Kate Cheney
Kate Cheney shares a quiet moment with her dog, Shorty, in June, 1999. After a psychiatrist's evaluation, her initial request for a lethal prescription was denied, which left her frustrated. "If you know your time is limited, you're not afraid to die, a physician should be able to give you the medication you need to do that," she says.
(Kathryn Scott Osler/The Oregonian)
EDITOR'S NOTE: Kate Cheney and her family agreed to tell their story so people could better understand Oregon's landmark physician-assisted suicide law. Their journey began with a letter to the editor expressing dismay that legal safeguards had become roadblocks to Kate's right to a lethal prescription. This story was originally published in The Oregonian on Oct. 17, 1999.
Kate Cheney survived the bombing of Dresden in 1945 by fleeing with her daughter and other members of their family from their apartment and later from their country.
So 54 years and a terminal cancer diagnosis later, it's not hard to see why Kate had trouble accepting a psychiatrist questioning her ability to make another crucial decision -- to pursue her own death with physician-assisted suicide.
But a psychiatrist could see that at 85, Kate's short-term memory was fading. It appeared that dementia was setting in. And her daughter's assertiveness about getting the lethal dose for her mother made the psychiatrist wonder whose agenda this really was.
Kate, less fiery than her daughter but no less pragmatic, firmly said she didn't feel pressured. "She makes more noise than I do," she said. "But that doesn't make me any less serious."
Kate's decision long ago to save her daughter, Erika, had come full circle -- now Erika wanted to protect her mother's right to die. Erika was forced to grapple with her own personality from an uncomfortable angle.
Kate's story reveals the complex dynamics that can test families when using Oregon's landmark law. And it provides the first public peek into the challenges that Oregon psychologists and psychiatrists face when called upon to be the gatekeepers to death.
Oregon's Death With Dignity Act says terminally ill and mentally capable adults, acting voluntarily, can get a lethal prescription. A physician often determines the patient's mental capability. But when they are in doubt, the law requires physicians to call in a psychiatrist or psychologist. In 1998, four of the 15 people who committed assisted suicide had a psychological evaluation first.
Mental health professionals often are asked to assess a person's competence. But many of these evaluations -- whether someone is competent to stand trial or manage their money, for example -- are to sustain life, not end it. Literature about how to do evaluations for assisted suicide has been published since Oregon's law took effect in 1997, but deciding competence will always be a judgment call.
"There really isn't a bright line, as lawyers like to say. This is an evaluation," said Dr. Robert Richardson, director of the Kaiser Permanente Northwest Ethics Service, who oversaw Kate's case. "This is the only place in the world where this evaluation has ever been formally made, so our understanding of what it takes to make this kind of decision is an evolving process."
Kate, a cloud of white hair surrounding her face, wrinkles framing her smile, relaxes in her Southeast Portland living room in June with her daughter, Erika Goldstein, and her dachshund, Shorty.
Kate can vividly recall fleeing with Erika, then 9, and another family to a Dresden schoolyard on Feb. 13, 1945, amid the terrifying brilliance of exploding bombs.
She remembers wrapping up in wet blankets to fend off sparks and, later, stepping over bodies to escape the city.
But she struggles to describe her initial psychiatric evaluation, the one she needs to get a prescription to die.
Kate keeled over at the hairdresser's May 9 before bowling league. Doctors at a nearby hospital discovered an inoperable, cancerous tumor in her stomach. She had perhaps a few months to live.
When her granddaughter, Pat Bowman, visited Kate, Kate took her hand, telling Pat she'd asked the doctor for pills to end her life.
Kate and Erika had joined relatives in Portland in 1948. Kate, who was divorced, had remarried and worked in Portland State University's German department until 1961. Her second husband died in 1989.
Kate wanted the option for assisted suicide in case she was in bad pain or if the indignities of losing control of her bodily functions became unbearable. But she said she didn't fear death.
"I'm going to meet my husband again and meet my father again," she said.
Erika, a retired nurse, came from Arizona to care for her mom. At 64, Erika is spirited and trim, competing regularly in seniors track events. A hearing impairment has sensitized her to injustice and taught her to stick up for herself -- and others. So Erika went with Kate to formally request the lethal prescription.
Erika thought the Kaiser doctor was dismissive; she requested a new one. Kate's second doctor arranged for a psychiatric evaluation, a standard procedure at Kaiser.
The notion of evaluating a person's mental fitness to commit suicide has stirred up the medical and mental health professions. Doctors are trained to preserve life. Mental health professionals are trained to view thoughts of suicide as symptoms of a problem in need of treatment. Oregon's law turned all that on its head.
Surveys have shown that most Oregon psychiatrists and psychologists are not confident that, in one visit, they could assess a dying person's competence to choose suicide. The law does not limit the number of visits, but the patient's ill health usually rules out multiple chances at insight.
Dr. Greg Hamilton, a Portland psychiatrist, says the law has shifted doctors from their medical caregiving role to a legalistic role as an evaluator.
But Tony Fahrenkopf, a Portland psychologist, and others distinguish between cutting short a viable life and hastening an expected death. And most Oregon psychiatrists and psychologists surveyed said they see a role for physician-assisted suicide in some circumstances.
The psychiatrist visited Kate at home on May 31. Kate was using pain medication after a recent fall but was not bedridden.
The psychiatrist declined to be interviewed, but the family released the psychiatrist's report for this story.
The psychiatrist found that Kate understood some things -- including that she was incurably ill and had weeks or months to live. But she didn't remember the details of her hospital stay in May or the names of her hospice nurses or her new doctor.
During the evaluation, Kate looked to Erika for answers and Erika coached her a few times, even after the psychiatrist asked her not to.
The psychiatrist noted that although assisted suicide seemed consistent with Kate's values throughout her life, "she does not seem to be explicitly pushing for this." After explaining that Kate did not have "the very high level of capacity required to weigh options about assisted suicide," the psychiatrist said that, although Kate seemed to accept the assessment, Erika became angry.
Kate's request for a prescription was denied.
"If you know your time is limited, you're not afraid to die, a physician should be able to give you the medication you need to do that," Kate said.
Erika was more blunt: "For me to sit there and witness someone coming in here with all their intellectual acumen and making a judgment call on my mother, it just incensed me."
There is no single method for evaluating a dying person's competence to commit assisted suicide or a foolproof way to gauge undue influence. Oregon's law says the person must be able to make and communicate health care decisions and be aware of his or her medical condition, the risks of using a lethal dose and the feasible alternatives. A psychological disorder -- senility, for example -- does not necessarily disqualify a person.
Doctors and therapists use their own combination of methods, drawing from mental status exams and the increasing array of journal articles and professional guides on the topic.
Dr. David M. Smith, a Portland geriatric psychiatrist, says psychiatrists have plenty of relevant experience from evaluating the competence of people who want to stop life-sustaining treatment, such as kidney dialysis.
Smith asks blunt questions to assess family influence: "Is someone hinting that you are a burden or a drain?" He listens and watches their body language.
Some scholars scoff at the notion that a person could make any decision -- let alone the decision to die -- without being influenced by others and say that such a standard is not a valid reason to deny them that choice.
Others say influence is a reason to recommend against assisted suicide, especially among people they consider particularly vulnerable -- the terminally ill.
Kate decided on a second competency evaluation. This time, it was with a clinical psychologist who asked to meet with Kate alone. After the June session, the psychologist came away with a somewhat different impression.
"Mrs. Cheney was alert and oriented to person, place and generally to time," the psychologist wrote.
The psychologist did a screening test and asked other questions. Kate knew the name of the governor and the date of Erika's birthday, for example, but could not recall when she was diagnosed with terminal cancer.
The psychologist said there was no severe impairment that would limit Kate's ability to make a medical decision, but she noted that Erika had wanted to audio-tape the evaluation.
The psychologist wrote that Kate's "choices may be influenced by her family's wishes and her daughter, Erika, may be somewhat coercive." But she wrote that Kate "demonstrated the capacity to weigh the differences and articulate her own values."
She sits in her living room on July 6 in a floral sweatshirt and corduroy pants. The clock above her piano ticks softly. She still hasn't been given her lethal prescription, even though the psychologist approved it.
"It's not that I have any plans to use it right away," Kate said. "I may never use it. But it's just to have the decision in my hands, rather than anyone else's."
She dismisses the notion that family members are pushing her. "They all feel I should do what I want," she said. Her family has always made a point of respecting one another's views, she says.
Erika and her husband, Bob Goldstein, who has come from Arizona, return from yard work. Erika has learned of the two therapists' concerns about her dominance.
"I realize I sound real aggressive and assertive," Erika said. "I realize I've been standing up on the roof with a banner and Mom's been standing behind with a little flag."
Now Kate's doctor and Richardson, the ethicist, had two evaluations but weren't ready to approve the medication. Each evaluation drew different conclusions. And the question of influence still hovered.
Kate's doctor relayed the concerns to her granddaughter, Pat, who lives in Portland and was helping Erika and hospice workers with Kate's care. The doctor said Richardson wanted to meet with Kate.
Pat, a social worker, and her husband, a psychologist; Erika and her husband; and Kate sat down for a family meeting.
Pat could see Kate was frustrated. She knew her grandma had been endlessly questioned. Pat even asked her once who the U.S. president was. Kate had leaned across the table and said with deadpan humor: "Nixon."
Kate waffled about whether she would submit to meeting with yet another person.
"Grandma," Pat told her, "I think they think we're trying to kill you."
Pat told her that getting the prescription was Kate's choice. The family made it clear they were there for her regardless.
The next day, Kate called and arranged to see Richardson alone. Once Kate warmed up to him, he said she was delightful. They talked for some time about her life and her experiences in Germany.
At 85, she wasn't as mentally alert as a 55-year-old, he said, but she knew without prompting who he was and why he was there.
She told him that if she could no longer attend to her personal hygiene -- she expelled waste into a bag through a tube attached to her intestine -- or get out of bed, she might decide that life had become unbearable.
Richardson was convinced not only of her competency but also that she was acting on her own.
"I had no reason to believe that this was anyone's agenda but hers,'' he said. Kate received her bottle of barbiturate capsules, two anti-nausea pills, a beta-blocker and some mouth-numbing lidocaine syrup on July 23.
The Kaiser pharmacist described how to use the medication. Erika put the package in a safe place.
"I am now the reluctant guardian of a lethal dose of drugs," Erika wrote in an e-mail. She said she still felt the pressure of her motives being questioned and vowed not to bring up the drugs until her mom did.
For s while, the issue went away. Erika and Kate watched videos. They visited Kate's neighbors, laughing about the time Kate caught the eye of a married man while on a cruise. They celebrated Erika's birthday. Kate let her daughter wash and set her hair. Erika used her mom's curlers, teasing her that she'd had them since the Crimean War.
But Kate was growing weaker. She was barely eating. She was using pain pills. She had begun having trouble cleaning out and re-attaching her waste bag. At one point, Erika got her mom into the shower to clean her off. Kate spoke of just wanting to use "the pill" now. But the moment passed.
By late August, Erika's husband, Bob, thought his wife needed a respite. Kate went to a nursing home for a week. Erika visited regularly. Kate ate well but always asked when she was going home.
On Aug. 29, Erika and Bob brought her home. They sat down in the living room to relax.
Kate spoke.
She said she realized something had to be done, given her declining health. She'd considered going into a German nursing home she knew of but had decided against it. She told them she wanted to use "the pill" and asked whether they would help her.
"When would you like to do this?" her son-in-law said.
"Now," Kate said.
Kate retired to her bedroom.
Erika said she summoned Pat and her husband. They sat on Kate's bed to hear her intentions for themselves.
Pat called Kate's three other granddaughters. Her grandson was en route from Seattle to say goodbye. Kate's granddaughters sobbed on the phone. But Kate remained serene.
Outside her bedroom was nervous activity. Finding the medication. Reading the directions. Standing together in the kitchen, breaking open capsule after capsule of the barbiturate and dumping the powder into a bowl of applesauce.
"We were holding ourselves up and holding ourselves together with this very thin thread," Erika said.
When it was time, Pat knelt at her grandma's bedside. Richard, Pat's husband, supportedKate on the bed in the crook of his arm. Erika stood at her daughter's side, with her husband at Kate's feet.
Pat explained that Kate must eat this mixture quickly and finish every drop.
Kate, who for months had mostly picked at her food, purposefully shoveled down the applesauce one mouthful after another.
Erika stared in wonder at her mother.
She leaned closer.
"You are such a strong woman," she said in German.
Kate, still lucid, corrected her daughter's word choice. Erika smiled.
Bob passed out the glasses of Liebfraumilch wine his mother-in-law requested. They raised and clinked their glasses with hers.
Kate took a sip.
After a while, Kate's breathing became erratic. Color and warmth drained from her face. Within an hour, she died.
The week after Kate was buried with a graveside service, Erika and her husband sit inKate's living room. Moving boxes clutter the floor.
Gone are Erika's indignant feelings about the injustice of the process to get a lethal prescription. During the course of the summer, she says, she has learned a final lesson from her mother. This one is about the importance of making it through a difficult process to reach a challenging goal.
"I'm glad this law is here for this state," Erika says. "I don't think I'd change it. I think it has to be here to protect the innocent. I wouldn't have been able to say that in the beginning."
-- Erin Hoover Barnett