Letter from Oregon — From the January 2016 issue

When I Die

An end-of-life doctor faces his own end

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Peter Rasmussen was always able to identify with his patients, particularly in their final moments. But he saw himself especially in a small, businesslike woman with leukemia who came to him in the spring of 2007, not long before he retired. Alice was in her late fifties and lived in a sparsely furnished farmhouse outside Salem, Oregon, where Rasmussen practiced medical oncology. Like him, she was stubborn and practical and independent. She was not the sort of patient who denied what was happening to her or who scrambled after any possibility of a cure, no matter what the cost. As Rasmussen saw it, “She had long ago thought about what was important and valuable to her, and she applied that to the fact that she now had acute leukemia.”

From the start, Alice refused chemotherapy, a treatment that would have meant several long hospitalizations with certain suffering, a good chance of death, and a small likelihood of truly helping. As the illness progressed, she also refused hospice care, though she did accept palliative blood transfusions. She kept meticulous track of her symptoms and hemoglobin levels; when she was too sick to come into Rasmussen’s office, she sent her husband with long, detailed letters full of updates and questions. She wanted to live until January 1, for tax purposes. Then she wanted to die at home.

“Last Bed,” by Virginia Woods-Jack

“Last Bed,” by Virginia Woods-Jack

Six months after Rasmussen started seeing Alice, he wrote in her chart about his admiration for her and her husband: “Together they are doing a wonderful job not only preparing for her continued worsening and imminent death but also in living a pretty good life in the meantime.” But there were more fevers and abscesses; there was more bleeding and weakness. Alice sent Rasmussen a card with a watercolor of flowers on the cover. “I don’t think I’m going to last much longer,” she wrote, “so I wanted to thank you now for letting me order my medical care à la carte.” In late January, she asked him to write her a prescription for pentobarbital.

Three days later he arrived at the farmhouse with four vials of bitter liquid — a handier form than he’d dispensed in earlier years, when he’d had to break open ninety capsules of secobarbital into applesauce or pudding. Though the law didn’t require it, he liked to bring the drug from the pharmacy himself, right before it was to be used, so that there would be no mistakes. It was one of the personal rules he imposed on the process to help himself feel less terrified.

Rasmussen made himself scarce during Alice’s goodbye with her husband, which was long and affectionate. There was no rush, he told her, as he always told his patients; he’d be glad to come back anytime. But Alice was sure. Rasmussen was impressed. “There was no prolonged final statement,” he remembered. “She just drank it down.” She fell asleep, and after a few minutes he interrupted her husband’s reminiscing to let him know that Alice had stopped breathing.

Over nearly three decades as a physician in Oregon, the first state to allow physicians to prescribe drugs for the purpose of ending patients’ lives, Rasmussen developed many strong beliefs about death. The strongest was that patients should have the right to make their own decisions about how to face it. He remembers the scene in Alice’s bedroom as “inspiring, in a sense” — the kind of personal choice that he’d envisioned during the long, lonely years when he’d fought, against the disapproval of nearly everyone he knew and all the way to the Supreme Court, for the right of terminal patients to decide when and how to die.

By the time he retired, Rasmussen had helped dozens of his patients end their lives. But he kept thinking about her. Alice’s pragmatism mirrored the image he had of himself and how he would face such a diagnosis. But while he had often conjured that image — had faced it every time he walked a dying patient through a list of inadequate options — he also knew better than to fully believe in it. How could you be sure what you would do before the decisions were real?

“You don’t know the answer to that until you actually face it,” he said later — after his own diagnosis had been made, after he knew that he had cancer and that he would soon die. “You can say you do, but you don’t really know.”

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lives in Seattle. She is a fellow at the Alicia Patterson Foundation.

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