On Our Own Terms: Moyers on Dying; 103; A Death of One's Own

On Our Own Terms: Moyers on Dying

#103 -"A Death of One's Own"

ANNOUNCER: Funding for this program is provided by the Robert Wood Johnson Foundation. Making grants to improve the health and healthcare of all Americans. The Fetzer Institute supporting programs that explore the mind, body and spirit. The Nathan Cummings Foundation, the Kohlberg Foundation, the John D. and Catherine T. MacArthur Foundation and by the Laurance S. Rockefeller Fund. Corporate funding is provided by Mutual ofAmerica. Building America's future through pension. and retirement plans, encouraging dialog and discussion. The spirit of America, Mutual ofAmerica.

BILL BARTHOLOME: Discovering what it's like to live in ...in the light of death.. .it. . .it just blew me away.

JOYCE KERR: Oh, they're lovely.

DR. DIANE MEIER: We will all die, but how we die, what happens before we die is under our control. DR.

DIANE MEIER: Fentanyl...400 micrograms ...

BENITA RESNICK: We'll do it to the best we can for as long as we can.

MARY KATHERINE MENIKHEIM: I'm not afraid of dying. I don't want to die anytime soon, but I'm not afraid of it.

GAIL HORVATH: Have you had enough breakfast?

DR, JOANNE LYNN: How we come to the end of life now is different. It takes different answers, new solutions.

JOE BROWN: He wants his life to end ...

MARCIE BROWN: Peacefully ...

JOE BROWN: ...on his own terms.

EDWINA TAYLOR: You are doing a wonderful job. You're a wonderful sister.

BILL BARTHOLOME: Here's to family and friends and love and ...

BILL MOYERS: Is it possible to achieve death on our own terms?

DR. DIANE MEIER: I've seen many people do it.

MOYERS: I'm Bill Moyers. Dying well, to many of us, means a measure of control over how and where we die. That basic fact has been lost in the bitter debate over the right to die. Under the media's glare, Dr. Jack Kevorkian framed the debate in the most simplistic terms: "Are you against physician-assisted suicide?" But talk to dying people themselves -and to their families and caregivers -and you learn that no one wants to die a minute too soon. How we take charge of those final days, however, depends on our personality, values, and beliefs; on the stage of our illness; on whether our pain is under control; how we bear the indignities; and whether the people around us understand what's happening and know our wishes. Having choices is part of good care; it's not just a simple matter of voting death up or down. So in this third program odor series, Dr. Kevorkian is not heard from. We hear instead from patients, loved ones, and doctors who talk about suffering and a death of one's own.

MOYERS: Was this sort of your retirement paradise?

JIM WITCHER: We had worked towards that and had everything in place for retirement.

MOYERS (v/o): JIM WITCHER IS A TEXAN WHO MOVED TO NORTHERN LOUISIANA TO DO THE WORK HE LOVES: VETERINARIAN, HORSE BREEDER, AND MEAT AND POULTRY INSPECTOR.

JIM WITCHER: We had built this farm here where we also had horses and -and thoroughbreds, and so I had two jobs. Susie had two jobs of taking care of the house and then running the farm when I was gone.

JIM WITCHER: How ya doing Eddie?

EDDIE: I'm doing pretty good doc.

JIM WITCHER: What do you think about the baby?

EDDIE: That's a big baby. Good bones, big baby.

SUSIE WITCHER: Okay Sweetie, gotta follow Momma.

EDDIE: Come on, come on.

MOYERS: Was it a good life?

JIM WITCHER: Wonderful life.

MOYERS (v/o): THIS IS WHERE WITCHER EXPECTED TO DIE ONE DAY. HE JUST DIDN'T EXPECT IT TO BE THIS SOON. IN 1997, AT THE AGE WHEN JIM & HIS WIFE SUSIE WERE DREAMING OF RETIREMENT, HE WAS DIAGNOSED WITH ALS -LOU GEHRIG'S DISEASE.

JIM WITCHER: It was just like a death sentence. That's the way it hit me.

MOYERS (v/o): ALS ATTACKS THE NERVOUS SYSTEM, LEADING TO GRADUAL DEATH BY PARALYSIS. THE MIND REMAINS ALERT, EVEN AS THE BODY SHUTS DOWN. WITH RAPIDLY PROGRESSIVE ALS, DOCTORS SAID JIM WOULD LIVE TWO TO FIVE YEARS. WHEN WE MET HIM HE WAS COMING UP ON TWO-AND-A-HALF YEARS.

SUSIE WITCHER: When somebody dies there's a finality to it and you probably get angry and then you get depressed and then you accept it and then you go on. With this, as each stage has hit him, its like he -another death and you die each stage and each stage you have to go through this being angry and depressed and then you get on with it and it's -it's just an ongoing thing and its something we have to accept, I guess, till however the disease takes his life. Every day I have to do more and more for him that he can't do anymore.

SUSIE WITCHER: Okay, ready?

JIM WITCHER: It started in my legs, so it's progressed up my body and I'm fast losing control of my arms.

JIM WITCHER: Help me get my hand up there where I can get started on this thing.

JIM WITCHER: It has affected my voice slightly. It will affect my swallowing and it

appears, in my case, the breathing will go last. Now all that I can" do is operate this

wheelchair. .

MOYERS (v/o): SINCE JIM WITCHER WAS FIRST DIAGNOSED WITH ALS, HE HAS SOUGHT THE LATEST TREATMENTS -GOING TO SPECIALISTS AT JOHNS HOPKINS UNIVERSITY HOSPITAL IN BALTIMORE AND TRYING OUT EXPERIMENTAL DRUGS. SUSIE WITCHER: So he's fought this; we've fought it.

JIM WITCHER: I've tried everything that anybody suggested that I thought, you know, had any merit.

SUSIE WITCHER: This was a man who was a collegiate wrestler. He was very athletic. Always held down two full time jobs. We've had a vet practice. We've had two farms.

JIM WITCHER: I don't know why in the mornings it's so hard to get my muscles going.

SUSIE WITCHER: Well they've been stiff all night long.

JIM WITCHER: I have been able to feed myself. It's not very pretty, but I'm still trying to do that, but I'm fast losing that.

SUSIE WITCHER: I'll call and ask.

JIM WITCHER: You lose just gradual control of everything up past your throat. Breathing, eventually, unless you take a respirator that breathes for you, you gradually can't breath, ofcourse, by that time, your swallowing, if you tried to swallow, you would inhale food or water into your windpipe because the muscles in your throat are gone, so you have to quit that.

SUSIE WITCHER: Neurontin.

MOYERS: So as it progresses, the next thing that's likely to happen is you will lose your voice? JIM

WITCHER: I am losing my voice at this time.

JIM WITCHER: Back it up so I can get my chin down.

MOYERS: And then what happens? You lose your ability to swallow? JIM WITCHER: To swallow. That's probably what's going to happen next.

SUSIE WITCHER: Okay, I'm going to pull you just a little bit, get you past this.

JIM WITCHER: Okay.

SUSIE WITCHER: Alright. Can you reach it? Here, I'll pull this way. Got it?

SUSIE WITCHER: You just have to take it day-by-day. Every day is a new day, and

before I get out of bed in the morning, I'm asking the Lord for strength physically to

be able to care for him.

SUSIE WITCHER: Ready?

JIM WITCHER: Mmm-hrnm. Okay.

SUSIE WITCHER: For compassion that I need, because I -I can fly off the handle pretty quick and get frustrated really easy, and -and this is all a new road for me to travel too, and -and I know I need to do something, but I don't know what or how.

JIM WITCHER: That feels good.

SUSIE WITCHER: I'm glad you still got good strength in your neck. I don't know what we're going to do when you don’t.

JIM WITCHER: At first you look back maybe six months to realize, well I could do that six months ago, now I can'!.

SUSIE WITCHER: Okay, while your head's soaking I'll go ahead and get you shaved.

JIM WITCHER: Then its three months, then it's a month that you could look back and know that you've lost something, and now it's daily.

SUSIE WITCHER: When I go to the grocery store, I'm worried about is he alright while I'm gone, you know, what if he falls out ofthe wheelchair or what if, you know, he needs a urinaL What if, what if, what if, what if, and we're out here in the country and I have nobody anywhere close that could come immediately and help him.

JIM WITCHER: Now there are ALS people that choose to go on a respirator, uh, for it to breath with and -and -and -and -and a stomach feeding tube when they can't swallow, and those people can live possibly ten more years with that type of-of help. I have chosen just not to go that route. Once I get paralyzed and can't move my limbs, and I'm not going to take a stomach feeding tube or a respirator, then I really wish that I could probably go on and figure out how to die at that time.

MOYERS: What are your options?

JIM WITCHER: Well, I'm not suicidal-prone and I wanted to live·as long as I could, but I would like to have it legal, to have physician-assisted, hastened death to where I would, if either would take an injection or if! could swallow at all at that time, just go ahead and take some kind of deal that would put me to sleep, and I would like to have my family there and my friends [choking up slightly].

MOYERS: If you could do what's best for you, what would you do?

JIM WITCHER: Maybe a month ago, I could have committed suicide with some drugs that a veter -veterinarians probably have. I probably have lost that ability. Vb, you don't realize how much you gonna lose, you know, in a month. I probably lost that ability. Can I have some water please?

MOYERS: So if you could, you'd have some doctor come and quietly give you enough morphine to help you die?

JIM WITCHER: Once -once I get to that stage, 'yeah, that was what I'd want.

MOYERS:. Well when is -when do you, what stage is it where you say to yourself no more?

JIM WITCHER: When I'm totally paralyzed up to the neck, can't swallow, can't and-and uh, you know, at that stage.

MOYERS: What can you do? What could you do?

JIM WITCHER: I'm not sure what I'm gonna do.

MOYERS: What would be a good death?

JIM WITCHER: A painless death where you just go to sleep.

MOYERS: And you've done that as a veterinarian for your animals haven't you?

JIM WITCHER: Many times.

SUSIE WITCHER: He made the choice that if there was any way that, I guess, he could have assisted suicide that's the way he would prefer to go, and he went to a lawyer and he drew up legal papers not to go on the respirator and not to go on the -on the feeding tube, so that's out of my hands and out ofthe family's hands, but I could -I could not myself give him a lethal dose of anything.

SUSIE WITCHER: Hey Jordan.

MOYERS (v/o): THE WITCHERS HAVE TWO GROWN CHILDREN, THEIR SON JAY LIVES NEARBY WITH HIS WIFE PAM AND THREE KIDS.

JIM WITCHER: Come on.

SUSIE WITCHER: Come on sweetie. Ye.a, darling.

MOYERS (v/o): THEY'RE STRUGGLING TO ACCEPT THEIR FATHER'S DESIRE

TO HASTEN HIS DEATH.

JAY WITCHER: It's getting to a point where he's just going to be able to lay in bed and that's basically it. I mean, you can't expect anybody in that situation to have to choose between -you know, taking a -a non-painful way out or having to suffer by refusing life support.

JIM WITCHER: He might take a flying leap.

JIM WITCHER: Hey. What do you say for Opah?

PAM WITCHER: I would want him to have another choice, but my belief system does not allow me to believe that the other choice is right.

JOEL WITCHER: Opah.

SUSIE WITCHER: Opah. Yeah, it's Opah.

JIM WITCHER: Yeah, it's Opah.

JOEL WITCHER: Ma!

PAM WITCHER: In our community, it's not an issue that I think has been discussed, physician-assisted suicide. It's just not something that's considered or discussed here.

SUSIE WITCHER: Okay, wait a minute. Let me help you down.

JIM WITCHER: Alright.

SUSIE WITCHER: Okay.

JAY WITCHER: With my dad, I understand it and I know what's going on, but I'm not -I'm not in his shoes, so I'm not dealing with those emotions that he's having to deal with. I'm dealing with my emotions that this is my dad, he's fixing to die and -you know, I want him to be happy and satisfied with whatever he's doing. But as far as talking in the community, nobody talks about it.

JIM WITCHER: Say Opah.

JOEL WITCHER: Opah. Hi.

JIM & SUSIE WITCHER: Hi.

MOYERS (v/o): ALTHOUGH JAY AND HIS FAMILY ARE CLOSE BY, SUSIE HAS BEEN RELUCTANT TO ASK THEM FOR HELP IN CARING FOR JIM.

SUSIE WITCHER: Pam, Jay's wife, teaches school.

SUSIE WITCHER: Yes. Jay has two full-time jobs and what we hate to do is take away from whatever little family time that they can manage to get together and urn, maybe this summer when -when Pam's not teaching school there'll be a little more time available, but right now it's just really an imposition to them.

JIM WITCHER: When I reach the point where I can't swallow or even where I -I can't move my arms, do anything, on my computer or anything like that -or come out and look at my horses, what I'd really like is just figure out how to go on and get it over with, because this is a terrible ordeal for me. It's been going on for the two-and-a half years and it's an even more terrible ordeal for my family and I just need it -I just need to go ahead and finish it.

KITTY RAYL: I think the first thing that runs through your mind are all the things that you wish you could do that you hadn't done. Hopefully, you're in a place in life where you don't have a lot of issues to resolve with people and fortunately I was in that place. I felt I was in a very good place in terms of my family. I think the hardest thing for me was to tell people that the time was short and for them trying to deal with

it because they went into a lot of denial and, you know, in some cases still are. That's

been the hardest thing.

MOYERS: They just can't face the world without you.

KITTY RAYL: Well-that'd be nice to think, but it's just-you know-seeing me die means they face their mortality too.

MAN: Good morning.

KITTY RAYL: Good morning. Thank you so much.

MAN: You're entirely welcome. Have a nice day.

KITTY RAYL: Bye. Thanks.

MAN: Bye.

MOYERS (v/o): KITTY RAYL IS 56 YEARS OLD AND LIVES ALONE. UNTIL

RECENTLY SHE WORKED AS A PURCHASING AGENT WITH AN ALARM COMPANY. EIGHTEEN MONTHS AGO SHE HAD A HYSTERECTOMY TO REMOVE CANCER. AT FIRST THE PROGNOSIS WAS GOOD, THEN

KITTY RAYL: About nine months later -after the original hysterectomy -I began to have back pain and sure enough I, you know, I had uterine cancer which when it spreads is -the way my doctor described it, he said it's not a good one. It's not one that has a history of being able to be cured and the time is not very good. It's usually very short. It could be a matter of months up to the longest he'd heard it was like five years, I believe. So I was hoping for the five years and it's come quicker than, than I had hoped.

MOYERS: You're not going to have those five years?

KITTY RAYL: No, I'm not. In fact, I -I'm -I'm doubt -I'm looking at months at this point.

MOYERS (v/o): KITTY TRIED THREE ROUNDS OF CHEMOTHERAPY TO SLOW

THE CANCER, THE LAST ONE JUST TWO MONTHS AGO.

KITTY RAYL: That was when I started having a lot of discomfort.

MOYERS (v/o): THE TREATMENTS AREN'T WORKING AND THE CANCER IS SPREADING. KlTTY'S CHOSEN TO BE AT HOME WITH HOSPICE CARE, COMFORT CARE.

FRITZE HAKKINEN: Hi.

KITTY RAYL: Hi, how are you?

HAKKINEN: I'm fine, how are you doing?

KITTY RAYL: Oh, I'm doing good.

HAKKINEN: Good.

MOYERS (v/o): FRITZE, KITTY'S HOSPICE NURSE, COMES SEVERAL TIMES A WEEK. SHE'S ESPECIALLY CONCERNED WITH TAKING CARE OF

KITTY'S PAIN. HAKKINEN: So how are you really feeling?

KITTY RAYL: Other than -than just, uh, weak, I feel fine.

HAKKINEN: Okay, the pain is less?

KITTY RAYL: Yes, it seems good today.

HAKKINEN: And how about yesterday?

KITTY RAYL: Yesterday was not a very good day my-it really bothered me.

HAKKlNEN: Urn hmm.

MOYERS (v/o): BUT KlTTY WANTS MORE THAN PAIN CONTROL AT THE END OF LIFE. LIKE JIM WITCHER, SHE WANTS TO CONTROL THE TIME AND CIRCUMSTANCE OF HER DYING. SHE CAN DO SO UNDER OREGON'S "DEATH WITH DIGNITY ACT", WHICH ALLOWS HER PHYSICIAN TO HELP HER DIE WHEN SHE'S READY.

KITTY RAYL: As you know, Oregon has a law that allows us to decide that we can -we can deal with this if we want and that we can get medication that helps us to -to die . . What I am watching for is just when I'm -I just can't -I -I -I -it's difficult 'cause I don't know. I don't want the point will be when I say it's time to do this, but, urn, I don't -I don't want to become a vegetable, I don't want to become so that I have to just lay and somebody has to come and spoon feed me and -I don't know, there's something about

MOYERS: You don't want to be helpless, do you?

KITTY RAYL: I don't want to be out of control. I think that's it. You don't want to be out of control. I -I've always been one who wants control over things and I want control over my -my decision to do that and I -I just can't think of anything worse than being helpless and -and, you know, there -there's nothing you can do.

HAKKINEN: Okay. Boy, it's up a little bit today.

KITTY RAYL: Is it? What's ...

HAKKINEN: Have you been moving around?

KITTY RAYL: Yeah, a little bit.

HAKKINEN: Okay. It's not because you're hurting?

KITTY RAYL: No.

HAKKINEN: No.

KITTY RAYL: No, I'm very comfortable.

HAKKlNEN: Alright.

MOYERS: What are the considerations you're weighing for when to choose?

KITTY RAYL: I don't really know. You take it a day at a time. So far, I've been able to stay at home.

HAKKINEN: And I'll listen to your heart.

KITTY RAYL: I'm getting very weak. It's even getting hard for me to get in and out of bed.

MOYERS: Uhmm.

KITTY RAYL: So, when you're getting to that place, you're starting to go uh, you know,

uh oh. What, you know, how am I going to handle this? What am I going to do? I don't know at this point what will press those decisions of what the next choice will be.

MOYERS: Of course, there's a gamble, isn't it, that you might reach that point where you can't do what you've planned all this time to do.

KITTY RAYL: Yeah, it's happened. Yeah, and I guess you just deal with it, you know, but I would hope that I -I know the point.

MOYERS: But, you clearly haven't decided to go somewhere else. You want to stay home.

KITTY RAYL: I would prefer that, yes.

MOYERS: You'd like to die at home?

KITTY RAYL: Yes.

MOYERS: I understand that. At this moment it's up to you. You could actually ask your doctor for the medication?

KITTY RAYL: Yes.

MOYERS: And she would give it to you?

KITTY RAYL: Yes, I could do it tonight.

MOYERS: Safely under the law she's protected?

KITTY RAYL: Yes.

MOYERS: You're protected.

KITTY RAYL: Yes.

MOYERS: And, you're just -every morning when you wake up, do you wonder if this might be the day?

KITTY RAYL: Ah, so far, not yet. Although it's -it's -it's starting to enter my mind more in the last week or so as I've seen my strength go and it get harder and harder for me to manage.

MOYERS: Why don't you want-

KITTY RAYL: I know the time -the time is coming, but this is a good day. I'm feeling fine. I've got a good book to read. My daughter's coming over later today. So, you know, things are Okay.

KITTY RAYL: Look at this one.

MOYERS (v/o): AS HER ILLNESS PROGRESSED, KlTTY AND HER YOUNGEST DAUGHTER, JAN, BEGAN TO ORGANIZE THE FAMILY PHOTOS, A WAY OF PASSING ON FAMILY HISTORY.

JAN RAYL KIERSTEAD: I know what -I remember that tree.

KITTY RAYL: That's -that's yeah that's Mesa, Arizona. Your tree.

MOYERS (v/o): BOTH KITTY'S DAUGHTERS SUPPORT HER WISH TO BE IN CHARGE OF HER DYING.

JAN RAYL KIERSTEAD: She talked to us about I guess just her thoughts about it and that she was looking into it and-

MOYERS: What did you think?

JAN RAYL KIERSTEAD: Well, I wasn't shocked. You know, I think that anybody in

this position would probably contemplate that. It wasn't a big surprise. To have some control

MOYERS: Have you all been talking about the, you know, about what happens now? About how you're gonna manage it? Are ...

KITTY RAYL: At this point we're pretty much taking it a day at a time and how we're feeling in ...

JAN RAYL KIERSTEAD: Yeah.

KITTY RAYL: In dealing with the, you know, living issues here. I don't think, you know, at this point it's...

JAN RAYL KIERSTEAD: We've talked somewhat about uh care options and, you know, when we get to point were we might need to hire a nurse full time or that kind of stuff, but I don't think we've talked about when you would maybe make that decision. I think she has gotten a little bit better about letting us know what we can do for her.

MOYERS: So caring is -is just really being here for her

JAN RAYL KIERSTEAD: Yeah.

MOYERS: when -when she needs you?

JAN RAYL KIERSTEAD: Yeah, and I think it's important to be able to bring Isabelle over here as much as possible and

ISABELLE KIERSTEAD: Ahhh.

JAN RAYL KIERSTEAD: [laughs]

JAN RAYL KIERSTEAD: Yeah.

ISABELLE: Bahh.

JAN RAYL KIERSTEAD: Bahh.

KITTY RAYL: That's the hardest thing my granddaughter and my-daughters, you know. They're young and just getting on with their life and they're-they're wonderful and I just, you know, I'm -I'm sorry I won't be there to go through life with them [choking up].

KITTY RAYL: I think you should have control over your life and dying is one of those things that's a part of your life.

MOYERS: And, it's not as if you want to leave prematurely. I mean, you're trying to take every day

KITTY RAYL: Oh, I'm -I'm wringing every day out. Yes. Yes. I want every day that I can get. You know, it's when you reach that point where, urn it's no longer bearable and I don't know what that will be, then I want to be able to make that decision.

MOYERS (v/o): JIM WITCHER'S BODY CONTINUES TO WITHER. AS HIS PHYSICAL CONDITION DETERIORATES, THE FINANCIAL BURDENS MOUNT.

JIM WITCHER: I guess about half of my estate that I'd built up probably is gone now. We had 240 acres and we've sold off about half of it.

SUSIE WITCHER: This wheelchair probably sells for about $24,000; the van if I bought that equipped the way it is new, it'd probably be about $45,000. We had to do some remodeling on our house for me to roll him into a shower and bathe him. You're looking at another twelve to fifteen thousand. It's astronomical.

MOYERS (v/o): JIM'S ILLNESS WOULD HAVE WIPED THEM OUT FINANCIALLY IF THEY DIDN'T HAVE GOOD HEALTH INSURANCE. IT COVERS EIGHTY PERCENT OF THEIR MEDICAL BILLS AND WEEKLY VISITS BY A PHYSICAL THERAPIST. BUT IT DOESN'T PROVIDE FOR SOMEONE TO DO FOR JIM WHAT SUSIE DOES AND NOTHING COMPENSATES FOR THE EMOTIONAL IMPACT ON BOTH OF THEM.

SUSIE WITCHER: He's had to accept so much and give up so much. He has sworn that when I have to feed him that he don't want to live any longer, you know.

MOYERS: Do you get depressed?

SUSIE WITCHER: Yes sir. I don't see how you could not and I think that's just part of it.

SUSIE WITCHER: Try not to cry when he can see me. Pray.

MOYERS (v/o): FOR SUSIE THE SACRIFICES OF CARING FOR JTh1 ON HER OWN ARE MANY. MOST OF ALL SHE MISSES GOING TO CHURCH.

SUSIE WITCHER: I cried Sunday morning. 'Cause I was looking forward to going. I knew I wasn't going to be able to -I hadn't been able to go the last Sunday and I wasn't going to get to go the next two, and I'm -I was a Sunday morning, Sunday night, Wednesday night. [laughing] If the church doors were open I was there.

SUSIE WITCHER: Wait a second let me put your shoes on so your feet don't get cold.

MOYERS: Do you have help Susie?

SUSIE WITCHER: Not at this point. The more I have to do for him, ofcourse, I do the yard and the house and the fan and the shopping and it's getting to where I have less and less time during the day to do the normal everyday things that people have to do to -in the course of living.

MOYERS: Who's taking care ofthe caretaker?

SUSIE WITCHER: [laughs, looks to Jim]

JIM WITCHER: That's something that we haven't done, and we -we -we've got to make some big decisions.

SUSIE WITCHER: He's tried to get me to do things, you know but if! were in his shoes to have a strange person or somebody come in and hold my urinal or wipe my bottom or -[crying] the things that you have to do for him, you know, I don't want him to be embarrassed that way any sooner than he has to.

JIM WITCHER: Its a -the caretaker really has it probably tougher than I do, you know because of the emotional thing attached to it, and -and -and -and then just the tremendous work -work load that it puts on them, and you put off having people come in I guess longer than you should, and we've done that, and it's a mistake, but...

MOYERS (v/o): EIGHT MONTHS AGO, JIM ALMOST DIED WHEN A BLOOD CLOT REACHED HIS LUNGS. HE AGREED THEN TO LET HIS DOCTOR DO A SURGICAL PROCEDURE TO PREVENT FUTURE CLOTS. IT HAS PROLONGED HIS LIFE.

DR. PIERRE BLANCHARD: Hey Jim.

JIM WITCHER: Hi Dr. Blanchard.

BLANCHARD: How you doing this morning?

JIM WITCHER: Fine.

BLANCHARD: Good.

MOYERS (v/o): BUT TODAY HE'S COME TO SEE DR. PIERRE BLANCHARD WITH A DIFFERENT AGENDA.

JIM WITCHER: I need to know what my options are. I guess what I'm concerned about is when I get to where I can't basically do anything but -but breathe and barely swallow and have to be just -have somebody take care of everything I do. Uh, I'm concerned about where I go from there. And -and what -and what you cando for me, if anything.

BLANCHARD: I mean, anything we can do as far as comfort care is concerned, I think we can do that. And I think we can talk about hospice at some point.

JIM WITCHER: I don't want to go to hospice.

SUSIE WITCHER: I don't.

JIM WITCHER: Well, I think I do, but-

BLANCHARD: Uh, it's-it's pretty-it's pretty good. I mean, they will keep you out of distress.

JIM WITCHER: They'll even send you home with a morphine drip and, you know, if in can get to it and to where I push the -the button enough and everybody else is out ofthe room, well, then, you know, so -so what? Makes no -makes no sense to me that you can do things like that and get away with it, and why we don't just change the damn law and -and get things different.

BLANCHARD: Well, I guess there's such a moral-religious issue here in the south, especially, about suicide, too, that that's probably impeded some of the progress in those areas.

JIM WITCHER: What would you do if you were in my position? What would you want done?

BLANCHARD: Well, I'd want to be kept comfortable, that's for sure. I don't know in could say what I would do. I can only tell you what I can do as your doctor, but I can't always say what I would do as a person. I guess you have to be put in that circumstance. It's not real easy to say, you know, I would do this or I would do that. I have a great deal of empathy for the things that are occurring, that's for sure.

JIM WITCHER: Well if the law were changed in Louisiana, to be like the Oregon law, would you have any objection to that?

BLANCHARD: I don't know in could kill somebody.

JIM WITCHER: The only thing that I think is unfair is I'm going to have to do it before I would really -really rather do it. [ choking up] And that's not fair. I'm going to have to do it while -while I can still swallow. And-and while I can still hold a straw, you know, something like that. And -and there's -there's no law against somebody putting something out in front of you and then me -me doing it? There -there's nothing wrong with that?

BLANCHARD: No. JIM WITCHER: Because that's me committing suicide.

BLANCHARD: Yes.

JIM WITCHER: And it's just I will have to -to do it [ choking up] before I really want.

BLANCHARD: Well, I think there are definitions of discomfort. And I still think that, you know, my experience with hospice has been that we can do things for people that don't keep things moving along for long periods of time.

JIM WITCHER: So-

BLANCHARD: You just have to trust me for that because I've seen it.

JIM WITCHER: So the law will help me die slowly.

BLANCHARD: Well, not in five seconds but-

JIM WITCHER: Well-

BLANCHARD: But you know, uh, certainly not, I don't think, dragging it out.

JIM WITCHER: Okay. Lord, I understand the position you're in. And I -I -I know that. I just don't -I think it stinks. Just to be real honest with you. It's -it's just it's not a mature way to look at certain end of death -or end of life situations such as mine. It's -it's not a mature way to look at it.

BLANCHARD: But as your physician it would be hard for me just to absolutely take you away. And it'd be my responsibility to shoulder that burden. I can assist you in making things comfortable. I can't really assist you in -killing yourself.

BLANCHARD: I think we can -should be alright. .

JIM WITCHER: Alright.

BLANCHARD: Are you having any respiratory problems? Breathing problems?

JIM WITCHER: None that I -except the fact I can't sneeze and cough like I used to.

MOYERS: What strikes me is that Jim Witcher is my age and when I look at him, I see a reflection of myself and I ask what would I do?

BLANCHARD: Well, you know, he asked me that too and I said well, I don't know. 1 you never know until you're put in that circumstance, and that's not evading the issue. It's easy to agree with somebody if you want to, but I really don't know what I would do. I like life, but I -I don't know if I'd like that kind of life.

BLANCHARD: I don't see much fasciculation really, urn.

MOYERS: What could you do for Jim?

BLANCHARD: I think that we can help give him support. We can help his wife by

getting him help, to help deal with him as far as his activities of daily living. I think if things progress to the point that he is in any distress, that we can give him medicine that will make him not be in respiratory distress.

BLANCHARD: Can you squeeze? Well a little bit there.

MOYERS: But he even loses control over that decision, doesn't he?

BLANCHARD: Yes, he does.

MOYERS: And he seems to me to be struggling for control. He wants to control...

BLANCHARD: He wants that and he wants more than that. He wants more than what

we're describing. He -I think what you say is true, he wants not for me to control the circumstance, he wants himself to be in control and to dictate how things go when that time arrives.

MOYERS: Is that an ethical problem for you?

BLANCHARD: It is.

MOYERS: Well, you took an oath to save people, not to kill them?

BLANCHARD: That's very true, but I guess included in that oath too is to make sure the people have comfort and dignity in the way that their illnesses are dealt with too. So, there's a little bit of a -a play there between those two.

MOYERS: If you were free to help Jim, if the law were not in your way, what would you give him -morphine?

BLANCHARD: I think the most direct way is potassium chloride. Uh, it's not painful, it

stops the heart, and it's quick.

MOYERS: But the law says ...

BLANCHARD: That would be a real no-no.

MOYERS: That would be ...

BLANCHARD: Because I know that we give people in terminal circumstances morphine drips and whatever they die from, we attribute it directly to their illness, but I guess the reality is that morphine probably contributes to it, when you have to get to a high enough dose to suppress the breathing process.

MOYERS: I think if! were the doctor, I could give him the medication, but I couldn't help him take it.

BLANCHARD: I could do that. I could do that.

MOYERS: You could give him the medication?

BLANCHARD: I mean, we -I could say -I mean, just this is for comfort or whatever and he could do with it whatever he wanted to do.

MOYERS (v/o): DR. NANCY CRUMP ACKER HAS BEEN A CANCER PHYSICIAN FOR MORE THAN 20 YEARS.

DR. NANCY CRUMPACKER: I've seen fifty to a hundred patients die a year, my own patients. So, I saw quite a bit ofthe end stages and watched some of those patients go through what they considered suffering and maybe that was not what they wanted.

MOYERS (v/o): KITTY RAYL HAS TURNED TO DR. CRUMP ACKER FOR HELP IN DYING. UNDER THE OREGON LAW, SHE CAN ASSIST KITTY WITH ADVICE AND MEDICATION.

KITTY RAYL: I'm getting weaker.

MOYERS (v/o): OREGON'S DEATH WITH DIGNITY LAW REQUIRES PATIENTS TO HAVE A SIX-MONTH TERMINAL DIAGNOSIS BEFORE A PHYSICIAN CAN HELP THEM DIE. TWO DOCTORS MUST CONFIRM THE DIAGNOSIS.

KITTY RAYL: This back pain is, you know, sometimes it's so bad that 1 really have trouble getting from

MOYERS (v/o): AND THE PATIENT MUST BE MENTALLY CAPABLE TO MAKE THE DECISION.

KITTY RAYL: It hurts.

MOYERS: Do you find that most of your patients are more afraid of pain than of dying itself?

CRUMPACKER: Yes. The conversations don't rotate around the actual death itself.

MOYERS: But the getting there.

CRUMPACKER: But the getting there. It's how we're gonna get there.

KITTY RAYL: When I'm looking at myselfI'm going, 1 -I can't do this anymore. I can't manage anymore. I can't get from one place to -to the other any longer -and it's coming.

MOYERS (v/o): KITTY FIRST MET WITH DR. CRUMPACKER SEVERAL MONTHS AGO. TOGETHER THEY'VE COMPLETED ALL THE PAPERWORK NECESSARY TO APPLY FOR THE MEDICATION THAT WILL HASTEN KITTY'S DEATH.

CRUMPACKER: It's a matter of you getting on the phone and calling me, letting me know what your thoughts are. If you urn KITTY RAYL: And, I need to talk to my daughters and find out whether they want to be here. CRUMPACKER: Right.

KITTY RAYL: So, I need to take those steps,

CRUMPACKER: I can't participate unless I feel that she has thought about this not just today, not just yesterday, but that it -that it's something she's given a lot of thought to, maybe over the years.

MOYERS: Mmm hmm.

CRUMPACKER: And, at least since she's had the cancer diagnosis.

KITTY RAYL: You know it's difficult for me to know at this point what the actual moment's gonna be.

CRUMPACKER: How can you predict, yeah?

KITTY RAYL: You know, and I guess I needed to have in my mind that it's gonna be a time that's available for you or I mean that's; uh, I'm a little ...

CRUMPACKER: Why don't -why don't you urn, when you've made up your mind that that's what you want to do and sort of have a time frame in mind, give me a call and we'll

KITTY RAYL: Work it out. Okay.

CRUMPACKER: We will work it out.

KITTY RAYL: Okay, okay.

CRUMPACKER: Yeah and obviously, if you call me and you've got something set up and you decide at the last minute you're not gonna do it, you know, you need

KITTY RAYL: Sure. I understand that.

CRUMPACKER: You are fully in

KITTY RAYL: In control.

CRUMPACKER: control.

KITTY RAYL: I understand that.

MOYERS: When she chooses to end her life, if she does.

CRUMPACKER: Ifshe does.

MOYERS: How will she do it?

CRUMPACKER: She will take a prescription of a barbiturate. And it's about a -two tablespoons of bitter powder. So, my job is to try to make it not so bitter. And~ 1 we just mix in water and add a bunch of sugary syrup, something to kind of hide the bitterness and you can swallow it in less than a minute. People do that and swallow it in less than thirty seconds. And that takes effect and people go to sleep usually within about five minutes and then they -comfortably they're in a coma, then they die.

MOYERS: And the signs are that it's peaceful?

CRUMPACKER: It's very peaceful.

MOYERS: And, you will write that prescription when she calls?

CRUMPACKER: Yes.

MOYERS: Will you be there when she dies?

,

CRUMPACKER: Oh, you bet.

MOYERS: You'll mix the medication for her?

CRUMPACKER: Mmm hmm.

MOYERS: Is that consistent with caring for the dying when you're actually helping them to die?

CRUMPACKER: If that's her sense or anyone else's sense of suffering, that's what I want to do is relieve that suffering. I am hastening an inevitable death

MOYERS: Mmm Hmm.

CRUMPACKER: of a terminal person

MOYERS: Mmm Hmm.

CRUMPACKER: Who's competent, an adult, an Oregon resident.

MOYERS: Which means it's legal.

CRUMPACKER: And it's legal.

MOYERS (v/o): DR. CRUMPACKER WAS NOT THE ORIGINAL CANCER SPECIALIST TO OVERSEE KlTTY'S TREATMENT, DR. KEVIN OLSON WAS. THEY'RE COLLEAGUES IN THE SAME OFFICE.

CRUMPACKER: Hey Kevin, what's going on with Kitty right now?

MOYERS (v/o): BUT WHEN KlTTY LOOKED FOR A PHYSICIAN TO HELP HER DIE, SHE DIDN'T GO TO DR. OLSON; SHE KNEW HE WAS OPPOSED.

DR. KEVIN OLSON: I don't feel like I can actively participate in an assisted suicide situation. Urn, I can't write the prescription. I'm happy to talk to patients about what their issues are around that and uh, but Ijust didn't feel like I -I could or should be the one that actually does this.

MOYERS: Help me to understand why that's so.

OLSON: WelI, I think it -I haven't been trained in that fashion, I don't feel like I'm competent, but I think more importantly my own moral framework is such that I don't think that I could do it and feel good about doing it and uh feel that I was actually helping the situation. I -I mean, it might be somewhat arbitrary on my part, but uh because certainly I've given extra morphine to a patient who is in pain knowing that maybe that extra amount of morphine might be something that would hasten their death, turn something -something visceral inside me just te\Is me that this -this is probably not a direction I should go persoria\Iy and so I haven't.

MOYERS: Is -is that a matter of religious conviction to you?

OLSON: Well, certainly I'm, you know, spent fourteen years in Catholic schools so I'm well versed in the religious issues, but I don't know that it's because a priest 00 somebody tells me I need to do this. Itjust doesn't -doesn't feel right to me.

MOYERS: Is it your oath? You took an oath to save life, not end life?

OLSON: I -I -I don't know how to -the oath really isn't the issue, it's just a matter of at the end of the day when -when things are done and what I feel good about what I've done and I just didn't think I could feel good about doing that myself.

HAKKINEN: Neurontin.

MOYERS (v/o): DR. OLSON DOES OVERSEE KlTTY'S HOSPICE CARE INCLUDING HER PAIN MEDICATION.

OLSON: One ofthe issues that comes up a lot when you talk about how helping patients die is that patients will worry that when the going gets really tough, maybe the doctors or the family members won't have enough guts to do the right thing and give them the medicine that they need.

HAKKINEN: The Dilaudid.

OLSON: For fear of making things go wrong.

HAKKINEN: And here we have the Amitriptyline.

MOYERS (v/o): THE OREGON LAW IS CONTROVERSIAL. BUT ALL SIDES AGREE IT HAS LEAD TO THE USE OF MORE PAIN MEDICATION FOR THE DYING. OREGON HAS THE HIGHEST PER CAPITA USE OF MORPHINE FOR PAIN CONTROL IN THE COUNTRY.

OLSON: I always tell patients that ifI'm ever going to err, I'm going to err on the side of giving you too much rather than too little because that fear of a painful death, of-of being in pain and not being able to do anything about it is -is really an overriding issue with a lot of dying patients.

HAKKINEN: Have you used any of the Dilaudid since I was -here?

KITTY RAYL: I took some this morning.

HAKKINEN: Okay, you did.

KITTY RAYL: Urn.

HAKKINEN: How about yesterday

KITTY RAYL: Yeah I took some yesterday.

KITTY RAYL: They think that I would be able to get some ofthe pain to go away if! took more of certain ones of these, but they also just knock you out.

HAKKINEN: You use four of them each time then?

KITTY RAYL: I was using three.

HAKKINEN: Okay -remember -we made -I kind of suggested that you take four.

KITTY RAYL: Okay.

KITTY RAYL: I want to be able to read and be aware and I don't want to sit and sleep all day long or, you know, just doze off. I don't want to knock myself out. So, we're trying to find something that will give me the quality of life I want and won't just totalIy knock me out. We haven't gotten there yet.

HAKKINEN: Otherwise you have that nagging, lingering feeling of pain all the time.

OLSON: There have been occasionally times when a -a patient in the hospital, the nurses will say, you know, he's clearly restless, he's, you know, he's delirious -we we're not sure if giving him more morphine might make things worse and he might stop breathing. I've not worried about that. I've said listen, we need to make that patient comfortable. Sometimes the only thing keeping them going is that painful stimulus and you relieve the pain and they -they die shortly thereafter. But I feel in my heart that it wasn't me that took that patient's life, it was their disease process and all I did is help them be comfortable in the last moments.

MOYERS: Is it a matter of control? You want to remain in control, as the doctor?

OLSON: WelI, actually, I mean, I'm happy to give the patient their own pain medicine and let them choose how to use it, but it's -it's not so much that. It's that if my mission is to make them die, that's a little different than to make them comfortable and, that's maybe where Nancy and I differ a little bit. Nan -Nancy doesn't see a distinction between that and I do.

MOYERS: What about that, Nancy?

CRUMPACKER: I -I don't see -I don't see a distinction. I see the hastening death with a prescription by a patient at his or her home as actually a much better situation, because then it really is, hopefully, all in the patient's control. In Kitty's case, I'll go out there and I, you know, if we've arranged a time, I'll say, Kitty are you -are you sure now's the time? I'm gonna give her plenty of chance to doubt and to change her mind. There's probably a dozen patients I've had conversations with who have done all-gone through all the steps who we've never gotten to the point of writing a prescription. They wanted to know that they could have that if the time came that they really wanted it. ..

OLSON: The last time I talked to her she said she wasn't sure she would follow through, but she liked the notion that -that -that she has the option if she wants.

CRUMPACKER: I called hospice ...

OLSON: The key thing, I think, if patients are gonna go this route is that they need to have a doctor who will take the time to really work through all the issues. And to really make sure that all other avenues have been explored before they go into this into this realm and Nancy's exceptional in that regard.

KITTY RAYL: Thanks for coming over.

CRUMPACKER: Okay. It's really good to see you.

KITTY RAYL: Thanks.

MOYERS: I cannot imagine taking that last act in which I'm taking something that I know is going to be the last thing I do.

KITTY RAYL: I know. It's -it'll be hard. It will be hard and I, you know, obviously you put it off too, you know, I'm not sure what's going press that button and say it's time. I can't tell you that. It'll just come -and we'll-we'll do it.

MOYERS (v/o): JIM WITCHER WANTS TO CONTROL THE TIME OF HIS DEATH, BUT CAN'T BECAUSE OF THE LAW AND HIS FAMILY'S RELIGIOUS BELIEFS. KITTY RAYL HAS CONTROL BUT DOESN'T KNOW WHEN SHE'LL USE IT.

PUBLIC ADDRESS SYSTEM: Dr. Carlos Gomez ..

MOYERS (v/o): MORE OFTEN THAN NOT IT'S THE DOCTOR AND LOVED ONES WHO MUST DECIDE FOR THE DYING. IT'S NEVER EASY. SOME HARD CHOICES NOW CONFRONT DR. CARLOS GOMEZ AT THE UNIVERSITY HOSPITAL IN CHARLOTTESVILLE, VIRGINIA. ONE OF HIS PATIENTS IS TERMINALLY ILL AND THE STANDARD AMOUNTS OF MEDICA nON ARE NOT EASING HIS SUFFERING.

DR. CARLOS GOMEZ: Ricky you hurting this morning?

RICKY TACKETT: [moaning] A little.

GOMEZ: A little? Do you remember who I am?

RICKY TACKETT: No.

MOYERS (v/o): RICKY TACKETT IS DYING OF LIVER FAILURE. HE'S ONLY FORTY-FOUR YEARS OLD. ROSE

TACKETT: You know yesterday he acted so calm and not at all what I was seeing at home but it come out last night that's what I had been dealing with

GOMEZ: Delirium? The agitation?

ROSE TACKETT: I mean -just -you could not get him to cooperate at all and

MOYERS (v/o): RICKY'S WIFE ROSE HAS BEEN CARING FOR HIM AT HOME WITH SOME HELP FROM VISITING HOSPICE NURSES, BUT HE'S BECOME TOO AGITATED FOR HER TO HANDLE.

GOMEZ: We went back up on the Dilaudid over night and I went back up on it again this morning, I called Karen at 7 o'clock, he's back up to 34.

NURSE: He's getting, right -he got real combative just a minute ago.

GOMEZ: Okay. Ricky, can you wake up enough to talk to me for a second? Are you hurting in your bell y right now?

MOYERS (v/o): DR. GOMEZ IS TRYING TO DETERMINE THE EXACT AMOUNT OF PAIN MEDICATION TO KEEP RICKY COMFORTABLE.

GOMEZ: Does that hurt?

MOYERS (v/o): BUT HE HAS ANOTHER CONSIDERATION. HE'S ALSO TRYING TO KEEP RICKY CONSCIOUS ENOUGH TO COMMUNICATE WITH HIS WIFE.

NURSE: He's gotten two good doses of his Dilaudid.

MOYERS (v/o): IT'S NOT WORKING.

GOMEZ: We've got a decision to make in terms of his level of consciousness. Part of the delirium is the medicines that we are giving him, I'm afraid. I think we will back down when he starts to get agitated. I don't want him to have that kind of agitation

NURSE: Wait a minute, wait a minute Ricky.

NURSE: Okay, it's alright. Alright, let me hold your hand-

GOMEZ: And urn, it seems to work for a little while so I'm just going to double the medicine right now. So he got Ativan Just when?

NURSE: Just now, Ijust gave it to him.

GOMEZ: Just one milligram?

NURSE: Hmmm.

GOMEZ: Let's go ahead and give two.

NURSE: Okay.

GOMEZ: Okay. Ricky, I am going to come back a little bit later on and talk with you okay?

RICKY TACKETT: Sure.

GOMEZ: Okay?

RICKY TACKETT: Sure.

MOYERS: You said in there we have a decision to make, what's the decision?

GOMEZ: The decision is there is a fine line between trying to keep him awake enough to be conversant and controlling his pain and we usually are very good about that, but he is encephalopathic at this point. He's literally out of his mind, he's delirious, and part of his agitation and part of his suffering is the delirium. It's not just for him, but for his wife and so, you know, we tried to back down on his pain medicine yesterday thinking that he was too somnolent. He woke up ,fbit, I was actually able to talk to him, he recognized me. I got a call during the night that he was in pain, we started backing up on his -going up on his medicine again and then this morning I called again and he was still in pain so we went up on his medicine again. We come in there now and I can't elicit pain, I mean I palpated over the site and he is not tender there, but he is clearly delirious and he doesn't recognize me this morning so what do you do at that point?

MOYERS: I mean wouldn't the humane thing to do to be really to relieve the pain, just let him sink into unconsciousness?

GOMEZ: Yes. Yes.

MOYERS: Can you make that decision or does his wife have to make it?

GOMEZ: I think we make it in -in a common.

NURSE: Is this worse than you thought it would be?

ROSE TACKETT: Ijust step back and let them do it and it's hard.

NURSE: You know you can be a part of this way you want, you know.

ROSE TACKETT: I know.

NURSE: You know 'cause there's days when you could be more involved and there's other days when you can just step away and we would understand

GOMEZ: But I also want her to be engaged in the decisions and I think we're reaching the point where the best that I can do for him is to sedate him and let him die. Uh, I would prefer that he be alert and talking all the way to infinity but I can't do that.

MOYERS: What's the difference between this decision to sedate him and let him die and what out there is called physician-assisted suicide?

GOMEZ: That's a great question. Urn, there are several dissances--differences. One is an intent. I don't want this fellow to die and I'm not trying to will his death and I am not actively trying to bring it about, urn, but I'm also not willing to let him sit there and suffer and is there -is there a hypocrisy here? Urn, there mayor may not be. Creating a myth that makes me feel better about what I'm doing, that may be true, but there is a line that I'm very firm about and Rose knows it, his wife knows it, and Ricky knows it, which is that I am not going to do something to bring about his death as a result of my actions -directly as a result of my actions.

GOMEZ: Did we change -oh we must've changed the Dilaudid orders last night.

GOMEZ: Am I willing to do things that may hasten his death? Sure. I'm not willing to give him fluids at this point, I am not willing to put a feeding tube in him, for example, I'm not willing to treat an infection at this point. Are all those exercises in assisted suicide? I don't think so. I mean that's a language that I'm not comfortable with. I think one ofthe first principles of medicine is you -you do no harm, and if you can't act so as to make the patient's life better, you step back and do something different. There is nothing medically that I think I can do at this point to make his life better, but I damn well can control his pain and his delirium.

MOYERS: You can make his dying better?

GOMEZ: I can make his dying better, absolutely. Not just for him but for the family.

GOMEZ: I just wanted to talk about what's going on with Ricky right now

MOYERS (v/o): BEFORE DR. GOMEZ DECIDES EXACTLY WHAT TO DO, HE WILL TRY TO UNDERSTAND CLEARLY ROSE'S WISHES AND THOSE OF HER DYING HUSBAND.

GOMEZ: The thing that I think is painful for all of us to watch is when he gets out of his head like that, his delirium, you kept saying he's not Ricky and you're right, he's not Ricky. The only way that I know how to control that right now is to sedate him, urn, because when we've tried to lighten up on his medicine he gets completely out of control. What it's going to mean though is that Ricky is probably going to be unconscious until he dies, or at least in and out of consciousness. He may respond by squeezing a hand, he may intermittently look at you, but he's not going to be thrashing about the way he has been.

ROSE TACKETT: When he's violent and all, he's not Ricky and he can't control that for whatever reasons and he's not been himself in awhile. Occasionally, a few words, but then he's back to not being himself and he wouldn't want to be that way. We discussed this when he was very clear-headed. He wouldn't want this.

GOMEZ: When he went back to Kentucky this last time, he had been pretty clear with me that he wanted to have some time at home, walk through his church, say goodbye to his congregation, and so on. Was he able to do that?

ROSE TACKETT: We had about four beautiful days at home. He went to church, we stayed through the meeting. He didn't participate, but he was there. Whatever made him feel he had to do that, he got to do it. . And sedation is welcomed. I think he would want that.

GOMEZ: Yeah, I urn -I agree, Ijust -it's a -it's always a tough call because the hope is always that you are going to be able to have some more quality time with somebody and there comes a point where it sounds like whatever Ricky felt like he needed to do he did and it sounds like whatever you needed to do with Ricky you've done also.

MOYERS: Did you talk to him about dying, did you two discuss it together, openly

ROSE TACKETT: Yeah.

MOYERS: Honestly?

ROSE TACKETT: Yes. Yes. I think the two weeks we were here before he had the opportunity to have a very good conversation with all of his family-people in the church, of what he wanted and I think they had the opportunity and I hope that they would satisfied with that time they got while he was of clear mind and he poured his heart out to everyone, including Dr. Gomez. He's suffered enough and he's tired and he wants to go home.

MOYERS: He's prepared?

ROSE TACKETT: Yes, but his body won't let him, or something won't let him, you know. I don't know.

MOYERS: He was a minister, he is a minister.

ROSE TACKETT: Yes

MOYERS: So faith has clearly-

ROSE TACKETT: He has a better place to go in our beliefs and that's why ...

MOYERS: Does that make it easier?

ROSE TACKETT: Yeah. That's -that is the only thing that makes it better for me. And

you know he's tired. He has a right to say I don't want no more and I think we should, uh, grant him that, you know. He's tried for us and I think we should give it up for him.

MOYERS (v/o): EVERY DAY MORE OF JIM WITCHER'S NERVE CELLS SHUT DOWN. HIS SPINAL CORD DEGENERATES, HIS MUSCLES WASTE AWAY.

MOYERS: Are you any closer to a decision since I was here a month ago?

________________

JIM WITCHER: Of Course you know you can talk big, but the doing it's a different thing. But my intentions are, uh, at the point to where I begin to really have trouble swallowing and before I 10 -lose the ability to sit in a wheelchair like this, uh, I intend to go ahead and -and take some drugs.

MOYERS: Do you have those drugs?

JIM WITCHER: Yes, I have the drugs. I'm a veterinarian and had a -have a narcotics license. You can always make a mistake, I guess and everything. But I think -I think I have exactly what I need.

MOYERS: But if you wait is. there is a danger that you might miss the moment -that you won't be able to -to swallow it?

JIM WITCHER: Sure. You know, uh -I know I can do it now. I want to live a little while longer, so I'm going to -I'm going to push the envelope as far as I can.

MOYERS: If you missed the moment and you are unable to do it, would you want Susie to help you?

JIM WITCHER: No. Uh, because she couldn't do it. And she -she would feel guilty forever after. Uh, she would feel like a murderer.

SUSIE WITCHER: Could I put the poison to his lips? Not now.

JIM WITCHER: Hey come here Garret. Get on this knee! Hey boy!

MOYERS (v/o): THE WITCHER'S DAUGHTER MARCIE HAS COME FROM MARYLAND WITH HER HUSBAND JOE AND THEIR THREE KIDS.

SUSIE WITCHER: The last time that they were here, he cried and cried and said he didn't think he'd probably ever see them or his grandchildren again.

JIM WITCHER: Hi Marcie.

MARCIE BROWN: How you doing?

JIM WITCHER: Love you -I'm doing fine.

SUSIE WITCHER: Now Marcie I do have those juice things out there too, so whichever.

MARCIE BROWN: It's not just him suffering, it's the whole family, cause we're watching him. And I know what he wants to do, but I don't want him to do it, but I I want him to be at peace. It's a struggle, trying to figure out, okay do I side with you or do I side with my heart or do I side with what society says should be, or what the legal system says you can do? I'm still struggling with what -what I -what I feel.

JOE BROWN: Our Father we thank thee for these and all thy blessings and forgive us our sins, we pray for Christ's sake. And dear God thank you for letting us get back down here to visit with our family one more time.

SUSIE WITCHER: I think all of us have an idea of what we think we'd do in a situation and when it comes to that time, we may change our mind. But he -he had said, when I get to where I can't do anything for myself anymore -well, the first thing he said was when I can't wipe my bottom myself, I don't want to live. The next step was when I can't feed myself, I don't want to live. Well, I'm having to feed him now and he's -he still wants to live. He still wants to see his grandkids. So far as having said by such and such time, I'm going to, he has not said another deadline to me now.

JIM WITCHER: ...realized that, but now that I can't raise my hands, I'll get a bug or an itch on my nose and you just have to -it's just mind over matter.

JOE BROWN: Wow.

SUSIE WITCHER: I'd never make it [chuckles].

SUSIE WITCHER: He is worried that he's going to have to be able to administer whatever.he chooses to do to himself and he's going to have to do it before he's totally incapable of doing it.

MOYERS: He would have to swallow it himself?

SUSIE WITCHER: Yes, sir.

MOYERS: But with his hands-

SUSIE WITCHER: I know.

MOYERS: How can he get it-

SUSIE WITCHER: I don't know. I don't know and I don't-I don't know that I want to ask -you know.

MOYERS: You haven't asked him?

SUSIE WITCHER: I -yeah, I have and he hasn't -he hasn't really said, so I don't know

whether he's got something in the back of his mind that he thinks he can do or-or what and it's not something I really want to talk about, you know. And I know I need to and probably need to for his sake, but I'm guilty of keeping just as busy as I can around here, so I don't have to face it, you know? I don't know how to explain that to you, but-

MOYERS: You're doing a good job. You mean-you mean, you just don't want to think about that moment?

SUSIE WITCHER: Right. I -you know, he's asked me if! want to be there when he dies. I don't know [choking up].

MARCIE BROWN: Ooo! Getting a little reckless there, Davis.

LAURA BROWN: Sassy! Sassy!

SUSIE WITCHER: Yes, it's Sassy, you're right.

JOE BROWN: He wants his life to end

MARCIE BROWN: Peacefully.

JOE BROWN: On his own terms, I think.

MARCIE BROWN: On his terms, instead of on the disease's terms. And I -I understand that, but who says you get to decide?

SUSIE WITCHER: Remember Spirit?

LAURA BROWN: Spirit 'members me too.

SUSIE WITCHER: That's Spirit, I think Spirit does ...

MARCIE BROWN: The spiritual side of me says that's God's decision, that's between

you and God, Dad, and when God deems it necessary, then that's when it's going to

happen.

SUSIE WITCHER: Remember Sassy?

JOE BROWN: I always understood that suicide was wrong, was a sin and it was not a moral thing to do. Uh, with -dealing with this situation, it -it blurs the lines.

JIM WITCHER: What I'm talking about is my choice. This is what I want, for me, and the only other thing I want is for society to -and people -to talk about it, plan about it, plan their own, decide for themselves.

MOYERS (vIa): TO ASSURE THAT HE'S NOT KEPT ALIVE WITH ARTIFICIAL MEANS, JIM HAS SIGNED A LIVING WILL. SUSIE KNOWS WHAT CAN HAPPEN WITHOUT IT.

SUSIE WITCHER: My mother died of ovarian cancer. I remember when she got to the point where she could not eat anymore and she refused to eat. I begged the doctor to put a -a Boviac tube in her, because I was still fighting to save her. That meant she had to be taken into surgery and have that inserted and it probably might have bought her four weeks -five -you know. Who knows? And looking back now, I'm so sorry I put her through that. It did not make her quality of life one bit better. [ choking up] I should never have done that. And I'm not going to do it to James because he's legally taken steps that he won't take it. I saw my mother suffer horribly, and it came to the point that I wished I could do something. I don't think I ever had the guts to help her die, but I feel really terrible that I sustained -you know, that I just made her miserable for that many more weeks. [crying] And that's just no way to go for anybody.

MOYERS (vIa): THE DECISIONS DOCTORS FACE WITH DYING PATIENTS ARE NOT OFTEN ADDRESSED IN MEDICAL SCHOOL.

GOMEZ: Ricky is back in the hospital.

MOYERS (vIa): DR. GOMEZ WANTS HIS FIRST YEAR MED STUDENTS TO START THINKING NOW ABOUT HOW PEOPLE DIE AND THE ISSUES THEY WILL FACE AS DOCTORS.

GOMEZ: He's intermittently lucid. Uh, but really not very well-focused. Uh, I don't think he is in so much pain as he is delirious. His, urn, liver is basically shutting down. And Rose is there with him, his wife. He will probably die in the next two or three days is my guess. He's not getting food. He's not getting water. He's simply getting pain medicine and something for his delirium.

GOMEZ: So, the question is what am I doing for what purpose? If I'd felt that we could sustain Ricky's life, in a way that he would want it sustained, this case would be entirely different. He says that he's ready to die. Now the question I've got is what am I going to do with N fluids and nutrition? What am I trying to accomplish? What is his wife trying to accomplish? .

MOYERS (vIa): THE STUDENTS HEAR FROM DR. GOMEZ THAT HE'S NO LONGER PROVIDING FLUIDS OR NUTRIENTS TO RICKY TACKETT.

GREG: Uh, it just seems to me that that's almost assisted suicide.

GOMEZ: Why?

GREG: Because, I mean, water and food is just such a vital part -I mean, obviously you have to have it every day. And it just seems like that's the same thing as taking away medications. I mean, you're taking away what he needs to live.

SUSAN GOINS-EPLEE: The level of responsibility that a physician feels about end-of life decision making ...

MOYERS (vIa): SUSAN GOINS-EPLEE, THE UNIVERSITY CHAPLAIN, TEACHES THIS ETHICS CLASS WITH DR. GOMEZ.

GOINS-EPLEE: Yet you're saying ifI were to remove hydration, then I've done something that's going to hasten his death and you feel responsible for the fact that this man is dying. And you're not. He's dying because he's sick and there's been a lot of intervention in between when he started to die and when he's going to die.

NEIL: I don't seem to have much of a problem with withdrawing ventilators in -you know, in a person in his condition or in other cases that we've discussed. But especially hydration and -and -and somewhat nutrition, I -I feel a little uncomfortable with that. And I understand if it's going to be an invasive procedure where you got to put in, you know, you gotta put in a central line. You got to put in a -a feeding tube. I understand not doing that, because that's invasive, actually, but the hydration seems like something you can do.

GOMEZ I will bet you that ifI hydrate him, or try and hydrate him, most ofthe fluid is going to go into his legs and his lungs, 'cause he doesn't have enough oncotic pressure in his vascular system to hold the fluid in.

HUNTER: At least at this stage ofthe game, you feel like, like you're training to preserve life. Where you learn about -you're learning everything that's -that works in the body and your-that's your goaL And you know that -you know, you know that that's -dying is part Of it, but facilitating it, or even accepting it, I -I don't -you know, I -you have to learn to deal with it somehow, but it's not something that comes right away.

MOYERS (v/o): DR. GOMEZ HOLDS OFF ANOTHER NIGHT, TRYING ONE LAST TIME TO FINE TUNE RICKY'S PAIN MEDICATION. IT STILL ISN'T WORKING.

ROSE TACKETT: Last night, he doesn't know what he's doing and he's, I mean, got both hands trying to break my arm and so I'm like I'll step back and let the nurses do it. Maybe I'm agitating him and I actually laid the cot out in the bathroom and tried to lay in there and I had to watch them try and use the restraints and hear him scream and -you know it was like, we have broke horses and it was a whole lot like trying to break a wild horse.

GOMEZ: Yeah.

ROSE TACKETT: You know what I'm saying.

GOMEZ: I do know what you're saying.

GOMEZ: I don't think its pain that's causing his agitation. I know he's-he intermittently complains of pain, I'm not sure that that's what is doing it. I think it has to do with his liver failure.

GOMEZ: Okay, so Ricky ... I can do almost anything I want as a physician, uh, to try and sustain his life and I will ultimately faiL If, on the other hand, the goal is more modest and different and it has to do with accepting the fact that we are all mortals and that there is, you know, something in fact absolutely natural about the fact that we die and that people whom you take care of, as their physician, are going to die, then it begins to raise all sorts of different questions. Not that the hydration question isn't important. It's actually very important and, if you feel a little morally queasy, which is what I think you're saying, I think that's a good thing. You should feel a little queasy. You should feel a little uneasy and it should make you think twice about what you're doing. These decisions should never be automatic or pedestrian, because they're not. They involve the life of another human being.

GOMEZ: Ricky was really clear with me that the one thing he did not want was to go out in pain or suffering. I mean he was just very, I mean, you heard it I'm sure many more times than I did, so Dr. Corum and I have talked about it and I think this is probably the best solution. Urn, I want to sedate him, but sedate him continuously rather than the Ativan every few hours I want to put him on something that is like Ativan. It means that there's going to be no more waking up, okay, even for the even for the delirious stuff, that won't be there.

ROSE TACKETT: I would welcome that.

GOMEZ: You would welcome that.

ROSE TACKETT: He doesn't want to be this way. That was his greatest fear was

having -he knew with liver failure the death you had to die. GOMEZ: Well, he doesn't have to die that death. Let's let him rest, let you rest. Alright. Right?

MOYERS (v/o): THE DECISION TO INCREASE RICKY'S PAIN MEDICATION AND WITHDRAW FLUIDS AND NUTRITION INVITES DEATH THROUGH THE DOOR. ONE BY ONE WE DIE. JUST AS EVERY LIFE IS A PARTICULAR LIFE, SO EACH OF US DIES OUR OWN DEATH. NO MATTER HOW WE PLAN FOR IT, WE CAN NEVER KNOW FOR SURE HOW DEATH WILL COME.

KITTY RAYL: Nancy Crumpacker came by today and urn, we just had a little chat she she was

MOYERS (v/o): KITTY HAS GATHERED HER DAUGHTERS, JILL AND JAN, TO TALK ABOUT HER LAST ACT AND DECIDE WHO SHOULD BE THERE.

KITTY RAYL: I guess you know I haven't really thought through, you know, are we going to have like everybody here, do you want to be here, do you not want to be here, you know, Nan -Nancy does want to be here and that kind of thing, so Ijust you know that kind of stuff.

JILL RAYL: Mmm hmm.

KITTY RAYL: We'll just think about it and talk about it later.

JILL RAYL: Okay.

KITTY RAYL: So, are you comfortable with that? Okay.

JAN RAYL KIERSTEAD: I mean I had already said that I thought I'd want to be here.

JILL RAYL: Yeah, I would too, I mean. The only thing would be if you didn't want us here, which I can't imagine...

KITTY RAYL: Oh. No.

J

ILL RAYL: So [ chuckles]

KITTY RAYl,: That -you know -that's totally not gonna ...

JILL RAYL: I mean I think that would be, that's kind of a given at this point.

KITTY RAYL: You're just so ready to crawl. You're just so ready. And then Mom and Dad are going to have their hands full.

MOYERS: Do you think about what's on the other side of death if there is anything? .

KITTY RAYL: My belief is that you come here to resolve issues with the people that are

around you and that you come back when .you,haven't resolved that issue because

you've got to do it again. You've got to get it right. When you run into people that

you've never met before and it's just like they're a soul mate. You can't believe that you have so much in common and that your thinking is so the same. Well, you've probably been with that person in a prior life, you know, and worked these issues out. I've got issues to work out with -with some of my family members. I'm gonna have to do it again. And, I, er -I hope I come back with my daughters and my granddaughter.

SUSIE WITCHER: There's a lot of things in the caretaker that I don't know whether anybody realizes it, but I get so tired and I think I Just wish this were. all over, I wish I didn't have to go through this, I want this to be over. And then I think, but that means he has to die. And then I feel guilty for having those feelings [crying].

SUSIE WITCHER: When it's that person's desire that if at all possible they could have a physician-assisted dignified death, when there's absolutely no hope, I think it's a kindness. I think it will be an act of love.

MOYERS: But the law won't let Dr. Blanchard love that way.

SUSIE WITCHER: Or me. Or his son. Or his brother. And instead we're going to be asked to watch him suffer. And he -he will die an agonizing death. I mean, suffocation or starvation -both.

MOYERS: So at this moment, Susie, you don't know exactly what you're going to do when the moment comes and he says I need help and I can't do it myself?

SUSIE WITCHER: No, I don't.

GOMEZ: You can always bear witness to somebody's suffering, but there is something very powerful about your presence as the doctor in the room with the patient who is dying.

MOYERS (v/o): RICKY TACKETT'S SUFFERING IS ABOUT TO END. WITHIN THE NEXT HOURS HE'LL BE TERMINALLY SEDATED. HE DIED FNE DAYS LATER. KITTYRAYLDIDN'T GET THE MONTHS SHE THOUGHT SHE HAD COMING. SHE DIED WITHIN TWO WEEKS OF OUR LAST VISIT WITH HER.

JILL RAYL: It became harder and harder for her to get in and out of bed and get in and out of her chair. I came home one day and the hospice nurse was there doing something that she really didn't want to have done or it was really uncomfortable for her.

JAN RAYL KIERSTEAD: She said to us that she had finally just got to a point where she felt like she had no dignity left.

JILL RAYL: And at that point she said I want to go ahead and do the pills and I want to get on with it.

JAN RAYL KIERSTEAD: She said, you know, call Nancy.

JILL RAYL: Yeah, I'mjust ready.

JAN RAYL KIERSTEAD: You know, I'm tired of this.

MOYERS (v/o): WHEN KITTY ASKED HER DAUGHTERS TO CALL DR. NANCY CRUMPACKER TO BRING THE MEDICATION, JILL CONVINCED HER MOTHER TO WAIT UNTIL MORNING BECAUSE THEIR UNCLE TOM WAS ON A PLANE TO PORTLAND TO SEE HER. BY THE TIME DR. CRUMPACKER ARRIVED THE NEXT MORNING, KITTY COULD NO LONGER SWALLOW.

JILL RAYL: The thing that was really hard for me was I had been the one who said let's wait for Tom, you know, let's not take 'em right now and then suddenly it's too late. So I had some guilt there about that.

MOYERS: But in the meantime Uncle Tom had arrived.

JAN RAYL KIERSTEAD: Yes.

JILL RAYL: He had.

MOYERS: She spoke to him.

JAN RAYL KIERSTEAD: Yes.

JILL RAYL: But at that time it was too late to administer the medication.

JAN RAYL KIERSTEAD: So we kind of all just sat there, you know, held her hand. Jill and Trish were on one side and our cousin James and me were sitting on one side and our uncle and Jerry the other friend. You know everybody was just sort of gathered around and then finally there was just that last breath and-

MOYERS: You knew it?

JAN RAYL KIERSTEAD: Yeah.

MOYERS: Did she die the way she wanted?

JILL RAYL: I don't know. I don't know if she did.

MOYERS: The way she managed it did enable her to be surrounded by family, to be relatively free of pain, and to be at home.

JAN RAYL KIERSTEAD: See in all of those ways I think it was the way she wanted it. You know, that finaL..

JILL RAYL: That's true.

JAN RAYL KIERSTEAD: forty-eight hours.

JILL RAYL: That's true.

MOYERS (v/o): THE SEASONS HAVE TURNED AT THE WITCHER FARM IN

LOUISIANA. IT'S BEEN SIX MONTHS SINCE WE LAST SAW JIM WITCHER AND NOW HE'S DYING THE VERY DEATH HE DIDN'T WANT.

SUSIE WITCHER: It is getting harder and harder for him to swallow and he gets very tired chewing.

MOYERS (v/o): THE CREEPING PARALYSIS OF ALS HAS REACHED HIS LUNGS AND THROAT AND THE MUSCLES OF HIS DIAPHRAGM. IF HE SITS UP HE CAN'T BREATHE AND BECAUSE OF HIS DIFFICULTY SWALLOWING, HE ISN'T EATING SOLIDS.

SUSIE WITCHER: About ready for some more tea?

JIM WITCHER: One more drink.

MOYERS (v/o): TWO WEEKS AGO HE HAD A CRISIS.

SUSIE WITCHER: I came into the room and found him blue.

MOYERS (v/o): SUSIE RUSHED HIM TO THE EMERGENCY ROOM IN TOWN, FORTY-FIVE MINUTES AWAY, BUT HE STILL WOULDN'T TAKE A RESPIRATOR OR A STOMACH FEEDING TUBE. DR. BLANCHARD SENT JIM HOME WITH AN OXYGEN TANK AND HOSPICE CARE.

JIM WITCHER: What happens to you when you start to die is there is an inborn influence in you that tells you you gotta breathe.

MOYERS (v/o): HOSPICE WORKERS VISIT SEVERAL TIMES A WEEK, BUT SUSIE STILL DOES THE LION'S SHARE OF THE WORK, GETTING HIM UP EVERY DAY IN HIS CHAIR. RECENTLY THEY HIRED A NEIGHBOR TO HELP RELIEVE SUSIE WHO IS BUCKLING UNDER THE STRESS.

NEIGHBOR: You want me to take your legs over?

MOYERS (v/o): SHE COMES TWO DAYS A WEEK AT THEIR OWN EXPENSE. AND WHAT DOES JIM WANT SUSIE TO DO WHEN HIS NEXT CRISIS MOST SURELY COMES?

JIM WITCHER: Just let me go. All of me.

SUSIE WITCHER: I want to try to honor his wishes and I won't, I won't call the ambulance or anything. It's not going to be easy. In fact, I guess it'll be the hardest thing I'll ever have to do. You know, I wish I could keep him alive. But I don't want to keep him alive suffering either.

JIM WITCHER: I love you. I love you.

MOYERS (v/o): AFTER OUR VISIT, JIM WITCHER MADE A DECISION TO REFUSE MEDICATION AND FOOD. BY THE END OF THE WEEK HE DIED. SUSIE SCATTERED JIM'S ASHES OVER THE HORSE PASTURE.

ANNOUNCER: On Our Own Terms continues on the web. Explore the issues, share your stories and hear from others: Find resources for help at pbs.org.

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ANNOUNCER: In the next episode, "A Time to Change":

MOYERS: What would happen if you had to pay for this care yourself?

WILLY FRED DAVIS: I'd just be out in the grass and go ahead and put me under the grass.

EDWINA TAYLOR: My goal is for people to be able to die peacefully. We can't make good deaths, but we can make better deaths.

DR. JOANNE LYNN: We the people-own the care system that we're now very unhappy with, so we could fix it.