Part of “Last Words,” a series on inequities in end-of-life care.
She thumbed through the newspaper over her morning coffee, just like any Sunday, except on this one she took the pill a little before 10 a.m.
The pill by itself is not lethal. It eases nausea and anxiety. The drink that follows an hour or so later, a powder mixed with juice, thick like pancake batter, is the fatal part.
Kathleen Kreiss sat back in the living room, in her blue easy chair, with her luminous, long-haired Norwegian forest cat curled in her lap, and waited for the pill to kick in. KING FM, the classical music station out of nearby Seattle, was on the radio, playing Bach’s Mass in B minor,. The front window looked out to her yard on a cul de sac.
One of her two adult daughters read poetry aloud, a special selection of poems about love and death. Kathleen listened stoically, until Walt Whitman cracked her calm, just a bit, and tapped into the emotion below.
…All goes onward and outward, nothing collapses,
And to die is different from what any one supposed, and luckier.
Kathleen’s eyes flooded. She nodded and softly agreed, “Yes.”
In the autumn of 2019, months before the COVID-19 pandemic, Kathleen had just turned 83. She lived by herself in a little house in Shoreline, Wash., about 12 miles north of Seattle. Doctors and family didn’t favor her living alone, but what could they do? Short of kidnapping her, nobody could make Kathleen live anywhere else.
She was a hospice patient suffering from heart failure. Her diagnosis was terminal — less than six months to live — so she applied for her state’s Death with Dignity program, which is known by many names, such as “medical aid-in-dying.” It permits certain terminally ill patients to get prescriptions for lethal drugs to hasten their own deaths.
More than a year ago, the Globe Spotlight Team reached out to Death with Dignity advocates in Washington and Oregon, seeking to speak to patients for research on inequities in end-of-life care. In October 2019, Kathleen, a retired schoolteacher, did some online research and learned that Massachusetts does not have a medical aid-in-dying law. For two weeks she debated whether or not to call a Globe number passed along to her. Oh, why not? she finally decided. Maybe she could help advance the cause in Massachusetts.
“My family is in agreement,” Kathleen said, in an interview. “I have the prescriptions filled. The target date is very likely to be Thanksgiving weekend.”
Friday, Nov. 29, 2019, in fact.
She planned to take the lethal drugs on what happened to be Black Friday.
Only a tiny percentage of US deaths every year are by medical aid-in-dying. In Oregon, which pioneered the program in the United States more than 20 years ago, the number of people in 2019 who died by consuming prescribed lethal drugs was 188; in 2018, the number was 178. The practice is also legal in Washington, Montana, California, Hawaii, Colorado, New Jersey, Vermont, Maine, and Washington, D.C.
The programs in each state differ slightly. But, in general, they are open to patients who are both terminally ill and mentally sound. This precludes dementia patients from participating; the typical patient is someone with end-stage cancer. If a patient qualifies, a physician can legally write them a prescription for lethal drugs.
A typical prescription is a cocktail of four established medicines, abbreviated as DDMA, according to Dr. David R. Grube, a retired Oregon physician who has prescribed lethal medications under the program in the past. The drugs are diazepam, a sedative; digoxin, a heart drug that in certain doses can cause a slow, irregular heartbeat; morphine sulfate, a painkiller that in large quantities causes the lungs “to gently stop”; and amitriptyline, an antidepressant that can also cause a side effect that affects the heart, Grube said.
The drugs are mixed with half a glass of water or juice to be consumed, said Grube, who is also the national medical director for Compassion & Choices, a group that supports medical aid-in-dying legislation.
“After ingestion the individual falls gently asleep in about 10-20 minutes, and a peaceful death occurs on average in about an hour,” Grube said by e-mail.
The program has a lot of names, such as “assisted dying” and “doctor-assisted death.” Opponents refer to it as “physician-assisted suicide,” a term supporters believe is loaded and pejorative.
Whatever it is called, for terminally ill people in Massachusetts and most other states, the option does not exist. That means that across the country, or just down the road over a state line, choices at the end of life depend on where you live.
In 2012, a Massachusetts referendum to permit medical aid-in-dying appeared on the statewide ballot. Early polling suggested voters were ready to pass it, but support collapsed in the final weeks before the vote, under an opposition campaign led by the Catholic Church. The proposal failed, roughly 51 percent against to 49 percent in favor.
Since then, supporters have worked to get medical aid-in-dying approved by the state Legislature, and believe momentum is slowly gathering to their side. In 2017, the most powerful physicians’ organization in the state, the Massachusetts Medical Society, dropped its opposition, after a survey of its members showed support for giving patients this choice.
“This year, for the first time we’ve been able to get [medical aid-in-dying] legislation moved out of the Joint Committee on Public Health,” said Roger Kligler, a Falmouth doctor who has been diagnosed with stage IV metastatic prostate cancer.
Kligler has become one of the state’s foremost advocates for medical aid-in-dying legislation. He has spoken about his desire to have the option available if his cancer advances, and was a plaintiff in a lawsuit that sought to have a court declare it legal under current law and the state constitution. That portion of the lawsuit failed in Superior Court.
A Boston Globe/Suffolk University poll conducted last November, as part of the Spotlight Team’s Last Words series about end-of-life disparities, found that 69.6 percent of Massachusetts adults believe medical aid-in-dying should be legal in the state, 19.4 percent disagree, and about 10 percent are undecided. The poll had a margin of error of 4.4 percent.
That polling result is a bit more favorable to the program than public surveys conducted eight years ago, during the referendum campaign; a Suffolk poll in September 2012 found that 64 percent expected to vote yes to legalize the program, before support collapsed.
On the phone from Washington state, Kathleen Kreiss did not sound sick. She was chipper and sharp and funny, full of gallows humor. “My target age was always 75; I was disappointed I passed that,” she joked.
She was disarmingly matter-of-fact in the way she spoke about her imminent death, as if she was describing plans to have her kitchen redone.
“It’s just reassuring,” Kathleen explained, “just knowing I can control that time and place. You just know when you’ve lost a great deal of the quality of life that it’s a reasonable time to check out. I’m doing it for me.”
That notion of control is a big deal among patients confronting the end of their lives in a medical aid-in-dying program. It seems to come up in every conversation.
In the autumn of 2019, 44-year-old Tempra Dawn Jones, a terminally ill cancer patient from Sedro-Woolley, Wash., was in excruciating pain from tumors, in her fourth bout with cancer in 13 years. She had a prescription for the lethal drugs, but first had to see her daughter’s wedding, she said. After that, if she could stand the pain a little longer, Tempra wanted a kiss from her boyfriend on New Year’s Eve.
She set Jan. 10, 2020, as the day to take the drugs.
“I am weirded out that I’m going to be dead in 10 days,” she admitted on Dec. 31, 2019, in a Globe interview.
“But I will not let cancer determine me. You already feel betrayed by your body. If I leave it up to cancer it will make me suffer for God knows how long. The most important decision? I do get control. That’s all that matters.
“Everybody is going to die. We’re just basically renting our bodies.” She laughed — not bitterly, a genuine laugh. “I’m going to turn mine in now. I’m done. This model sucked.”
She died on Jan. 10, surrounded by friends and family.
For Mel Bryson, the lethal drugs were Plan B.
He was a 74-year-old retired dentist, from Vida, Ore., who liked to sail and drive race cars. In 2015, he was days away from death when a double lung transplant saved his life. The operation gave him several good years, but by late 2019, his body was rejecting the transplant, he said. He didn’t have long to live and was out of medical options.
“I don’t know what the next week or month will bring,” he said, in a slightly labored voice. “I’m getting weaker by the day.”
He had gone through anguish while waiting for the transplant, a terrifying feeling of suffocation as his diseased lungs failed.
“I’m not willing to go through that again,” he said. Not without hope for a cure.
He set no date to die. If his suffering became unbearable, he would decide on the drugs; they were a contingency that brought him peace of mind.
Five days after that interview with the Globe, Mel Bryson died — without taking the lethal cocktail, according to his family.
One statistic that jumps out from the experience of medical aid-in-dying in other states is that those in the program are overwhelmingly white, significantly whiter than the populations of those states. In Washington, for instance, where about 67 percent of the population is non-Hispanic white, 96 percent of medical aid-in-dying patients have been white, according to state records.
John B. Kelly, director of Second Thoughts Massachusetts, a group opposed to medical aid-in-dying, explained the program’s racial discrepancies this way: The predominantly “middle- and upper-class white” demographic is “obsessed with achievement and the ability to perform their own self-care.” If illness makes them dependent on others, this group “feels a loss of dignity.”
“Let’s be frank,” said Kelly, 62, of Boston, who was paralyzed in 1984 due to an injury. “This demographic — middle- and upper-class white people — look down on disabled people as living inferior lives, and when they themselves become disabled [through serious illness], they turn that prejudice on themselves,” and can become convinced they would rather die.
In minority and working-class white communities, however, achievement and autonomy often take a back seat to the virtues of family and personal connections, Kelly said. These communities are less likely to feel such unbearable loss of dignity brought on by the debilitating effects of illness. The results of the 2012 referendum affirm that many of the state’s wealthiest, best-educated municipalities strongly supported medical aid-in-dying, communities such as Concord, Cambridge, Brookline, Newton, and Northampton. In some of these cities and towns, the vote was greater than 2-to-1 in favor.
The referendum was rejected by large margins, though, in more diverse and working-class cities, such as Brockton, Fall River, Lowell, New Bedford, and Springfield.
The Rev. Gloria White-Hammond, a physician and the co-pastor of the Bethel African Methodist Episcopal Church in Boston, said Black people may have a particularly skeptical reaction to medical aid-in-dying options, given their difficult history with the health care industry. Many who believe they were denied care or got inferior care in the past due to racism are going to be wary of a medical program that shortens life.
“Absolutely!” Hammond said, empathetically.
She paraphrased a joke about end-of-life care from the late Dick Gregory, the Black comedian and political activist. “Roughly his response was, ‘If we’ve lived all of our lives with you not paying attention to us living well, why do you want to talk about us dying well?’
“There’s this suspicion that he very appropriately voices,” Hammond said.
Opposition to medical aid-in-dying is fundamental to Catholic teachings about the sacredness of life, said MC Sullivan, chief health care ethicist for the Roman Catholic Archdiocese of Boston. Beyond religious opposition to the practice, Sullivan said there are compelling practical reasons not to legalize it in Massachusetts. A primary one, she said, is that palliative care, the medical specialty for people diagnosed with a serious illness, is designed to specifically address the physical, mental, and emotional reasons that sick patients might have for wanting to end their lives.
“To advance the assisted suicide notion,” without first making palliative care universally available to every seriously ill person from the moment of diagnosis, “is to leapfrog over a step we have yet to do as a society,” Sullivan said.
Kathleen Kreiss was born in 1936, into a family of educators, and became a teacher. She taught English, speech, and drama in public and private high schools in Washington. She enjoyed reading highbrow books, such as presidential biographies and novels by Pearl S. Buck and Jane Austen. She married, traveled the world, had two daughters, and then divorced after 23 years. Her ex-husband predeceased her.
She said she was not afraid to end her life. In fact, the opposite. “I’m afraid I will prolong it,” she said. “I may decide to stay around long enough to find out if the Democrats can take the Senate.”
Between the jokes, she wondered aloud about how her decision would affect those who love her, though both of her daughters supported her choice to seek a prescription under the program. “In some ways it would be easier to have a heart attack and die suddenly,” she said. “In some aspects I think it might be easier on my immediate family.”
Looking back over her life, she found little to regret. She had been encouraged as a young woman to pursue drama, but chose to teach it instead. It was the safer path. It’s not a regret, exactly, though she thinks about what might have been.
“I’m satisfied with the life I’ve lived. It certainly hasn’t been perfect, but it could have been much, much worse. I feel for the families who have elderly members with dementia.”
“Thanksgiving weekend is the date,” she insisted in October 2019 — with a hedge. “You don’t have to stay with that date. It’s important to have control over that decision. At first I thought Thanksgiving would be a downer. But there will be family here. It will be easier for everyone.
“Or I could wait until I have a heart attack so I don’t have to pay all that money for the medications,” she deadpanned.
Two days after that interview, Kathleen broke her arm in a fall at home. “I set myself back a lot,” she said in a follow-up call. Suddenly she was completely dependent on health aides and her daughter Jenny, who lived locally, to do everything for her. The injury was very painful.
She decided to move up her date.
Kathleen’s daughter Alison hurried in from Montana.
“She just felt she had lost all sense of independence and dignity,” Alison said later. “She was just ready and she didn’t have to postpone it just for the logistics.”
On Friday, Nov. 8, Kathleen made a bunch of goodbye calls to in-laws, grandkids, friends.
On Saturday, Kathleen and her daughters spent the day together, talking and paging through photo albums. Kathleen’s pastor came for a long visit. Kathleen made more calls.
Her daughters tried to keep up a normal routine that evening, putting their mom to bed, and then picking up the routine on Sunday morning with coffee and the newspaper.
And then a little before 10 a.m. she took the pill.
Mark Arsenault can be reached at firstname.lastname@example.org. Follow him on Twitter @bostonglobemark.