow physician, I recognized that everyone dies eventually. But if there was anyone I would have thought incapable of choosing death over life, it was David. Seven months later, I reached out to his widow, Carol. I hoped the passage of time had dulled the pain of her loss, at least enough to explain what happened. A week later, we were sitting together in the living room of her home overlooking the ocean, talking about David’s love of both furniture and untamed creatures. We laughed as she remembered the time David boxed up a mahogany armoire (which resembled a black rhino in both shape and size) before shipping it cross-country as an unsolicited anniversary gift for old friends. He never once contemplated the possibility that they’d have neither the space nor taste for this quarter-ton creation.
Thinking back to the first time I met David, I asked Carol if she’d be comfortable telling me about the sole imperfection I had seen but failed to ask about: his limp. She graciously agreed, starting the story at the beginning.
As an incoming freshman at Dartmouth College in New Hampshire, David stood six-foot-three. While waiting in line to register for his classes—his head poking several inches above those of his fellow classmates—David was approached by several members of his dorm’s intramural football team. Though he hadn’t played in high school, he was flattered and looked forward to making new friends. His innate competitiveness and athleticism made him a natural, earning him a nickname: the Bearded Brawler. When fraternity rush came, all of the houses on campus hoped he would pledge.
But early one March day during his senior year, David’s life and body were turned upside down. All of his life, David loved to ski. Having grown up in Vermont, David chose Dartmouth in part for its proximity to the mountains. During a coed ski trip to the White Mountains, David lost control coming off an icy cornice, crashing headlong into a grove of white pines. In this pre-helmet era, he not only fractured his pelvis, but also suffered a major head injury. He was rushed to the nearest hospital, where he lay in a coma for two weeks.
Carol had met David just six months before the accident. He was beginning his final year of college, hoping to go to medical school at Yale, just a few hours south of Dartmouth. She was a sophomore, trying to figure out her future. She remembered their first date, a blind date, the kind of setup destined to send both singles home feeling disappointed. But the night defied all expectations. She recalls the magic of it. They agreed to meet at a campus library just north of the Dartmouth Green. Carol was walking down a long staircase from a second-floor reading room when she saw him waiting below. Carol was taken by how attractive he was. David would later confess that he fell in love as he watched her descend the stairs.
But now, seeing David in his hospital bed, Carol wasn’t sure he was going to make it. Even if he did, she worried he would be cognitively impaired for the rest of his life. Doctors put him in a refrigerated bed to keep his brain from swelling. She remembers that he had frost on his mouth and on his eyebrows. It was a terrible sight. Half a year into their relationship, their love was like a flower in full bloom. When he received his acceptance letter from Yale, they dreamed of long weekends in New
Haven and talked of their future together. Being that it was love at first sight, you can imagine how difficult it was for Carol to see David lying in a hospital bed, fighting for his life, just months after they met. She remembers seeing him in a full-body cast, in traction, unconscious. Sadness weighed on her day after day.
Looking back, Carol could’ve bailed right then. They were a new couple. Nobody would’ve blamed her. Besides, it was college. She was smart, attractive, and eager to embrace the fullness of her twenties. She could have had her pick of boyfriends. Perhaps David’s mom suspected as much. At the hospital, she encouraged Carol to stop visiting her son. “Move on with your life,” she insisted. But Carol wasn’t going to be told what to do or whom to love. She decided to stay. Every afternoon, she’d return to the hospital. At David’s bedside, she would run her fingers through his hair, stroke his rusty beard, and whisper words of encouragement while he slept.
Slowly, David began to emerge from the coma with retrograde amnesia. He could hardly remember anything. But whenever Carol went to see him in the ICU, she insists that David’s pulse sped up, something everyone in the room could see on the heart rate monitor. At first, David couldn’t even remember her name. To help jog his memory, Carol told him that they were together and in love. Still unable to recall, David looked around the room, then at Carol, then at the nurse adjusting his IV, and then he whispered to his girlfriend, “Have we slept together?”
Carol blushingly replied, “I’m not going to say. Let’s see if you remember.”
David gradually got his memory back. He remembered seeing Carol at the top of the staircase and falling in love with her as she walked toward him that first night. He eventually remembered almost everything, except the accident itself. He even remembered the answer to the embarrassing question he asked Carol in the hospital. In the months that followed, he learned to read and write again. Over the next two years, David underwent five surgeries, spending weeks at a time in a hospital bed, encased in plaster.
Carol stayed by his side through it all—through the cognitive rehabilitation, and the bed rest, and the infection that nearly cost David his leg. She cheered him on as Yale allowed him to matriculate. In recognition of his ongoing medical needs, the school provided accommodations to help him to master the basic science material in anatomy, physiology, and pharmacology, all from his hospital bed. And it was in that same hospital room that David proposed to Carol, more than fifty years before his death.
Sitting beside her, I could see Carol’s eyes welling up. They had only grown closer as time went by, she said. In their early years as a couple, she celebrated the wildness in her husband. He adored her in return. Carol was quite often the only stabilizing force in his life, keeping him close to earth even when his world seemed to be spinning out of orbit. She had accepted the challenges life handed him. She understood what he needed to get past the accident and through his surgeries. In the years that followed, she was the rock that helped David survive a string of hardships: various illnesses, career challenges, and a drinking problem that nearly ended their marriage. Decades after that, she helped him cope with age-related arthritis that limited David’s ability to create the furniture he dearly loved.
But of all the scares, bumps, and bruises, Carol remembered one incident in 2011 as a turning point, the moment their world started to fall apart. David was in the changing room at the gym when he started feeling dizzy. Next he felt pains in his chest, and he called out for help. An ambulance took him to a nearby hospital. There, in the emergency room, doctors came in and out, giving Carol bits of information at a time. When the medical team finally let her enter the curtained-off area, she wasn’t prepared for what she saw.
David’s skin was waxy, his eyes were rolling in the back of his head. Doctors couldn’t get a pulse. He was dying. Carol yelled into his ear, “David! David! Hold on, David! Hold on! Don’t let go! David, baby! Don’t let go!”
He didn’t respond immediately, but a few minutes later, David opened his eyes. He took a moment, looked around the room, found Carol standing there, and winked at her. With David resuscitated, Carol watched as the doctors wheeled him to the catheter lab. There, they unblocked and stented the occluded blood vessel, restoring the full flow of blood to his heart.
I smiled at this image of David, a big cat with nine lives. Time and again, he seemed to snap back to life—either literally or figuratively—at the sound of Carol yelling in his ear. So often it seemed David’s survival wasn’t the product of mere luck, or providence shining brightly upon him. With each close call, as he neared the edge, Carol was there to yank him back to safety and surer footing. She was his ballast against the storms, against his own demons. For half a century, he filled her life with love and endless adventure. In return, she grounded and protected him.
After the heart attack, David’s cardiologist ordered him to enroll in a rehabilitation program. Carol would accompany him as often as possible, and that’s when she noticed something odd. While walking through the parking lot on the way to the clinic in 2014, Carol noticed her husband scuffing his foot. She assumed David, ever the daydreamer, was lost in his thoughts, lazily shuffling along, perhaps planning his next beastly creation.
But perhaps it was more than that. David was getting older. Time, disease, and surgeries had taken a toll on his limbs. Carol could usually ignore these limitations, accepting them as nothing more than old scars. But this problem seemed different, more troublesome. It wasn’t long before David could barely clear the stairs with his bad leg. He took a few nasty tumbles. Then a few more. Within a month, he was falling all the time. Carol scheduled a visit for David with his primary care physician, Dr. Samuelson, and took a day off work to accompany her husband. She wanted to hear what the doctor had to say.
Dr. Samuelson, cognizant of David’s prior heart attack and his arthritis, put his stethoscope to the patient’s chest and inspected his hands. The doctor asked if David was having any trouble climbing stairs, and he said “no.” He then inquired if the anti-inflammatory meds were working, and David replied, “Yes, doctor.” Like good physicians do, Dr. Samuelson asked if there was anything else bothering him. “No, doctor,” David said, choosing not to mention his difficulty walking, the falls, or the fuzziness in his head.
Frustrated and fearful, Carol jumped into the conversation. With tears streaming down her cheeks, she told the doctor there was something terribly wrong with her husband. She explained what was going on: the scuffs, the falls, everything. Carol pleaded for help.
With eyebrows raised, the physician returned his gaze to the patient. “Okay, David, let me see you walk down the hall.” Sure enough, David struggled to lift his uninjured leg, so Dr. Samuelson ordered a battery of diagnostic tests.
The root problem, it turned out, was not easy to pin down. For an abnormal gait, the differential diagnosis (the totality of conditions that share similar signs or symptoms) is massive, filling entire sections of textbooks. David’s brain scans and nerve conduction tests were inconclusive. Physical therapy and a trial of high-dose steroids didn’t help either. His physicians tested for myasthenia gravis, then multiple sclerosis, and a host of other potential causes. They couldn’t identify the problem, nor could they rule out the worst. Over the next few months, the falls became more frequent. David’s ability to walk diminished. Soon he was forced to use a motorized scooter.
As Carol told me this, I was reminded of the paradoxes of aging: how quickly our world expands when we are little and how fast it contracts when we grow old. As newborns, our universe is measured by the size of our crib and then the length of the living room. As we grow, our domain expands. We discover the block surrounding our house. We ride bikes to new neighborhoods, drive to new towns, fly across the country, and then around the world. In our youth, each day is a new adventure, exhilarating and mind-opening. But by 2015, David’s world was closing in on him, sucking him in toward a dark and constricting unknown. Soon he would be confined to his house, then a room, and then finally a bed.
Neurological diseases can wreak havoc on the mind and body, but they torture their victims in different ways. Polio, for example, is compassionate. Though it can be devastating, physically, its severity doesn’t progress after the initial assault. Alzheimer’s is gentler, too. As the mental deterioration progresses, the patient is spared knowledge of its impact.
In contrast to these neurological conditions, there are a few that prove more sadistic. They completely spare cognition while progressively destroying all motor function. One such disease, amyotrophic lateral sclerosis (ALS), is a neurodegenerative condition that destroys nerve cells in the brain and the spinal cord. With it, weakness slowly grips the body, ascending the legs first, then the arms, and, finally, the diaphragm and chest muscles, ultimately choking its victims to death. It has been compared to sitting in a bathtub, motionless, as water slowly rises to your neck, then your lower lip, and to your nose. The only way to escape suffocation is by inserting a tracheostomy tube in the throat, making it impossible for the person to speak or breathe on their own. It’s a living hell.
David had long suspected that ALS was destroying his body, but he kept that concern to himself. Carol, normally the only one in the relationship willing to confront painful truths, wore blinders, as well, refusing to acknowledge the probability, even to herself.
Neither confessed their fears aloud. Both hoped they were wrong. In February 2016, David and Carol got their answer. As the doctor read the results from David’s chart, Carol climbed into her husband’s lap and wept. Though his arms were too weak to hold her, David did his best to comfort his wife, returning to her the emotional support she’d given him for half a century.
They both knew what the ALS diagnosis meant but hoped David might have anywhere from to two to three years left. It ended up being less than one. As the truth of his condition pressed on him, David bargained for whatever meaningful time he could get. Until that point, despite his physical challenges, he controlled his own destiny. Now that was longer possible.
Living with ALS means accepting progressive losses, followed by a series of retreats, then a few hard choices, each with the potential to be the last. In the months after his diagnosis, when he could no longer walk, David told himself that it would be a wonderful day if he could propel his own wheelchair. And when he couldn’t do that or make it out to his woodworking shop or even past the threshold of his bedroom without assistance, David was determined to make his last days on earth as wonderful as they could be.
It was early winter 2016. Normal seasonal illnesses were making the rounds, infecting neighbors and friends. They all recovered as healthy people do. But a chest cold hit David full force, knocking the wind and the spirit right out of him. Unable to cough or clear his throat, he was drowning in his own phlegm. He gasped for air with every word he spoke. Carol and David both knew the end was near.
David had stretched his point of no return beyond its logical limits. There were two remaining boundaries he refused to cross. First, he would not, under any circumstances, die in a hospital. He made it clear he was going to die at home. Second, he wouldn’t consent to having a tracheostomy tube placed in his throat. He couldn’t tolerate the thought of depending on a machine to breathe for him.
By early January, David had lost everything he was willing to lose. He was now left with a pair of final choices: how and when he wanted to die. In a way, luck was on David’s side. California’s End of Life Option Act had gone into effect the previous summer. Thus, two nights after New Year’s Day, David became one of the first California residents to sign his final papers, exercising his legal end-of-life option.
The next morning, he awoke in good spirits. As those closest to him arrived at the house, one by one, David looked out his bedroom door at the wooden treasures that filled his home. There was the crocodile armchair, the elephant bench set in oak, and the hungry lions poking out from the dining room—dear friends he would never see again. He was proud to have given life to these majestic creatures. They would live on long after he departed.
Friends and family took turns visiting David in his room, holding his hand, and saying their permanent goodbyes. David smiled widely at each of them and said, “I’m going home.”
A mixture of secobarbital capsules and applesauce was David’s final meal. Carol opened a nice bottle of Cabernet Sauvignon while the record player hummed songs from their youth. She toasted to incredible memories, to a life filled with joy, to more friends and wonderful experiences than most people could dream of.
As David closed his eyes, Carol ran her fingers through his hair, just as she did when they were college sweethearts. This time, there would be no yelling him awake. And for the first time in her life, Carol accepted there was nothing more she could do for David. She leaned over and whispered in her husband’s ear, “You can go now, baby. We will be okay.”
David died in his bed, surrounded by candles and family and dear friends. In the hours that followed, his wrinkles began to unfurrow as peace settled across his face. There was no more pain.
David went out the way he lived, on his own terms. And when he knew there was no way of making tomorrow a wonderful day, he decided to make the fourth day in January of 2017 his last.
How doctors view death hasn’t evolved or kept up with the changing beliefs and values of their patients. In a survey of more than one thousand Americans, people were asked what they thought should be the most important thing at the end of life. They were given two options. Seventy-one percent chose “helping people die without pain, discomfort, and stress.” Only 19 percent selected the other: “preventing death and extending life as long as possible.” These findings suggest most of us would choose to follow David’s example if given the option. Doctors can’t decide whether patients should have the choice.
At the request of David’s survivors, the names, locations, and identifying details included in this story have been modified. But my gratitude for David’s surgical skill and his friendship are both authentic and eternal. May he rest in peace.
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Dr. Robert Pearl is the former CEO of The Permanente Medical Group, the nation’s largest physician group. He’s a Forbes contributor, bestselling author, Stanford University professor, and host of two healthcare podcasts. Pearl’s newest book, “Uncaring: How the Culture of Medicine Kills Doctors & Patients,” is available now. All profits from the book go to Doctors Without Borders.
