Tillie’s Choice

“Dr. Loengard I think it is time”

my patient announced when I returned her call. Tillie had read an article in the New York Times a year earlier about a couple who decided to stop eating and drinking and die together. She was calling to let me know that this was now her plan too. Her time had come she said. Despite being over 90 and enjoying more of what New York City than I did as a young mom – she went to the theater regularly, enjoyed concerts and had many friends in the assisted living where she resided. I told her I would come see her to discuss further. She was one of my patients who was most alive, vital and positive and it seemed impossible that she would want her life to end. I discussed with my colleagues in our morning meeting where each of us would bring clinically or emotionally challenging situations. All agreed with my plan to see her and assess for depression or some other secondary condition that might be influencing her decision to opt out of life.

As I entered her apartment, she greeted me with a smile and what always seemed a twinkle in her eyes. As we sat and she humored me by answering the standard depression screening question – finally becoming impatient and exclaiming with a laugh “I laugh at the Daily Show every night, I am not depressed!”. Hard to argue with a 92-year-old who appreciated Jon Stewart. After getting her permission, I spoke with her two daughters, themselves in their late 60’s. They knew of their mother’s plans and despite it making them sad, agreed that she did not seem depressed and her plan to take charge of how she exited this world made perfect sense in the context of her personality and how she had lived her life til now.  

She needed a week or so to say her goodbyes and make sure her affairs were complete. Top of her task list was mailing in her ballot for the coming presidential election. When she shared her plans with her adoring long term caregiver Violet, she was so distraught that she could not stay on to help as my patient moved forward with her final plan. Hospice was called and she was enrolled and an out-of-hospital DNR was filled out a posted to her refrigerator. The daughters scrambled and found new people who were willing to help but having people who didn’t know Tillie and her routine proved challenging. After two days of not eating or drinking she was weak and as her aide helped her out of bed, she fell. Unable to stand again and complaining of pain in her leg and hip, 911 was called. Soon after her arrival in the ER, I got a bemused call from the ER physician asking if I knew Tillie and what was going on. Once I acknowledged she was my patient he chuckled and said she had immediately grabbed his tie as he was speaking and looking him sternly in the eye demanded “do not give my IV fluids!”. It turned out her old hip replacement had been jarred out of place and they were able to maneuver it back. A discussion began about how to keep Tillie safe if she went back home. The option of an inpatient hospice bed was brought up and everyone agreed this would be best. Her family could visit and not worry about having to provide medications or being afraid of not having needed support. 

I went to see the following Wednesday morning, which happened to be after election day. As I entered her room she was peacefully lying in bed. “Tillie” I whispered. She stirred and half opened her eyes asking me the outcome of the election. When I told her, she closed her eyes again and said “I made the right choice.”