The family is waiting at the open door of their apartment before Dr. Sandy Buchman is halfway down the hall. When he steps inside, they tell him things have declined sharply in recent days. Buchman asks to see his patient, John, before they talk further—he knows he’ll be able tell a lot just by looking at the man. John’s wife, Margaret, and their three adult daughters (names have been changed) lead Buchman into a small bedroom, where a cold, wet early-May morning is sliding past a broad swath of windows.
John, who is 90 and has metastatic prostate cancer, lies unresponsive in a hospital bed in the middle of the room. His face is pinched rather than slackened in repose. “He’s in pain now,” Buchman says softly. One of John’s daughters remarks that their names are the only thing he’s been able to say in recent days. Buchman asks her to speak to her father; she does and receives a low moan in response.
The family has a host of questions about the changes they’ve noticed. Buchman explains that the purple, cool spots on John’s feet and legs are called “mottling,” then he addresses the long, uneven pauses in John’s breathing. “This is called apnea,” he explains. “It’s a late sign that someone is actively dying.” His tone is gentle but straightforward. One of John’s daughters begins to weep: “It’s so fast.” By this point in the dying process, families generally grasp the reality, but it’s difficult to hear their fears confirmed. “I think it’s a matter of hours,” Buchman tells them. “I wouldn’t be surprised if he passes today.”
With John’s family clustered around his bed, Buchman discusses controlling his pain using morphine drops that will absorb into his system even though he can no longer swallow, and he recommends using moistened swabs on his mouth to keep him comfortable. “What do you have for wives?” Margaret asks with a wobbly laugh. “Well, we have lots of TLC,” Buchman says, placing a hand on her shoulder. Before they leave the room, she proudly shows the doctor their wedding portrait and family snapshots arrayed on the windowsill.
Later, at the dining room table, Buchman walks the family through how to care for John through his final hours. “When he passes, you don’t call 911, you call me,” he says.
Buchman has been helping dying patients—which to him means helping them live as well as possible until death overtakes them—and their families for three decades as a palliative care doctor. But there’s now a new and profoundly difficult issue on the frontlines of death and dying: patients who want their doctors to actively help them die on their own terms and timeline. The legalization of assisted death in Canada—commonly called medical assistance in dying, or MAID—a year ago has prompted a sort of existential reckoning among doctors across Canada, but nowhere so dramatically as within the specialty of palliative care.
Individual palliative care physicians, including Buchman, 62, have had to sift through their deepest emotions, values, tenets of faith and the very reasons they chose this field of medicine in order to decide whether they will help their patients die. Palliative care specialists seemed to their colleagues like the obvious people to handle the highly fraught issue and practice of assisted dying. But the mission and philosophy of palliative care is, for many who do this work, uncomfortably at odds with helping people to die. The World Health Organization definition, which guides many hospices, physicians and nursing staff, holds that palliative care “provides relief from pain and other distressing symptoms,” “affirms life and regards dying as a normal process” and, crucially, “intends neither to hasten or postpone death.”
It took Buchman more than two years to puzzle through all of this before he ultimately decided that helping eligible patients who wanted and needed to end their lives was an extension of what he’s been doing all along: relieving suffering. And the first patient he helped to die was in many ways the ideal partner with whom to venture into this unknown territory: a fellow physician who knew too well the fate of his disease and was determined to take control of his own ending.
“I have a lot of colleagues I highly, highly respect in palliative care—I even worry about it now—and I just know how strongly opposed they are to medical assistance in dying being legal,” Buchman says. “I have total respect for their beliefs and values, and I think they’re good people. Still somewhere in me is the fear that they’ll think I’m not a good palliative care physician.”
He harbours the same worry you hear again and again from palliative care specialists who have landed on either side of this charged decision, and at every point in between: they’re afraid to be judged.
By mid-morning, when Buchman leaves John’s apartment building in east Toronto and tosses his red-and-black backpack into his SUV, he’s been working for hours. His pager starts going off at 7 a.m., and the team at Sinai Health System’s Temmy Latner Centre for Palliative Care (TLCPC), where Buchman has worked since 2005, begins each day with a “huddle” by conference call to discuss what happened overnight and how their patients are doing. TLCPC is one of the largest palliative care programs in Canada, and unusual for operating largely through home visits.
Perhaps because his car is his mobile office, Buchman drives with the pitiless confidence of a cab driver, navigating from one patient’s home to another with his phone’s GPS yelling directions.
Palliative care came to Canada in the 1970s, when cancer treatment was rapidly expanding. But those who work in the field say it’s still poorly understood or inaccessible for too many people who need it. “There have been so many misunderstandings about palliative care over the last 50 years, where people have thought, ‘Oh, they go in, they give them morphine, they hold their hand and they die quickly,’ ” says David Henderson, medical director of the Colchester East Hants Palliative Care Program in Truro, N.S., and president of the Canadian Society for Palliative Care Physicians (CSPCP). “For 50 years, we’ve been trying to help people understand that palliative care doesn’t hasten death and that it can really promote improved quality of living.”
As a new doctor, Buchman had just opened a family practice in Mississauga, Ont., when, in 1984, a patient in his 40s came in suffering from a mysterious pneumonia. There was no test for HIV/AIDS at the time and little understanding of the illness. Buchman offered to refer the man to a specialty clinic opening at a Toronto hospital. “He said to me, ‘Do they know anything more than you do?’ I remember those words. And I said, ‘I don’t think so,’ ” Buchman recalls. “And he said to me, ‘I’m too sick and it’s too far. Will you look after me?’ I said, ‘Of course I’ll look after you.’ ”
That’s how Buchman launched into learning about AIDS and palliative care at once. It hadn’t been covered in medical school; all Buchman knew was what he’d learned from reading Elisabeth Kübler-Ross’s seminal 1969 book On Death and Dying. He set about looking for resources to study, attending any information sessions he could find and apprenticing himself to a colleague.
To Buchman, palliative care is “total care” that addresses “total suffering.” That encompasses physical symptoms such as pain, nausea, loss of appetite and fatigue; the psychological and emotional toll of a life-limiting illness; the existential or spiritual suffering of people facing limited remaining days; and support for their families. It means letting a patient define what makes their life worthwhile and enjoyable—be it painting, being able to communicate with loved ones or simply enjoying a bowl of ice cream—and what would rob them of dignity or their sense of self, like having someone look after their bodily functions or being unable to recognize people they know. “It’s about providing a good death, if I can put it that way—about optimizing the dying process for a patient and their family,” Buchman says. “So in a way, it’s always about living.”
Research shows that introducing palliative care as early as possible after a diagnosis results in less depression, better quality of life and even a few extra months of life. But too often, Buchman says, patients are shuffled off to palliative care once their oncologist or other specialist declares they’ve exhausted all options for controlling their disease. “It’s synonymous with end-of-life care: ‘Nothing I can do to help you,’ ” he says. “And that leaves a sense of abandonment, anger, shock—they’ve never had the conversations about what they want, where they want to be at the end of life.”
Those who work in palliative care could see the issue of assisted death headed their way well before the February 2015 Supreme Court decision. “It’s been a little of a love-hate thing: in many ways we’re almost glad this issue has come forward, because people are finally starting to talk about palliative care,” says Henderson, the CSPCP president. But his organization worried that such a divisive issue would cause a schism that could bring an end to their national organization. The most recent survey of their members, from February 2015, spotlights the profound discomfort many in palliative care feel toward assisted death: 73 per cent opposed legalization of euthanasia (in which a medical professional administers the life-ending medication) and 69 per cent opposed the legalization of assisted suicide (in which the patient administers the drug themselves), while 74 per cent believed that if they were legalized, they should not be provided by palliative care services or physicians.
“Within the government and the rest of the health care world, everyone was assuming palliative care would just take this on and do it, because they thought we were already doing it,” Henderson says. “There was a lot of shock when we said, ‘No, this is not what we do.’ ”
Last summer, the issue moved from philosophical contemplation to pragmatic reality for Buchman when he met Gordon Froggatt. Froggatt was, as his obituary would sum up, “a cardiologist at Sunnybrook Hospital, a professor of medicine at the University of Toronto and a bon vivant known to his many friends and colleagues for his love of life.” He also loved the Toronto Maple Leafs, Chelsea F.C. and debating politics. When he met someone new, he would exclaim to his wife, Diane, “He’s such a nice guy!” She would point out, “But you don’t really know him yet,” and they’d laugh about his resolutely sunny view of his fellow man.
Five years ago, in his mid-70s, Gordon began to seem disengaged from conversations, and Diane wondered if it might be hearing loss or Alzheimer’s disease. His eventual diagnosis was Parkinson’s disease; by the summer of 2015, he could hardly walk or talk. “Among friends, people would be chatting about things, and he had his opinion but he couldn’t express it,” Diane says. “By the time he actually got to say something, the conversation would move on.” Boating and fishing at his cottage at Pointe au Baril gave way to simply sitting on the deck drinking in the scenery. When they packed up to leave one day, Gordon said, “I think this is the last time I’ll see the cottage.”
When he started talking about wanting assisted death, before the law passed, Diane initially didn’t take the idea seriously—she figured it would be years before such a thing was available in Canada. She changed her mind as everything Gordon enjoyed in life was gradually chipped away. “I know this ‘First, do no harm,’ but you can interpret that in many ways,” she says. “You can be doing harm by keeping people alive.” As the months passed, every time Gordon brought up MAID with his doctors, they sidled away from the idea. “Nobody would countenance the thought of it,” Diane says.
Following another health crisis that landed Gordon in the hospital last spring, he was referred to TLCPC, and Buchman became his palliative care doctor. At the end of their second visit, as Buchman was working to manage the worst of his symptoms, Gordon asked him, “When the law comes in, can you help me?”
From the time he could see the Supreme Court case coming, Buchman had been wrestling with this question. He started with the deepest and broadest of queries: Who am I? What are my values here? He examined his personal support system, because to him it was critical that his family be comfortable with MAID if he chose to provide it. He couldn’t imagine going home roiled with emotion and not being able to answer freely if his wife asked about his day, or wondering how his three adult sons saw him. “I’m their dad,” he says. “Am I doing something that would rub them the wrong way? Are they conscientious objectors?”
Buchman also took stock of how his faith aligned with what he was contemplating. He doesn’t consider himself a religious person or follow the rituals of his Jewish faith, but many of Judaism’s big concepts form compass points in his life. One of those is “tikkun olam” or repairing the world, which to Buchman—he stresses with a laugh that he is no theologian—means relieving human suffering with whatever skills he has. He spoke to rabbis and sought out theological readings before deciding that assisted death fit with his faith and deepest values. “It ultimately came down to relieving suffering and my role in relieving suffering,” he says.
And then he moved to contemplating his own death some day. What he wants is autonomy, dignity in his care and some control over his fate. Ultimately, Buchman could not imagine that if he refused to help his patients die when they wanted and needed it that he would have a right to ask for it himself. “That was really, really important to me. I don’t think I could live with myself,” he says. “I may be suffering unbearably and not be able to ask for it.”
When Buchman began grappling with assisted death, he started out believing it was simply not part of palliative care. He still doesn’t believe palliative care is about hastening death. Rather, he came to see MAID as one more tool in service of palliative care’s core mission of alleviating suffering. “Some people will say, ‘Thank you, I appreciate it so much [but it’s] not acceptable. I want MAID. My life is not worth living to me anymore for A, B and C,’ ” Buchman says. “I have to say to myself, ‘Who am I to judge?’ ”
Henderson, in contrast, is one of the many palliative care physicians who just can’t see himself providing assisted death. The longer he’s worked in the field, the more he’s come to see dying as a natural process that is profound and meaningful—especially in a society that so fears death and tries to shove it aside. “I truly believe there’s value during the dying process,” he says. “I think it is a process that still has value and not to hasten it, because I think you can miss out on some very special times.”
When Gordon asked Buchman if he would help him die once the law passed, Buchman gave him virtually the same answer he’d given the AIDS patient who set him on the path to palliative care more than 30 years before: “I will help you.” Gordon’s wife Diane watched, stunned, as the tension melted out of her husband’s body. “I realized it was that terrible for him, that he was absolutely so relieved to think that somebody would end his pain,” she says. She’s thought often about that moment, and she wonders if it registered with Buchman the same way.
It did. “You know Leonard Cohen’s saying, ‘There is a crack in everything, that’s how the light gets in’? I opened a crack and the light got in. It illuminated him,” Buchman says. “It was the beginning of a metamorphosis for me. I could see just the option of me as a physician being willing to deal with it was hugely helpful to these patients.”
It’s typically not physical pain that leads people to request MAID, but rather psychological or existential suffering. Palliative care is particularly good at controlling physical pain, and can do much for psychological suffering too, Buchman says, but not every patient is satisfied by what it can offer. “We can do a lot, but we can’t do everything; we couldn’t stop this relentless progression of his disease,” Buchman says of Gordon. “And he knew. He was a physician: he knew what was going on.”
Soon after the legislation passed on June 17, 2016, Buchman visited Gordon and Diane to conduct the first of two eligibility assessments required for MAID. Assisted death in Canada requires two different doctors to evaluate the patient and confirm that they have a serious and incurable disease that causes suffering the patient considers to be intolerable, and that they are in an advanced state of decline and their death is “reasonably foreseeable.” The physicians must also confirm that the patient is mentally competent to make medical decisions and that they have requested MAID with no outside pressure.
“At one point, I had to leave,” Diane says. “I just went upstairs for five minutes to calm myself down, because all you’re thinking about is that you’re agreeing to your husband’s death. We were married for 54 years.” By the time their two witnesses had signed the forms, everyone in the room was tearful—except Gordon. “He knew what he wanted,” Diane says.
A second doctor assessed him and declared him eligible, and so they set July 15, 2016, as the day Gordon would die. Over the course of a week, Gordon’s cousins, close friends and colleagues in cardiology arrived in pairs and trios, with bottles of great wine in hand, to say their farewells. “Anybody Gordon valued and loved came,” Diane says. She was nervous about it, but kept herself busy hosting and feeding the visitors; she bought a bottle of her husband’s favourite wine, a Gevrey-Chambertin, waving off the $100 cost. The week was happy and sad on the deepest of levels. “What he had was a seven-day wake, while being alive,” Diane says. “It probably wouldn’t happen in any other circumstance.”
The day before the procedure, Gordon’s brother from England said goodbye, along with Gordon’s brother-in-law, granddaughter and grandson, and his son, Graham. The group that remained in the morning when Buchman arrived were the people who felt they could handle seeing his final moments: his daughter, Jackie, her husband, Diane and a lifelong friend of hers.
Buchman was feeling anxious. There was no doubt Gordon qualified for assisted death, knew exactly how his illness would proceed and why he wanted to end his life now, and his certainty shored up Buchman. The doctor knew he had found his way to the right decision to help patients in this way, and he had seen the burden that lifted from Gordon when he agreed to do so. “It really was an ideal first case for me,” he recalls. “He was so ready that I knew I was doing him such an important service.” Still, Buchman had no way of knowing how he would feel on the other side of helping a patient to die.
He arrived shortly before 10 a.m. and sat on Gordon’s bed to ask him for the last of many times if he was certain he wanted to go through with this. Gordon did not waver. Then Diane and Jackie sat on Gordon’s bed, kissed and embraced him and said goodbye, before Buchman and a colleague administered the sedative that begins the death process by inducing unconsciousness.
“I think he was quite frightened. He held our hands,” Diane says. “But he knew that he wanted to go.” Just before Buchman administered the medication that would stop Gordon’s heart, Diane said, “Bye, Gordon,” and left the room. She could see that her husband was unconscious, and she couldn’t bear to stay for the last moment. “It was incredibly peaceful. It was beautiful,” Buchman says. “I’ve never actually seen someone die so peacefully.”
His colleagues had given him the rest of the day off to process everything, and Buchman returned home to be with his wife and his thoughts. But no avalanche of distress overtook him. “I didn’t fall apart,” he says. “I actually felt I had done the right thing for my patient.” Gordon had gotten what he wanted, and what Buchman had done simply felt to him like helping. “It was so peaceful and loving that I said, ‘This can’t be inconsistent with who I am as a doctor,’ ” he says.
One of the big concerns among palliative care specialists now is how to avoid tension between colleagues who make different decisions about assisted death. At TLCPC, they didn’t want anyone to feel abandoned—patients or staff, willing practitioners or objectors—says Russell Goldman, director of the centre.
The big sticking point was referral: the requirement that a physician who does not want to be involved in assisted death refer their patient to someone else. “Some people feel a referral is being complicit in the act, and that was against their ethical belief,” says Goldman (Ontario’s requirements on this have sparked a court challenge).
His centre’s solution was suggested by one of their objecting physicians. Doctors report all sorts of information on patient charts as a matter of course, so if a patient requests assisted death, a TLCPC doctor who does not want to be involved simply notes the request on the electronic medical record. That triggers an alert to one of the doctors in the centre’s MAID oversight group and they take over the tasks related to assisted death, while the original doctor continues to provide palliative care for the patient. “It’s very nuanced and subtle, but it’s just enough to make that difference for that group of people,” says Goldman.
About two-thirds of his staff of two dozen doctors have chosen not to be involved in MAID; Goldman and Buchman are members of the three-person oversight group that coordinates assisted death cases. The centre hasn’t yet analyzed its full data from the first year under the new law, but Goldman estimates that of the 500 to 600 patients his team cares for at any given time, two or three are working their way through the MAID process.
Buchman doesn’t keep a tally of his own assisted death cases, but he estimates there have been about 10. He remembers details from each one. One man made his exit while Louis Armstrong rasped his way through What A Wonderful World in the background. Buchman instructed another patient to have only clear fluids before the procedure, prompting her to inquire, “Is Scotch a clear fluid?” He gave his blessing, so that’s how the woman and her family toasted her final hours.
There is one common element to each case in which Buchman has helped a patient die. “Every single one of them has been filled with gratitude,” he says. “Because I’ve seen so many patients relieved in so many ways and their families so grateful, it’s persuaded me that it’s the right thing.”
In mid-afternoon on the day he sees John, Buchman gets a page from John’s wife, Margaret. When he calls back, she tells him John has died. Buchman murmurs his condolences and tells her he’ll be there as soon as he can.
Once again, the family is waiting in the doorway when he arrives. Margaret wears a fragile smile until he asks how she is, and then she crumbles a little. That morning, with John in his final hours, there had been a tautness in the apartment and its inhabitants, like the surface of a balloon inflated just beyond capacity. Now, the atmosphere feels like a few breaths have been released, the tension replaced with a sadness that is heavy, but also somehow gentler.
Buchman goes into the bedroom where John lies on the bed with his face angled toward the windows. Everyone gazes at him for a long moment, then Buchman turns to the family. “So, check me if I’m wrong here: does he have a smile on his face?” he asks. “Yep, he does,” Margaret agrees. “Wow,” Buchman marvels. He uses the flashlight on his iPhone to check for fixed pupils, then places a stethoscope on his patient’s chest and listens for a long time. When he’s done, he tugs the plaid flannel sheet and fuzzy blanket up over John’s chest and murmurs, “Rest in peace.” The phrase comes out less like a benediction than the last line in a conversation the two of them have been having.
Out at the dining room table, Buchman begins to fill out the death certificate and asks Margaret for a piece of photo ID. She locates her husband’s wallet and hands over his health card. As Buchman completes the paperwork, he talks the family through practical matters like calling the funeral home and returning John’s unused medication to the pharmacy. In between, they tell him bits about how the day unfolded and what it was like to care for their husband and father until his final breath.
John’s wallet sits in the middle of the dining room table, grooves worn into its leather contours. When Buchman passes the health card back to Margaret, she starts to slide it back into the wallet, but her youngest daughter reaches across the table to point. “Gotta put it in the right place,” Margaret murmurs as she fixes it.
Buchman finishes up with the practicalities and ensures they have no further questions. “It’s really my honour and privilege to know you,” he says. “I wish I’d known John better, because he was sick. I just remember him sitting here the other day and kidding around. As I see people, they’re sick. But thank you for allowing me in.” When he walks to the front hallway to leave, Margaret and her daughters can’t stop thanking and hugging him.
Now, a year after Gordon’s death, Diane continues to marvel at the gentle compassion—not pity, which to her is a very different thing—with which Buchman cared for her family, though she worries about the emotional cost she feels sure his work must exact. She is more inclined to grieve now than she was when Gordon first died, which she suspects is because she did so much mourning while he was alive and in decline.
His absence is a constant sadness, but she holds close the idea that his suffering is gone, too. In her memory, she tries to keep Gordon in the happy moments, rather than letting him drift into the terrible times that came later. Earlier this spring, she and her son attended the game in which the Maple Leafs secured a playoff spot. They cheered wildly, then Diane burst into tears because Gordon would have loved what he was missing.
She contemplated having a memorial service or party around the anniversary of his death, but she can’t quite face it. Instead, her son-in-law, a cabinetmaker, has fashioned a beautiful wooden box with Gordon’s name on it. In June, close to Gordon’s birthday, they interred his ashes in a little wall niche at a cemetery in Pointe au Baril, not far from his beloved cottage.