I knew the question was coming, but I didn’t expect it from a longtime patient who at 84 was still relatively healthy.

“I wanted to ask you about getting that prescription; you know, the one that I can take if I want to go already. Can I have it?” she asked me on the first week of the year when medical aid in dying became legal in Hawaii.

I was shocked, and completely unprepared to answer this woman, who I’ve known for over a decade and is doing pretty well despite chronic kidney disease. Just a month earlier, she had talked about dialysis, wondering if she should go ahead and do it when the time comes. But luckily for her, the time wasn’t coming anytime soon. She has what is considered stage 4 chronic kidney disease, but it really hadn’t progressed much in the last year.

There is more than one option for the terminally ill. Doctors need be prepared to talk about all of them, including the now-legal medical aid in dying.

Vinoth Chandar/Flickr.com

Dialysis is considered when someone is further along with their kidney issues, and given her age, I was surprised that she was even considering the treatment. But she seemed insistent that she wanted to live.

She didn’t have any other major health problem. Her cholesterol was good, her blood pressure under control, her blood sugar, never an issue. She followed her restricted diet and all of the health recommendations that each of her doctors prescribed.

True, we also had been talking about advance directives in the past year or two. Initially she wanted to have all possible life-saving treatment in case of an emergency, but after her kidney issue developed, she agreed that she wanted only limited interventions.

Now, we had gotten to the heart of the issue. With all of the publicity about the medical aid in dying bill, the real issue for this woman was the fear of pain.

Yes to an evaluation in the hospital, yes to treatable conditions, but no to prolonged breathing on a machine. She had not made a final decision on dialysis.

“Has your kidney doctor told you that you have less than six months to live?” I asked her.

“No, but just in case, I want to know if I can have the prescription,” she told me.

“You might not know this, but if you don’t do dialysis, then dying from kidney failure is a slow process, and usually not one that entails a lot of time in the hospital,” I said, wondering how much her nephrologist had gone over with her regarding this, and not wanting to contradict his advice.

“But I don’t want to be in pain. That’s what I’m afraid of the most, being in pain. And not having any medication to take care of it, without having a lot of side effects. I just don’t want to be in pain.”

Now, we had gotten to the heart of the issue. With all of the publicity about the medical aid in dying bill, the real issue for this woman was the fear of pain.

In fact, this is one of the biggest fears for the terminally ill population. But there are many treatment options for these patients, and hospice organizations are well versed in treating pain and keeping patients comfortable in their final days.

I asked my patient if she had talked about this with her family, and she admitted that she had not. She was planning on it, but hadn’t even looked into hospice either. After all, she was not projected to live less than six months, she could have a couple more years, or even longer.

But what she wanted to know was if she could have a prescription for the medication to make sure she wasn’t going to have to suffer.

She mentioned that she had talked about it with a few friends and they each had said they were going to ask their doctors, then compare notes. I wondered if any of the other providers were going to be caught off guard with relatively healthy patients asking them about prescribing medication to end their lives.

But the law is in place, and the answer she wanted didn’t have to be for tomorrow, or next week, or even next year. Would I write the prescription, if she met the criteria, and had followed all the rules? I had to admit I wasn’t even sure about each required step myself.

“If you ever had less than six months left to live, and you and I worked through all the requirements, I would write you a prescription,” I said. “But I would want you to enroll in hospice, too. They have a lot to offer and can definitely help you with any issues that you have with pain. And we would need to have you talk with your family so everyone would know your wishes.”

I saw the tension in her face release almost immediately. She didn’t need to have a prescription written today, she might not need one ever, but she needed to know that I would support her choice, and help facilitate her wishes if the time ever came.

We were each having a practice run. She now knew it was possible, and I now knew that I needed to be a bit more prepared for the next time one of my patients asked, even those I least expected.

What was once theoretical is now here, and the time has come for all physicians to make a decision about how they are going to answer the question, and for patients to know it’s okay to ask.

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