Patrick Macmillan, M.D.

Patrick Macmillan is a Palliative Medicine Physician from California’s Central Valley seeking to raise awareness of and increase accessibility to medical aid in dying. This is the story of the first time he prescribed under California’s End of Life Option Act and his takeaways since.

“If I can help somebody, especially in this vulnerable period of their life, I feel obligated as a physician to treat all forms of suffering.”

When I first met Nathan Whittington and his daughter Shamara in my palliative care clinic his sense of humor was evident. However, he came to see me for the sole purpose of securing his right to die, something he took very seriously. California enacted the End of Life Option Act (EOLOA) in 2016 but if you ask some medical providers in California about physician-assisted death they refer to Oregon, which passed their Death with Dignity law in 1997.

Nathan was a high school biology teacher. His students have gone on to become doctors, scientists and teachers among many other esteemed professions. When it was discovered by the community of Sanger, California that Nathan had terminal brain cancer known as glioblastoma multiforme, the dam burst with testimonies from former students on the impact he had on their lives.

Nathan and his family researched the End of Life Option Act and scrambled to find a physician who prescribed aid-in-dying medications. Sadly, through the process, Nathan and his family discovered that despite being law, the option is often not presented as an option to a patient by medical professionals. Shamara voiced, “Why? I’m not sure. But dad and I agreed on this – keeping it secretive is wrong.” After various attempts to reach me, they were put in touch with me via a colleague in northern California.

The evolution and controversy surrounding this law goes back a long time. Hippocrates, the Father of Medicine, wrote the oath to which I pledged as a young medical student and states a physician’s first duty is to “Do No Harm.” I went back and reread the oath multiple times and realized it’s my duty to help those who are sick. Medical aid in dying is helping people who are terminally ill, and without the option some terminally ill individuals commit suicide to put an end to their suffering.

According to my calculations and judgment, Nathan was sick and it was my duty to treat him. Before he met me, Nathan was told he had six months to live and enrolled in hospice care at home after he was given chemotherapy and did not tolerate it. But even with the caring hands of hospice, Nathan’s existential pain was not well controlled.

I can assure you I did not enter medical school with any thought of causing harm. No physician I met ever does. Furthermore, never in my wildest imagination did I envision someday meeting with individuals with terminal illnesses, usually cancer, to discuss their goals of care that included a planned death. So how did I get to this point?

My first awakening came from reading Dr. Timothy E. Quill’s book, Death and Dignity: Making Choices and Taking Charge. It opened my eyes to something to which I only gave superficial thought. Dr. Quill had a patient named Diane with leukemia. For her own reasons, she chose not to pursue treatment. He assisted her in dying before any laws were on the books. He wrote in an article, “I wonder how many families and physicians secretly help patients over the edge into death in the face of severe suffering. I wonder how many severely ill or dying patients secretly take their lives, dying alone in despair.  …I wonder why Diane, who gave so much to so many of us, had to be alone the last hour of her life.” 

Driving into the “Whittington Compound” I saw peacocks that had multiplied over the years. As I sat with the family, Nathan ingesting the prepping medications taken prior to medical aid in dying prescription, they began to tell me of the animal kingdom. As I was told about the rabbits, deer and peacocks, a twenty-two-year-old cat slowly walked across the room. Nathan’s daughter remarked that her dad was upset that the cat would outlive him. The experience was unlike anything I could have expected. The Whittington’s seemed to be acknowledging the pain of the moment without deflecting it. Through their humor, I saw the expressions of grief.

“No one should have to go through this,” Nathan told me minutes before ingesting his medications. Nathan had considered moving to Oregon, without the knowledge that California had its own aid-in-dying law. Nathan was a biologist and, before I met him, he began to think of ways he could end his life through chemistry. Nathan had to search the state and connect with a supportive doctor nearly 200 miles away to find me in his own backyard. Nathan didn’t want to die, he just didn’t want to live with a quality of life that did not match his standard.

No dying person should have to jump through these metaphorical hoops. The fact that this law exists and how it works is not well known. Nathan and his family were informed people and they didn’t know about it. I promised Nathan in those last minutes of his life that I would do what I can to build awareness of this law, thus making it more accessible.

Moments later, on April 4, 2019, Nathan died peacefully in his easy chair at home, surrounded by loved ones.

Making a sacrifice for the greater good of the community. That’s what Nathan Whittington represented to his community. He gave to the folks in the Central Valley and did not want any recognition. His students, fellow teachers, and family know his service well. It’s fitting that one of his last acts on this earth was to think of others, to find a teachable moment in the midst of such an intimate and personal venture. He desired a better road for others traveling behind him.

It’s important to bring this conversation out of the shadows. To facilitate that change, the law should be written differently to encourage doctors to talk to their patients about their options at life’s end. If you read the law, it comes across as if doctors can’t initiate the conversation. Doctors are always worried about liability so this is a major deterrent. 

Without the law changing, patients are left to raise the subject themselves and often must bring it up by name – an unnecessary barrier. Doctors should feel free to tell someone about all their options. It’s unfair to handcuff physicians from sharing the information. 

For doctors who are unwilling to write the prescription, I think it’s a physician’s duty to at least take it upon themselves to direct their patients to the right people. It took me some time to get to a point where I was comfortable with prescribing. For medical providers who are uncomfortable talking about it, I suggest telling the patient that’s the case and that you will get them in contact with a doctor who knows about the law and is willing to talk to them about it. We should never abandon our patients because of our personal judgments.

Peace of mind. Relief of anxiety. Dignity. Comfort. That’s what medical aid in dying provides and that’s what families want.

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