When Is It Time to Pass?

Get Permission

Assisted suicide gets a lot of press, as if it were a new event. About 20 to 30 years ago, it was ever present but neither defined nor acknowledged. When patients left the hospital for what they and I believed to be the last time, I did one or both of two things: gave them my home number or, if they wished, a follow-up appointment that they and I knew they would not keep.

Sir Murray F. Brennan, MD

Sir Murray F. Brennan, MD

There were clues as to what some planned. One patient on every prior visit asked for a narcotic renewal from the staff, although he told me he had little pain. There was a request from the funeral home to fill out the death certificate, as I was the last person to see him alive, and, yes, the funeral was the next day. Yes, they would meet me in the lobby to sign the certificate. Yes, I did that and recorded progression of his malignancy as the immediate cause of death—did I really know what had taken place though?

Personal Tale of a Patient’s Last Day

A more dramatic example was a high-profile physician inpatient who, after deciding he had had enough, not in pain but in indignity—unable to control his bowels, unable to deal with an ostomy, embarrassed by nausea and unheralded vomiting—announced to the staff that Dr. Brennan had agreed “when the time came, he would help me exit. Well, that time is now, and he will come by tonight.”

Imagine the furor that hit my clinic: “The assassin is coming.” I arrived that evening to the bedside, well, not quite the bedside. Staff, administrators, and ethics committee members were arrayed as a formidable army outside the patient’s door.

“You know euthanasia is illegal” was a foolish confrontation from one of the dark suits with little appreciation of the issues.

“Perhaps,” I said, “I should speak with my patient.”

“We will come with you.”

“No, you will not. There is enough damage done already.”

The patient, let us call him Dr. Courageous, was with his wife, who was completely composed. A prominent physician, author, bon vivant, accustomed to dealing with the rich and famous, just wished to talk about next steps. “It was time,” he said. “This is not a life I wish to live. You promised to help me when the time came.”

“Yes, I did, but your announcement to the staff that I would deliver a lethal injection here this evening was not exactly what I had in mind!”

“Fine. I wish to go home.”

“Sure, what else do you need?”

“Not much, perhaps a hospital bed?”

“I will write the discharge; you call for a car. The bed will not come until tomorrow.”

Exit me, the uniform army still arrayed in rank order, albeit farther down the hall, attracting unwanted attention from patients and physicians. En masse, they moved toward me.

“Thank you for your help,” I said. “Dr. Courageous has decided to go home; he does not wish to sign out against medical advice, and I agree with that. I will write the discharge order. Now, if you’ll excuse me, I have other patients to see.”

It was a long day, and I barely got to bed by midnight, when his wife called to say they would not need the bed, as he had died. I suppose today she would have said he “passed.” Passed where, I always wonder? Where do you pass to? I learned a week later he had taken the time to write some handwritten notes. One of them was to my children, thanking them for sharing me with him, so I could care for him and emphasizing he knew how much time he had taken from them. More courage, insight, and empathy. Time for me to look for that letter.

I still feel a dark foreboding as I think about that letter. I guess I knew what had happened, but I could never be quite sure. I wonder what the staff thought when I told them he had died the night he left the hospital. Did they secretly suspect I was the assassin? None were willing to confront me. Is there a hidden memo stored safely in the long-forgotten minutes of the ethics committee? Or even in my personal file of some previous Physician-in-Chief? Perhaps it was just “time for him to pass.”

‘A Time to Be Born, and a Time to Die’

There is an epilogue. A year or so later, another physician walked into my office asking me if I would review a computed tomography scan for him. “Of course.”

“It looks bad, doesn’t it?”

“How does the patient feel?” I asked.

“Oh, not bad, tired, not much appetite, losing some weight.”

Reading the name on the scan and the loose-fitting clothes on the physician in front of me, it was not hard to see that he was the patient. A brief discussion about the outcome of inoperable pancreatic cancer, the options and what to expect, and he was ready to leave. Quietly thanking me, he said: “You know, Dr. Courageous and I were friends.” It was then I recalled who he was and when I had last seen him: the evening before Dr. Courageous left the hospital. I apologized and began to speak. “No, no,” he smiled almost whimsically. “Will you help me as I helped Dr. Courageous?”

In sports, there are times to run, times to kick, and times to pass, but in life, as in death, there is no passing.

“To every thing there is a season, and a time for every purpose under the heaven: A time to be born, and a time to die” (Ecclesiastes 3:1-8). 

DISCLOSURE: Dr. Brennan reported no conflicts of interest.

Dr. Brennan was Chairman of Surgery at Memorial Sloan Kettering Cancer Center for 21 years and is now Senior Vice President of International Programs and Director of the Bobst International Center, Memorial Sloan Kettering Cancer Center, New York.

Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.