A year before Hawaii adopted medical aid in dying as an end-of-life recourse for terminally ill patients, Jeanne Elder told her oncologist in 2018 that she might wish to drink a lethal cocktail to end her life if she were ever suffering and out of treatment options.
At the time, Dr. Melvin Palalay of the Hawaii Cancer Center was against it. The idea of hastening his patient’s death just didn’t jibe with his Catholic faith.
With two decades of oncology under his belt, Palalay had seen dying people suffer, even with the aid of palliative care. It could be painful to watch, at times.
But in no way could he see himself prescribing a lethal medication to help someone die on their own time.
As the years-long debate over legalizing medical aid in dying continued to simmer in the Hawaii Legislature, Palalay sometimes approved his name and likeness for use in anti-assisted suicide lobbying campaigns.
But in 2018, when lobbyists asked him to renew his public pledge against the practice of ending a patient’s life unnaturally, Palalay said he declined.
“At that point I had a real patient talking about this as an option for the future,” Palalay said. “I was hesitant to come out against it in such a black-and-white way. ”
The doctor told Elder that there would be other people who could help her receive medical aid in dying and that he would steer her in the direction of those folks — when and if her health deteriorated to that point.
Hawaii lawmakers enacted the controversial medical aid in dying legislation on Jan. 1, 2019. And by February, Elder had exhausted her treatment options.
After receiving a cancer diagnosis three years earlier, Elder quit working, altered her diet and endured a regimen of clinical trials and surgeries in Hawaii and California. But now she was out of options. She could no longer walk.
And one thing was certain: She did not want to outlive her ability to enjoy her life, according to her daughter Kim McAden and her doctor.
A former beauty pageant contestant, Elder had long ago relinquished the lifestyle of a glamour girl to go back to school to become a plant designer. She became quite renowned for her horticultural expertise, working out of a backyard garden at her home in Kaneohe.
“I really felt like I was pegged into a corner. Either I abandon my patient completely or I go ahead and do this.” — Dr. Melvin Palalay
All that was behind her now. She told her doctor she wanted to access Hawaii’s fledgling medical aid in dying law.
“She was a very vibrant and elegant and eloquent woman,” Palalay said. “She’s somebody who, to me, explored every potential standard and non-standard option to prolong her life and, maybe more important, to preserve her quality of life. For her, that was the most important thing.
“She was able to do the critical thinking and present her thoughts clearly to me on why she was taking steps to do this,” he said.
Palalay told Elder he would refer her to a hospice team that could facilitate her wish to ingest a lethal medication and die.
The doctor thought he could pass the buck. This way, he wouldn’t have to reconcile his moral and ethical reservations about hastening the death of his patient.
Looking back, Palalay said he was naive.
“I got an abrupt call from the hospice physician and he explained to me, ‘Look, we’re not going to run with this at all,'” Palalay recalled.
“The family and the patient are committed to doing this and unfortunately the decision comes down to you,” Palalay said the hospice worker told him by phone. “Either you punt on this and refuse, or you choose to advocate for the patient.”
At home that night, the doctor asked his wife, “What do you think I should do?”
He posed the same question to God.
Wrestling With His Obligations
Hawaii’s “Our Care, Our Choice Act” establishes a patient’s right to request assistance in dying — not receive it. There are legal protections in place for medical providers who wish to participate in good faith and for those who wish to opt out.
In Elder’s case, the hospice facility where she was receiving care had declared it would not facilitate aid in dying for its patients. If she wanted to pursue this option, she’d need to find a new nurse and doctor and arrange for a medical transport back to her home.
Palalay needed to decide where he stood — and quickly. Elder had a neurological condition that threatened her with paralysis. If she lost her ability to swallow, or to hold the cup containing the lethal cocktail to her mouth, she would lose her eligibility to participate in the state’s new end-of-life program.
“I really felt like I was pegged into a corner,” Palalay said. “Either I abandon my patient completely or I go ahead and do this.”
Palalay decided to travel to hospice to meet again with Elder and her family.
“That meeting was profound,” Palalay said. “We had a wonderful time. She was her usual self. She wasn’t on her last vestiges of life yet. She was strong, we joked around, we cried.”
Elder reasserted her desire for medical aid in dying. Her family said they supported her completely.
Palalay didn’t want to let his patient down.
“My religious message was that life is precious and you’re not going to do anything to shorten life, so this is not something that you would consider,” said Palalay, who is a graduate of numerous Catholic and Jesuit universities and primary schools. “But I also had a duty to my patient, my wife reminded me.”
And so Palalay became Elder’s advocate, helping the 83-year-old woman attain a lethal medication that on a sunny Easter Sunday would end her life as she drifted into a deep sleep.
“I had another patient named Jeanne who was dying around the same time,” Palalay recalled. “She had very advanced lung cancer and she was only in her 50s. We had done everything that we could do, but she was a devout Catholic. There was no way that she would ever think about taking that route to end her life.
“These two cases were sort of juxtaposed and I came to believe that my patient with lung cancer was absolutely right in what she did — and Jeanne was absolutely right in her decision. I got to see in really clear contrast that the course that Jeanne chose to take would have been absolutely the wrong decision for my other patient, and vice versa.”
His Patient’s Last Day
On Easter morning, Palalay received a text message from Elder’s daughter: “We’re choosing to do this today.”
She welcomed the doctor to attend Elder’s final hour.
Palalay didn’t know what to say.
Gripped by anxiety, Palalay discussed the invitation over Easter brunch with his family.
“I couldn’t get Jeanne off my mind,” he said. “I felt really nostalgic. It was a beautiful day, your typical Hawaiian Sunday. And I kept counting down the time. I knew that this was going to happen around 5:30 p.m., so I kept looking at the clock and counting down the hours.
“You realize how short a day is when you know that there is going to be some finality at the end of it. These were thoughts that I had never, ever had before, like, ‘Jeanne has 10 hours left. Jeanne has 8 hours left.'”
Palalay buckled into his car and drove 45 minutes to Elder’s home in Kaneohe.
Elder greeted the doctor with a hug and a quip. He was given a celebratory cup of fine liqueur to sip.
Palalay joined about seven other people gathered around Elder’s bedside. They recited poetry and imbibed their Easter digestifs. They exchanged stories and laughs.
Then Elder mixed the medication in a cup and drank down the chalky liquid.
“It’s not that bad,” she remarked. She said she’d tasted worse.
In five minutes Elder was asleep, eyes shut.
A half hour later, she was gone.
Driving home that night, Palalay heard an inner voice tell him he had done the right thing.
“People will disagree with it,” Palalay said. “But I think that your relationship with God, or whatever you believe in, is a very personal thing. I’m at peace with it.”
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