témoignage / perspective

Ending the Journey of Suffering

Ohad Avnya, Batya Grina

Résumé

Abstract

La relation entre un médecin de famille et ses patients dure souvent de nombreuses années. Le médecin de famille guide le patient tout au long des procédures médicales et des décisions complexes. Même si le médecin n’est pas celui qui prend toutes les décisions ou qui adapte le plan de traitement, il est souvent considéré par le patient comme le gestionnaire de cas. L’importance de ce rôle est particulièrement évidente dans la population gériatrique, où le défi consiste à trouver un équilibre entre les avantages du traitement de maladies complexes et l’impact potentiel sur la qualité de vie du patient. La capacité du médecin à résoudre des problèmes aussi complexes découle non seulement de ses compétences professionnelles, mais aussi de la relation personnelle qu’il entretient avec le patient. Si l’amitié qui tend à se développer au fil des ans entre un médecin et son patient peut souvent aider le médecin dans ce processus de prise de décision, cette relation peut parfois constituer un piège. Une relation médecin-patient fondée sur la compassion optimise le processus de prise de décision afin de mieux répondre aux besoins du patient. Cela étant dit, il est également entendu que le fait de franchir les limites de la relation médecin-patient traditionnelle peut poser d’importants dilemmes moraux. Cette histoire illustre la relation entre un médecin de famille et un patient âgé qui s’étend sur plus de vingt ans. Leur amitié, due en partie à une connaissance antérieure, influence nombre de leurs interactions, qui aboutissent à la mort tragique de la patiente. Ce texte explore les obligations parfois contradictoires de l’amitié et du professionnalisme, ainsi que le dilemme éthique que posent ces responsabilités croisées.

The relationship between a family physician and their patients often spans many years. The primary care physician guides the patient through medical procedures and complicated decisions. Even if the physician is not the doctor making all the decisions or tailoring the treatment plan, they are often viewed by the patient as the case manager. The importance of this role is particularly evident in the geriatric population, where the challenge lies in balancing the benefits of treating complex diseases against the potential impact on the patient’s quality of life. The physician’s ability to navigate such complex issues stems not only from their professional capabilities but also from the personal relationship between them and the patient. While friendship that tends to develop over the years between a doctor and their patient can often aid the doctor in such decision-making process, occasionally such a relationship can be a pitfall. A doctor-patient relationship grounded in compassion optimizes the decision-making process to better meet the patient’s needs. That being said, it is also understood that crossing the bounds of the traditional doctor-patient relationship can present significant moral dilemmas. This story illustrates the relationship between a family physician and an elderly patient that spans over two decades. Their friendship, partially due to a prior acquaintance, influences many of their interactions, culminating in the patient’s tragic death. This text explores the sometimes-conflicting obligations of friendship versus professionalism and the ethical dilemma in of those intersecting responsibilities.

Mots-clés

Keywords

patient, médecin, relation, amitié, démence, mort médicalement assistée, suicide, souffrance

patient, physician, relationship, friendship, dementia, medically assisted dying, suicide, suffering

Affiliations

a Clalit Health Services, Department of Family Medicine, Hebrew University, Jerusalem, Israel

Correspondance / Correspondence: Ohad Avny, ohadavny@gmail.com

The following is a true story, experienced by the two authors. Dr Avny was the treating family physician of the patient, Shoshana (a pseudonym), and tutored Dr Grin, who was a resident in Family medicine in the primary care clinic.

Shoshana was entering her 60s in excellent condition. Half of her time in my office was dedicated to medical and administrative matters, while the other half was spent sharing her life experiences. As her primary care physician, I prayed that I would continue to witness the graceful aging of this wonderful woman.

During one of our earlier appointments, as she gracefully skipped onto the exam table, she said, “Dr. Avny, do you know that I knew your mother? I worked as a nurse with your mother thirty years ago, I loved her very much.”

I recall my heart skipping a beat. My mother, a primary care physician, passed away suddenly during my teenage years when she was in her late forties. I feared that my memories of her were dimming.

From that moment on, during Shoshana’s visits, we frequently discussed my mother. I was grateful for how Shoshana’s presence revived my memories of her. Occasionally, Shoshana would remark on how I reminded her of my mother, and I felt as though my mother was sending her regards.

Years passed: Shoshana was now 76. It was a wet and gloomy day when Shoshana came to share some unfortunate news.

“I have a mass in my breast. They did a biopsy: it’s breast cancer.”

I was lost in thought but snapped out of it when she said, “I am weighing surgery against other treatment options. Who knows: the tumor is small, it might grow slowly, and it may not have any effect on my current health. Or, if the disease progresses, maybe surgery can help. I am confused.” She looked up at me with her big sad eyes. “Can you help me decide?”

“That is the dilemma of intervention in early-stage malignancies at your age. If you decide you want to undergo treatment, I think you can choose a less aggressive course of action. Knowing you, I assume you already did your homework and made up your mind. Am I right?” She smiled at me, and I recognized the familiar glimmer. “Yes, I made up my mind, but I wanted to hear what you thought.” She decided to undergo a lumpectomy and begin Tamoxifen treatment after the surgery (1). I was surprised.

It wasn’t long before Shoshana returned to my office, this time suffering from insomnia. After a brief conversation, I suspected she was experiencing a depressive episode, likely due to Tamoxifen. I discontinued the medication, and two months later, with family support and regular clinic visits focused on mental health, Shoshana had successfully overcome her depression (2).

By autumn, Shoshana recognized her cognitive abilities were slipping away. Despite discussing a formal evaluation with MMSE (Mini mental state examination) and MOCA (Montreal cognitive assessment) questionnaires, she refused, believing it futile given the lack of effective dementia treatments. She asserted, “Dr. Avny, don’t forget that I don’t want to live without quality of life.” I reassured her of my commitment to alleviating her suffering and again suggested antidepressants, which she declined.

I hadn’t heard from Shoshana in a year until she called me in distress, urgently requesting a house call. Although I usually do not make residential, I made an exception. “My memory has deteriorated significantly,” she began. “I’m struggling and often confused.” She kept looking down, revealing that she had noted several points before my arrival. Her condition had worsened since our last encounter. “You know that part of the forgetfulness is due to anxiety. I can help you with anti-anxiety medication.”

For the first in a long while, Shoshana smiled at me. Her eyes gleamed with compassion. She felt my strong urge to help her as well as my utter helplessness. “I have decided to commit suicide.”

I stared at her, dumbfounded, and then at her husband and son. It was evident that this topic had been brought up and a resolution was reached long before I arrived.

“I am asking you to come to my house after my death and write my death certificate. I want you to write that I died of a natural cause, to spare my family the grief of a police investigation.”

I pondered her request as she, suffering from dementia, sought to end her suffering with full awareness of her condition. Her insight and judgment seemed intact, she appeared capable of making autonomous decisions, and her family supported her. I found myself commiserating with this woman, painfully aware of the agony that had brought on such a desire (3).

Her eyes full of sorrow, she pleaded “Please don’t stand in my way.” (4)

I was torn between my compassionate instincts as a human and my ethical responsibilities as a doctor. “Shoshana,” I said gently, “I recognize the gravity of your situation. However, I cannot actively participate in ending your life. I can, however, promise to respect your autonomy.”

I felt deeply upset, helpless and hopeless. I sensed that she was suffering terribly and that she was trying to reach for help with no hope. It was all “deja vue” as she anticipated, and she could not bear her prospect. If we were sitting having the same conversation in Canada where euthanasia is legal, she could choose to end her suffering. As in our country, Israel, euthanasia is not legal, it was not an option for me to help Shoshana end her life.

“You promise?”

“I promise. But I do have one request. Please try taking Venlafaxine. Your decision may be affected by depression and anxiety. You may feel better…you may feel differently.”

“I will try,” she said, “as long as you promise to respect my wishes.”

As I left, I pondered the irony of life. Shoshana, who had come to tell me of her travels, agile throughout her 60s and 70s, had now come asking that I help put an end to her life.

Several weeks later, Shoshana fell, cut her arm, and was brought into the ER. I called to see how she was doing. She notified me that she had stopped the antidepressants; they had not made a difference.

A week later, Shoshana’s son called me: she had committed suicide. She was surrounded by her children and grandchildren, he said.

Since that day I’ve pondered Shoshana’s choice. As a nurse, she had treated dementia patients, whose health deteriorated to a point where their quality of life would be unbearable for her. She had specifically mentioned that the prospect of a purposeless life filled with suffering terrified her. Whatever her exact motivations were, she was decisive and informed in her decision.

I have also been bothered by the ethical dilemma of knowing that Shoshana was going to take her own life and my obligation to her as her physician to respect her autonomy. As a nurse, Shoshana knew I could not assist with her suicide, as MAID (Medical assistance in dying) is not available in Israel. Why did she want my involvement? Perhaps she thought the bond between us, partly due to her connection with my late mother, had blurred the lines of our professional relationship and led her to expect I would deviate from my ethical duties (5).

I shared Shoshana’s history of her tragic death with our resident Dr Grin. She reflected on her two encounters with Shoshana’s husband after her death. It was the first time that Dr Grin was involved in enabling a patient to fulfill his final wish of passing away in the comfort of his own bed. He too was, in the progressive stages of dementia. Just as she finished examining him, her hand already on the doorknob, he looked at her, his eyes filled with a distant anguish and said: “Dr Avny tried to save her”. Confused she squeezed his shoulder gently and was on her way. It was through the eyes of Dr Grin, after telling me of their conversation, that I realized, I truly engaged in trying to save Shoshana’s life. It was a moment that allowed me to understand that I was a professional treating a friend and trying to prevent her death. My sense of guilt of somehow adopting a permissive attitude to her suicidal ideation found comfort that it did not affect my medical ethical judgement when actively trying to prevent her suicide.

I have kept in touch with Shoshana’s family since her death. I am still witnessing there suffering. They all respected her wishes and let her end her journey. Yet, I sense that the fact that she had to take her own life actively was heartbreaking for them. Since then, I find myself in certain clinical scenarios talking about euthanasia in countries where it has become legal. I sense it might give hope, that when their time comes, they could consider euthanasia as an option by going abroad.

Defining boundaries in the patient-doctor relationship is always challenging. The bond built over years is sacred but sometimes tested, which can be beneficial to patients. Shoshana, with whom I had a sincere and honest relationship, shared her suffering and expected me to empathize. Our friendship likely influenced my medical decisions. She may have revealed her intent to end her life out of trust as her physician, respect as her friend, or a combination of both. Perhaps my awareness offered her some inner peace before her departure.

Reçu/Received: 10/12/2024

Publié/Published: 28/04/2025

Remerciements

Acknowledgements

Merci à Michael Gordon, Ronnit Yochel Chittin et Harry Hanson pour leurs commentaires.

Thanks to Michael Gordon, Ronnit Yochel Chittin and Harry Hanson for their comments.

Conflits d’intérêts

Conflicts of Interest

Aucun à déclarer

None to declare

Édition/Editors: Jacques Quintin & Hazar Haidar

Les éditeurs suivent les recommandations et les procédures décrites dans le Core Practices de COPE. Plus précisément, ils travaillent pour s’assurer des plus hautes normes éthiques de la publication, y compris l’identification et la gestion des conflits d’intérêts (pour les éditeurs et pour les auteurs), la juste évaluation des manuscrits et la publication de manuscrits qui répondent aux normes d’excellence de la revue.

The editors follow the recommendations and procedures outlined in the COPE Core Practices. Specifically, the editors will work to ensure the highest ethical standards of publication, including: the identification and management of conflicts of interest (for editors and for authors), the fair evaluation of manuscripts, and the publication of manuscripts that meet the journal’s standards of excellence.

references

1. Desai P, Aggarwal A. Breast cancer in women over 65 years – a review of screening and treatment options. Clinics in Geriatric Medicine. 2021;37(4):611-23.
   2. Bui KT, Willson ML, Goel S, Beith J, Goodwin A. Ovarian suppression for adjuvant treatment of hormone receptor-positive early breast cancer. Cochrane Database of Systematic Reviews. 2020;3(3):CD013538.
   3. Cohen J. Personal view. British Medical Journal (Clinical research ed.). 1987;294(6574):767.
   4. Hertogh CM, de Boer ME, Dröes RM, Eefsting JA. Would we rather lose our life than lose our self? Lessons from the Dutch debate on euthanasia for patients with dementia. American Journal of Bioethics. 2007;7(4):48-56.
   5. Avny OM. Unexpected gifts. Patient Education and Counseling. 2013;90(2):279-80.

## Références

P, Aggarwal A. Breast cancer in women over 65 years – a review of screening and treatment options. Clinics in Geriatric Medicine. 2021;37(4):611-23.

KT, Willson ML, Goel S, Beith J, Goodwin A. Ovarian suppression for adjuvant treatment of hormone receptor-positive early breast cancer. Cochrane Database of Systematic Reviews. 2020;3(3):CD013538.

J. Personal view. British Medical Journal (Clinical research ed.). 1987;294(6574):767.

CM, de Boer ME, Dröes RM, Eefsting JA. Would we rather lose our life than lose our self? Lessons from the Dutch debate on euthanasia for patients with dementia. American Journal of Bioethics. 2007;7(4):48-56.

OM. Unexpected gifts. Patient Education and Counseling. 2013;90(2):279-80.