Physician-assisted suicide is illegal in most states in the U.S. But there are gray areas where doctors can help suffering patients hasten their death. The problem is nobody can talk about it directly.
This can lead to bizarre, veiled conversations between medical professionals and overwhelmed families. Doctors and nurses want to help but also want to avoid prosecution, so they speak carefully, parsing their words. Family members, in the midst of one of the most confusing and emotional times of their lives, are left to interpret euphemisms.
That still frustrates Hope Arnold. She says throughout the 10 months her first husband J.D. Falk was being treated for stomach cancer in 2011, no one would talk straight with them.
"All the nurses, all the doctors, everybody we ever interacted with, no one said, 'You're dying,' " she recalls.
Until finally, one doctor did, she says. That's when J.D., who was just 35, started to plan. He summoned his extended family and Hope made arrangements for him to come home on hospice.
The day he was discharged from the hospital, Hope was dropping off some paperwork at a medical office when she bumped into one of J.D.'s doctors.
"He hugged me and asked me how I was holding up," she says. "And then he handed me a bottle of liquid morphine. He said, 'You might need it.' "
Hope says she handed the bottle back. She told the doctor the hospice was going to drop off a machine that would administer J.D.'s pain medication automatically.
"And he looked at me," she says, "and he held my gaze for a second. And he put it back in my hand and he said, 'You might need it.'"
She slipped the vial into her purse.
"When I got home, it hit me like a ton of bricks," Hope remembers. "And I said to J.D., 'I think he may have given this to me so I can give you an overdose.' And he said, 'Maybe.' And then we didn't talk about it anymore."
Over the next couple days, J.D. deteriorated quickly. Hope worried that J.D. was in a lot of pain but she couldn't tell. She was afraid that if she asked the nurse, it would betray the thoughts she was having about that extra vial of morphine.
"I couldn't ask the nurse that," Hope says. "I couldn't ask anybody anything."
If Hope had asked Stanford medical ethicist David Magnus, he would have explained what assisted suicide is – and what it isn't. It is legal for people to take or give large doses of narcotics to relieve pain, even if a known side-effect is that it may hasten death.
"The difference really has to do with intent," Magnus says. "And that's a tricky thing because it has to do with what's going on in the mind."
He and others say this kind of situation is a symptom of a much bigger problem: Doctors are just plain bad at communicating about death.
"Across the board with end-of-life care clinical interactions, they're full of misunderstandings," he says.
He suggests that what some people interpret as hints on how to hasten someone's death, maybe aren't.
Just over 3 percent of U.S. doctors say they have written a prescription for life-ending medication. Almost 5 percent of doctors reported giving a patient a lethal injection.
"Those practices are undercover; they are covert," says Barbara Coombs Lee, president of Compassion and Choices, an advocacy group. "To the degree that patients are part of the decision-making, it is by winks and nods."
Coombs Lee's organization helped tell the story of Brittany Maynard, a 29-year-old woman who moved from California to Oregon to be able to end her life legally after she was diagnosed with a brain tumor. Now the organization is backing legislation in California to make it legal for doctors to prescribe lethal medication to terminally-ill patients who request it.
Coombs Lee's group guides dying patients on current law.
"We talk with people about how they might broach the subject with their physicians," she says, "and quite frankly, how to play the wink-and-nod game in a way that doesn't jeopardize their physician."
In the end, Hope didn't do anything with the extra vial of morphine. Her husband died within days of coming home on hospice.
"J.D. never told me, 'I do want you to give me too much morphine,' " Hope says. "Actually, I don't know whether or not he wanted that. That's not the point. The point was nobody could talk about it."
This story is part of a reporting partnership that includes NPR, KQED and Kaiser Health News.
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