Originally published in West,the Los Angeles Times magazineMarch 11, 2007

Both men were dying, and both wanted the end to come at the time and place of their own choosing.This is the "director's cut," an expansion of the published piece.Fourteen months ago, Tom McDonald heard the news no one wants to hear. He was an active, jovial retiree who lived in a comfortable ranch house overlooking Lake Oroville, an hour and a half north of Sacramento. At 75, he was still a good-looking man with a luxuriant head of silver hair and a handsome, fleshy face with the ruddy color of an outdoorsman. He had a good life. He and his second wife, Dolores, doted on each other. They traveled the West Coast in their 27-foot RV. They took weekend jaunts to Tahoe. They lounged with friends and family on their “party barge.” Tom went trout fishing. He puttered around the house inventing gadgets.Two years before, he had felt a pinhead-sized bump behind his right knee. The dermatologist who looked at it thought it was probably nothing to worry about but did a biopsy to make sure. When the results came back positive for melanoma, Tom took the news calmly. He had had a cancerous growth removed from his lip years before and figured this was no different. They’ll just take it off, he thought, and I’ll be done with it.The surgery went well. The doctors thought they got it all. But a CAT scan a year later showed that the melanoma had penetrated deep into the tissue. There was another surgery, and another CAT scan, and then a PET scan.On Jan. 5, 2006, in his doctor’s office in Roseville, Tom and Dolores heard the results of that latest scan: The cancer had spread to his shoulder, into his lungs and was threatening to move to a lymph node beneath his jaw. Chemotherapy doesn’t work well in these cases, the doctor told him, and radiation is not much better. Tom had a year to live.It took him only a few days to think through his situation. Tom was a take-charge guy. A 30-year career as an electronics technician, much of it in the aerospace industry, had taught him to look at problems dispassionately, find the elegant solution — simple, workable, quickly implemented — and then go to it. His terminal disease was the problem. His solution was simple: When the time came, he told his wife, his daughter and his son, when he felt he could no longer tolerate whatever the end-stage illness was doing to him, he would take matters into his own hands. He would end his life.In the U.S., citizens have many rights, but they do not, strictly speaking, have the right to control their own death. Although attempting to take one’s life is not considered a felony in this country, aiding and abetting the act is. If Tom McDonald wanted, or needed, medical help to end his life, he couldn’t, legally, get it in California, where it’s a crime to help terminally ill patients hasten their own deaths. Although the language used in public debate to describe the issue reflects a moderation of popular opinion — from “physician-assisted suicide” to “physician-assisted death” to “aid in dying” — legislation has not followed.Now Californians are trying once again, for the fifth time in 15 years, to enact legislation that would permit people such as Tom McDonald to control their deaths. A new bill — essentially a carbon copy of the death with dignity legislation that died in the state’s Senate Judiciary Committee last summer — was just re-introduced. Proponents of the law hope to take advantage of what they see as a more favorable atmosphere in the state legislature since the election of 34 new members last November. In 1992 voters defeated a ballot measure by a 9% margin. In 2000 opponents kept a bill from being voted on by the full Assembly. Then this past June, the California Compassionate Choices Act, was defeated in committee by a single vote. Should this next attempt be successful, California will be the second state — its neighbor, Oregon, is the first and only — to legalize physician-assisted death. The California bill, modeled after the Oregon law, will allow a doctor to prescribe lethal drugs to a terminally ill patient.When the Senate Judiciary Committee held hearings on the previous bill last June, Tom McDonald was there to testify. He was then six months into what he had been told would be the last year of his life.“My doctor said I’d know when I’m near the end because I’ll be coughing up blood,” he told the committee. He was sitting motionless, a little slumped, at the witness table. “I’m not too thrilled with the prospect of ending my life drowning in my own blood.” He didn’t want to subject his family to “such horrors.” His voice cracked, and he struggled not to cry. Someone brought him a glass of water. He composed himself and went on. He didn’t want to lose his dignity, he told the committee. In the absence of a humane and legal way to end his life, in the absence of help from a compassionate doctor, Tom said he would “leave this life violently.” He had been more precise, and chilling, in a letter of support he had written to California Assemblywoman Patty Berg, co-sponsor of the June 2006 legislation. He would end his life, he told her, by “a 9mm injection to my head.”Earlier that spring, a survey by the Field Research Corporation showed that California’s registered voters favored the physician-assisted death bill by a margin of 63% to 28%. But on June 28, 2006, two days after Tom McDonald’s testimony, the bill died in committee, defeated by a single vote.During the months between Tom McDonald’s first and second surgeries David Bradley also was diagnosed as terminally ill. He had esophageal cancer, which is, like melanoma, tough to beat. He had noticed months before that he was having trouble swallowing, but David was not one to run to a doctor. He was 80 years old, and although he was Midwestern born and bred, he had become, in his later years, part desert rat, part cowboy.He lived alone in the high desert of southwest New Mexico, up the road from the town where Billy the Kid had been a kid. He spent his days quietly, stopping every morning for coffee at a cowboy diner, riding his horse, Julio, painting, socializing, taking photographs. He had always been healthy. He still worked out at a gym several times a week. You could see it in his biceps. A member what Tom Brokaw dubbed “the greatest generation,” he defied the stereotype. He was a free spirit, a nature-lover, a man who carried an eagle feather talisman, a man who had married and parted company with four wives.David Bradley had a peaceful life and a faithful dog and, that winter, a prognosis of six months to live. For him, as for Tom McDonald, the reaction to the news was swift and decisive. When he learned there was no effective treatment, when he understood what the end-game would be, he told his family: “I’m just going to take care of this myself.” They knew what he meant.But David had something that Tom did not. David had family in Oregon. If he moved to Oregon to stay with one of his daughters, he would have — if he cared to exercise it — a choice about how and when he died. He could, unlike Californian Tom McDonald, legally and with medical consultation and support, end his own life.For almost nine years it has been possible in Oregon — as it is nowhere else in the U.S. — for a competent, communicative, fatally ill person with a documented prognosis of six months or less to live to obtain a prescription from a doctor for a lethal dose of barbiturates. The terminally ill person must be capable of taking the medication him or herself. There are no injections. There is no Dr. Kevorkian standing bedside.Although Oregon’s Death with Dignity Act is simple and straightforward, the public battle to keep it in place has been anything but. Oregonians passed the law in 1994 (it came to voters as a citizen initiative), only to have it immediately challenged by the National Right to Life Committee, the powerful anti-abortion lobbying group that has also concerned itself with what it calls “euthanasia.” A U.S. district judge ruled in favor of Right to Life, and an injunction against the Oregon law kept it in limbo until the Ninth Circuit Court of Appeals overturned the ruling a year and a half later. Right to Life then sought a review by the Supreme Court, meanwhile lobbying the Oregon legislature to call for a special election to repeal the act. When the high court refused to hear the case, and when Oregonians overwhelmingly re-endorsed the legislation at a special election in 1997, it looked as if the battle was over.It wasn’t.Four years later, there were new challenges, from then-U.S. Attorney General John Ashcroft and his successor, Alberto Gonzales. It took a lawsuit by the state of Oregon, a U.S. District Court case, two appeals to the Ninth Circuit and, finally and decisively, a Supreme Court ruling in January 2006 to uphold Oregon’s Death with Dignity Act.During all this Sturm und Drang, the Act was quietly, without incident, working. According to the most recently available figures compiled by the Oregon Department of Human Services, 246 people took lethal medications between 1998 and the end of 2005. Information about these people — who they were, what diseases they had, why they chose the option they did — has been dutifully compiled in annual reports. The picture that emerges is nothing like the picture feared by those who have argued, in California and elsewhere, against such a law.Those against the Oregon law — and its cousin in California — feared that physician-assisted death would be used disproportionately by the poor, the uninsured, the uneducated or those living with lifetime disabilities. Those who couldn’t afford decent end-of-life care might choose death to lift the financial burden on loved ones. Those with life-long disabilities might conclude that their lives were not valued if society provided a way for a quick exit. More sinister was the argument that the state might be tempted to put less priority on providing assistance for the poor and disabled because the option of death was easier and cheaper.So far, the none of that has happened in Oregon.All of the people who have used the Act have had health care coverage, and almost all of those who died by ingesting a lethal dose were enrolled in hospice — and thus already receiving compassionate end-of-life care. Well educated Oregonians (those with a baccalaureate degree or higher) were almost eight times more likely to use the Act than those without a high school diploma. And, contrary to fears, those with lifetime disabilities have not used the Act. Oregonians who hastened their own deaths were most likely to be in the end stages of cancer, AIDS or ALS.As for the broader concern that the option of physician-assisted death would make a state’s citizens, politicians and medical community callous to end-of-life care, the opposite has happened in Oregon. The state is a national pioneer in such care, according to national data compiled at Dartmouth and studies conducted by the Oregon Health Sciences University Center for Ethics in Health Care.Oregon is one of the nation’s leaders in hospice care, at-home (versus hospital) deaths and pain management. More than three-quarters of all Oregonians die with an advance directive or physicians orders in place (specific instructions about what they want and do not want at the end of life), the result of a well-funded and energetic statewide (pre-Terri Shiavo) campaign spearheaded by OHSU’s Center for Ethics in Health Care. Clearly, the state is paying more — not less — attention to end-of-life issues. And that, say many in the health care community, is a direct result of the extensive public discussion that has surrounded Oregon’s death with dignity legislation, as well as the existence of the Act itself, which has challenged stalwart opponents (including the Catholic hospitals) to enhance end-of-life care.Sitting in room 4203 in the California state capitol, Tom McDonald didn’t know much about the Oregon law. What he knew, as he testified before the Senate Judiciary Committee, was that he was dying. He was dying, and he didn’t want to die in pain.Pain — the very idea of pain — was a big deal for Tom. He vividly remembered his mother’s death more than 40 years before. She was at home, in bed, dying of cancer. These were the days before hospice, before palliative care, before physicians had become sophisticated about pain management. A shelf in the kitchen refrigerator was stacked with little bottles of liquid morphine. Tom’s older brother stopped at the house once in the morning and once in the evening to give injections. Maybe the pain was too great, or the dosage too small, or the twice-a-day injections too infrequent, because what Tom remembered when he came by the house was his mother, in agony, waiting for the next shot.Tom was not afraid of the fact of death. He was afraid of the act of dying.Dr. Nick Gideonse had testified before the committee a few days before Tom McDonald. The Oregon physician understood what Tom was going through. Dr. Gideonse had talked with dozens of patients about Oregon’s law. He had written eight prescriptions for life-ending drugs under the law. He had been at the bedside of six people who took drugs to hasten their own deaths. He knew that terminally ill patients often feared pain, along with loss of independence and loss of control. He had learned that, for many people, simply knowing that they could take control, that they could die on their own terms, was relief enough. They didn’t actually have to do it. Oregon’s experience with the law had shown that this was true: Many more people requested the drugs than actually used them. In 2005, doctors had written 64 lethal-dose prescriptions, but only 38 people had used the medication to end their lives.Dr. Gideonse was a tall, lanky, energetic man with wiry salt and pepper hair captured in a low ponytail. He’d gone to Harvard and Case Western Reserve. He’d been an EMT in Boston, a country doctor in rural Oregon and was now a family physician and part-time medical director at a clinic in Portland that served the poor. He was, as doctors often are, intense and driven, but he also was tender-hearted and soft-spoken, one of those rare physicians who understand the extraordinary medicinal qualities of eye contact.He was in Sacramento that day last June to explain to the committee how he, a Hippocratic-oath-swearing, “Do no harm” physician, could support and be actively involved in helping people die. He had not been an immediate fan of the law. His patients had converted him. He spoke passionately about honoring and respecting patients. “The notion that physicians know best and that patients cannot be trusted with the ability to make good decisions about their care, even the care at the end of their life, is an outdated ethical precept,” he told the committee.David Bradley first met Dr. Gideonse in the Veterans Administration hospital in Portland. David had moved to Oregon from New Mexico a few weeks after getting his six-months-to-live prognosis. One of his daughters, Allison, had driven down to get him. They’d talked on the phone about his illness, about the time he had left, about what he wanted to do. When David told his daughter that he’d “take care of it himself,” she was scared. She knew that she’d support him, whatever he decided to do, but she heard fear and panic in his voice, and she wanted any decision to come from another place entirely. She told him that, if he wanted to, he could come to Oregon, that she and her family would take care of him. Exactly how the topic of Oregon’s Death with Dignity Act came up, or who first broached the subject, she doesn’t remember. But when Allison got off the phone with her father, she immediately called Compassion & Choices of Oregon and spoke to George Eighmey, an attorney and former state representative who is the nonprofit group’s executive director.Since 1997, the organization had been providing support and information to Oregonians considering using the aid-in-dying law. George and his assistant — the group is a two-person, bare-bones operation — spent their days on the phone counseling terminally ill patients and their families, talking with health care providers and making connections between the two. Allison reported the conversation to her father. A self-reliant, independent thinker his whole life, David Bradley wanted an equally independent, self-reliant exit. He would come to Oregon, stay with Allison and begin to plan a peaceful death.It was a month and a half after settling in Portland that David woke up angry one morning. Installed in a spare bedroom upstairs that was filled with his own books and memorabilia, he had been spending his days quietly, coming to terms with what he had and hadn’t accomplished in his life, contacting old friends, strengthening his connection to his grandchildren. His health was failing. He couldn’t swallow and was taking nourishment from a tube, but his attitude was generally serene. The night before, though, had been bad. Lots of coughing, little sleep. He awoke furious at the cancer growing in his throat.Allison organized a ritual on the spot. It seemed that so much of these past weeks were about rites and rituals, about constructing small ceremonies and homey celebrations. Knowing the end was so near, and that they could plan for it, freighted everything they did with meaning. That morning Allison organized a quick trip to a bucolic patch of land just outside the city. There they built a small fire, and David burned all the tissues he had used the night before. He stood before the blaze and yelled, flicking his eagle feather, again and again, as if directing the anger out of his body and into the fire. That night, he hardly coughed at all.But soon he was coughing again, a combination of not being able to swallow and, it turned out, a case of pneumonia. The last thing David wanted was to be in a hospital, to die in a hospital. But he had to go. It was there in the hospital that he realized he was running out of time. Soon he would be too sick or too weak to self-administer the lethal drugs. He needed to make his first request under the Oregon law to get the process going. Dr. Gideonse was called in to see if David “qualified.” Did he indeed have a six-month or less prognosis? Was he mentally competent? Did he understand all his options?David’s medical records confirmed the prognosis. That was the easy part. But Dr. Gideonse needed to know that David was not desperate or depressed, not mentally unstable, but rather fully competent to make this decision. When the doctor walked into David’s hospital room that day, David immediately launched into a long, circuitous story about being ill as a child, how he had suffered from pneumonia and had to have one rib removed and his lung drained. He had been in the hospital for a long time and bedridden for even longer.This man is rambling, Dr. Gideonse first thought. This guy is befuddled. But then, he understood. In telling this story, David was saying that he had experienced long-term disability and knew what it was like and did not want to experience it again. He wanted to “wrap things up,” he told the doctor. He wanted to “finish the story.”“I am hoping you will help me die,” he said.Dr. Gideonse wanted to know what David was afraid of. There was good pain management these days. David did not have to die in pain. But David was clear. It was not pain he feared. It was that his quality of life was untenable. Just five months before David had been riding his horse every day. Now he was virtually bedridden with a tube in his stomach. Dr. Gideonse understood. You could palliate pain, he thought, but you could not palliate loss of independence.When David was released from the hospital the next day, Dr. Gideonse visited him at Allison’s home, the first of four house calls he was to make during the next two weeks. They talked it all through. David understood what medication he would take, how he would take it and what exactly would happen. All the necessary paperwork was filed. In a week, David would get his prescription for liquid Nembutal.It was Dec. 5, 2006, exactly one month from what Tom McDonald thought of as his personal D-Day. He had taken his doctor’s “you have one year to live” prognosis — delivered 11 months before — literally. He had, he thought, one month left. But with the clock ticking, he still had no plans in place to control his own death. Because of his involvement in the fight for the aid-in-dying legislation the summer before, Tom had become more knowledgeable. From his home overlooking Lake Oroville, Tom was now in e-mail correspondence with a counselor at the national Compassion & Choices organization, a nurse named Helen Beum who had specialized in working with AIDS and cancer patients before joining the organization eight years before. Helen worked out of the organization’s headquarters, a pretty, vintage building in residential northwest Portland. She was one of five national counselors — the organization also had 130 volunteers in 26 states — who fielded questions from people all over the country. The office got more than 250 calls a month and actively worked with about 200 clients at a time. Working with a client meant providing emotional support, discussing end-of-life decisions and, if the conversation moved in that direction, helping people such as Tom, terminally ill people without the legal choice Oregonians had, figure out how to hasten their own deaths.Tom had decided against the “9mm injection” as a way to end his life. It would be too traumatic for his family. He didn’t want to leave behind a mess. He wanted to do what Oregonians could do — take a lethal dose of barbiturates. But Helen knew how difficult getting a prescription could be, how nerve-wracking the process could become, how much time and energy it could take away from the last months or weeks or life. It was possible, though. At Compassion & Choices, they called it the “wink-wink approach,” a covert discussion that went on between terminally ill people and sympathetic doctors and hospice workers.It worked like this: A Compassion & Choices counselor provided information about which one of six different drugs to ask for (depending on the person, the illness and other medications being taken) and how to phrase the request to a physician. Then a terminally ill person, using coded language that obscured how the drug would be used, asked for a prescription from the doctor. Although nothing was said about ending life, the doctor almost always knew why the prescription was being requested. A sympathetic doctor might write such a prescription. But prescriptions for such drugs could be written for only a one-month’s supply at a time — and a one-month’s supply, if taken all at once, was not enough to reliably cause death. That meant the terminally ill person had to stockpile the pills, ask for another one-month prescription, stockpile those pills and then ask for a third prescription. Only then would there be enough to comfortably, peacefully end life. Advance planning was essential. A two-month minimum was necessary. Tom McDonald, with what he thought was a month left, hadn’t begun the process.In southeast Portland, in the spare bedroom in Allison’s house, David Bradley was sitting up in bed dressed in a thick scarlet-colored robe. A bright, bold Pendleton blanket lay over his legs. His dog Scooter napped by his feet. The bottle of Nembutal sat on the night table. It was a big bottle, almost a cup of liquid, the dosage equal to the powder in a three-month’s supply of pills. When Dr. Gideonse arrived in the early evening, the family was finishing up its goodbyes. Each person had spent time alone with David, their farewells, for the most part, simple and brief. Knowing that this day was coming, they had been saying goodbye, slowly, for weeks. They had all sat together in David’s room that last week watching episodes of the TV mini-series “Lonesome Dove,” David’s favorite movie, in which – it was hard not to notice — the fiercely independent main character chooses to die on his own terms.David had asked that only the doctor be present at his death. He wanted his family to remember him smiling, not falling into a coma. Allison had planned a ceremony downstairs for the family, nothing funereal, nothing fussy and nothing — David had insisted — that involved eating cake. “No cake!” David had told her, laughing. “Cake is what people eat at funeral parlors.When David and Dr. Gideonse were alone, they talked about his decision to take the medication. David said he was getting weaker and weaker, not just going downhill but speeding downhill. Dr. Gideonse wanted him to know that he could change his mind, that right now, in this room, he could decide to put off taking the medication or never take it. David understood that, but he was ready. They talked through how the procedure would go, how he would feel, when he would fall asleep.Then David picked up the end of his feeding tube and took out the plug. With the other hand he picked up the bottle of Nembutal, held up the tube and poured in the liquid. He placed the bottle back on his night table and poured a cup of water down the tube to make sure the medicine went down. He put the plug in tube and settled back on his pillows. He was calm and lucid. He talked to Dr. Gideonse about the gratitude he felt toward his family, about how much he loved them and was going to miss them.Downstairs, Allison had started the ceremony. Each intentional death, Dr. Gideonse knew from experience, was different; each family was different. But all the deaths he had witnessed were ceremonial in some way, involving what Dr. Gideonse had come to think of as a “celebration of the end of dying.” He had been present at one death where a feisty dying woman toasted herself with a shot of Canadian Mist, another where the patient was the center of elaborate Native American rites.At Allison’s, eight people sat in a circle on the floor, including David’s three daughters and his sister. Family had traveled from California, from Florida and from across town to be here. In the middle of the circle were objects Allison had gathered that were important to David: the eagle feather, the Leatherman tool he carried with him to fix and tinker, a battered stuffed animal he had when he was a child and sick with pneumonia, a pamphlet on birds of prey.Around the circle, each person, in turn, picked up an object and talked about it. Everyone had a little story, an anecdote, a remembrance. Then they went around the circle again, this time each person holding David’s eagle feather and saying what they wanted to say, maybe a quotation or a piece of poetry. David had wanted someone to recite the strong, unsentimental poem that John Wayne had said at Howard Hawks’ funeral, “Do not stand at my grave and weep,” and so someone did.Upstairs, David yawned. The Nembutal was beginning to take effect, and David knew it would be only a few minutes before he was asleep. He motioned Dr. Gideonse closer. He had one more thing to say. Dr. Gideonse wondered if it was a secret he’d been saving, or a piece of wisdom he wanted to pass along.“You know,” David said quietly, “I’ve done a lot of things right.”Then he closed his eyes and fell asleep. Within a few minutes, he was unconscious. Within 10 minutes he stopped breathing. Dr. Gideonse felt for his pulse and found none, listened for his heartbeat and heard none. Downstairs, Allison felt a change in the air pressure in the room, as if someone had opened a window.It was January 2007, a year and a half after David Bradley’s death, a year after Tom McDonald’s diagnosis. Tom’s Compassion & Choices counselor, Helen, had been e-mailing him. She was concerned that she had not heard from him, concerned that he was not beginning to take the steps that would allow him to control his own death. Tom hadn’t followed up.Partly that was because, to his great surprise, he had not been experiencing significant pain. Although his lungs were so compromised that a slow walk from his deck to his living room left him breathless, he wasn’t in agony like his mother had been in agony. If he wasn’t in agony, then everything was OK. If he wasn’t in agony, then perhaps he wasn’t really dying. When the time comes, he said to himself, I’ll do something.He knew it wasn’t that simple, but he hadn’t allowed himself to think about just how hard it really would be. He didn’t want to think about it, and no one but Helen, in an occasional e-mail, was pushing him to think about it. Helen had told him about how he would have to stockpile drugs, but it hadn’t really sunk in that he would need to fill three separate prescriptions over the course of more than two months. How could he think about that when he didn’t even know where he would get the prescriptions?Compassion & Choices does not give referrals to physicians in other states. There is no master list of doctors who might agree to write prescriptions. Helen can tell Tom what to ask for and how to ask, but she cannot tell him who to ask. In Oregon, most prescriptions are written by primary-care physicians because they know their patients best. Tom liked and respected his primary-care doctor, but he thought it was unkely she would write a prescription for him. Who else would he ask? He had no idea.In California, doctors couldn’t openly and honestly discuss such end-of-life issues with their patients. Tom had never had what Dr. Gideonse called “The Conversation,” the compassionate but frank talk with a knowledgeable, sympathetic physician who knew him well, the talk about end-stage illness, about death, how it would occur and how it might be hastened. Tom had testified in favor of California’s aid-in-dying legislation, but now, when it counted, he had very little aid for himself.Maybe Tom McDonald will find a California doctor to write a prescription, and maybe he will live long enough to stockpile the pills. And maybe, when the time comes, he will still be physically able to take the pills. Or, if California’s fifth attempt at passing aid-in-dying legislation is successful, Tom McDonald can relax into his final days and still get the kind of death he wants, the kind David Bradley had: peaceful and painless and in his own bed, at home.