Ely State Prison 2

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March 10. It's 1 A.M. Yesterday started at 3 A.M. when I awoke having to urinate badly, had some trouble pulling myself out of bed, began huffing and puffing as I moved to the bathroom, was afraid that I would dribble all over, too breathless to stand and search for my urine stick that seems able to hide easily these days and about whose orientation in space I have little knowledge--It's About Schmidt for me at this point in my life. I have not taken enough hytrin and the bladder remains full without any flow and I'm still huffing and puffing and hoping that something will begin to dribble out and relieve the pressure and finally it comes and a I'm able to slow down my breathing and relax and let things flow. Urination? has achieved a place in the pantheon of major concerns. Urination?Yes! has achieved great standing. At 5 A.M. and 6:30 A.M. there were minor replays despite my use of some extra hytrin.

Ely State Prison 2
Thinking back on my time there, I am struck by the organizational efficiencies demonstrated in the privatized system of medical care at Ely when compared to what I have seen in the past three or four years in a State-run system in California. The Nevada prison was small enough to match an expected general practice for a family physician. This means that a relationship was possible and much more likely. In a bigger prison with multiple physicians, there will be temptations to manipulate by physician shopping. Even when caseloads are assigned, inmates realize that they can receive emergency treatments by the strength of their complaints and by their knowledge of symptoms which can be woven into the story of illness.
In California there is a lot of micromanaging of medical and psychiatric care. Some of that has to do with improving standards of care, but a good bit of it is plain "Cover Your Ass" beforehand. An example is the family Tricyclic Antidepressants (TCAs). There are no more effective antidepressants and they have been around since the 1950s and 1960s. However, they can be used to overdose and this can be done with a 2 to 4 week supply if hoarded and taken at once. In California, these drugs were taken off of the Psychiatrist's formulary some years ago and could no longer be prescribed for depression.
In Nevada, Tricyclic Antidepressants are just as lethal but were continued safely by crushing each dose, mixing it with liquid, and requiring the inmate/patient to drink medication while the nurse observed. I found the class of TCAs sometimes useful for treatment of Attention Deficit Disorder without resort to amphetamine-like drugs that are likely to be abused in prisons. In 4 years at Ely I never saw a TCA overdose.
Eric Stokmanis M.D., an internist was the Medical Director. He was excellent. In addition to Internal Medicine, Eric had an overall curiosity about all of medical practice, particularly minor surgery and orthopedics. He was able to handle the full range of outpatient department complaints from the prisoners. He also knew when patients needed to be shipped out for local surgical or tertiary care.
The medical observation rooms and the infirmary at Ely State Prison did not distinguish between psychiatric and medical cases. The same staff of nurses and mental health technicians cared for both. I think this is a huge strength. It makes it harder for a medical department to look at bizarre behavior and automatically attribute it to a psychiatric condition rather than a delirium. There were seldom more than 2 psychiatric patients behaving badly at the same time and our overall incidence of physical restraints declined while I was there. In Nevada the process for using psychiatric medications over the objection of patients was based upon a Supreme Court Decision.
http://en.wikipedia.org/wiki/Washington_v._Harper
The Supreme Court ruled that the patient was entitled to a full institutional review and not to a court hearing. This is a much more efficient mechanism than is currently used in California. In California, three lawyers will be paid for each hearing--a judge, an attorney for the inmate, and a California attorney who will prepare and file the papers for the State.
The Death Row
Death row housing is done at Ely although executions are carried out in Nevada State Prison in Carson City.

http://en.wikipedia.org/wiki/Capital_punishment_in_Nevada

I generally visited the death row once or twice a week. There were several patients who received antidepressant medications and some suffered from anxiety attacks. These patients were seen on a regular basis for medication evaluations and changes. Any of the inmates could request a mental health visit and generally these were screened by 1 of 3 mental health professionals, after which the therapist would discuss the case with me before I followed up.
The atmosphere on death row was very calm. Nevada is a state that is in no hurry to execute anyone. You are more likely to die of natural causes than executions unless you decide to forego your appeals. The warden designed the schedule on the Death Row with an eye toward maintaining a low-key atmosphere. There were live weights on Death Row but not elsewhere. The men were allowed out of their cells for considerable periods of time during the day. There was no evidence of racial animosity. Many of the inmates continued to work on their "cases."
One of the first of the inmates I got to know was Lawrence Colwell, Jr.
http://en.wikipedia.org/wiki/Lawrence_Colwell,_Jr.

My first impression of Mr. Colwell was an empty cell that was so neat and tidy that one would expect that a monk was living there (at least Sohr's interpretation of how such a monk's room would appear). He was initially receiving some medication. When asking him about the future, he told me that he expected to be executed--that he had committed a horrible crime for which he had no real explanation. He believed that justice demanded his own execution. As you can see from the Wikipedia article, he appears to have represented himself in such a way to guarantee his execution. Although Colwell had committed a heinous crime there remained for him a need to face and own his own behavior, rather than to deny or mitigate his actions. He saw no alternative but a life for a life.

In contrast to Mr. Colwell was another death row inmate who had come to Ely State Prison with depressed mood, failure to maintain hygiene, difficulty sleeping, difficulty thinking, weight loss, etc--the classic signs of a major depressive episode. He was maintained on antidepressants for about 6 months until he adjusted to the death row and stopped medications. There was definitive video evidence of his crimes. However, when I interviewed him a year after arrival, he was no longer depressed. He was angry and complaining of the way his "case had been handled." He expressed outrage that he had been "in the marines to protect his fellow countrymen" and they had the nerve to give him a tainted trial for his multiple murders. He was able to separate himself from his actions using the vehicle of his "case." This is one of the weaknesses of our adversarial legal system--the case takes precedence over the admission of responsibility and the possibility of rehabilitation.

Here is some recent activity with respect to the Nevada Death Row:
http://ccadp.org/nevada.htm

What do you think? Penpals anyone?

http://nevadaprisonwatch.blogspot.com/2011/09/costs-of-nevadas-death-row.html

Guilty But Insane
Nevada was one of a few states that eliminated a plea of "Not Guilty by Reason of Insanity," (NGRI) and instead permitted a plea of "Guilty But Insane." In most states, a patient found NGRI would be committed to a state hospital for treatment. However, in Nevada, patients found Guilty but Insane were very likely to come to Ely State Prison and be included in available mental health programming. This meant that a Schizophrenic man who had killed his parents and offered passages from the bible as justification would likely be one of our prison patients during the first few years subsequent to the crime.
Uncertainty in Medicine
The Guilty but Insane plea is at the heart of one of the most bizarre experiences I have had as a physician. Sometime around 2000 we received a patient from the prison mental health center near Las Vegas. He had pled guilty but insane to a murder charge. As I recall, he was in his early 30's and arrived with a diagnosis of schizophrenia. A part of the narrative that came with the patient was that the transfer to a prison had been "pushed" by the family of the victim who demanded that the patient be treated like everyone else and spend the first year of incarceration at the maximum security center at Ely. It was also curious that there were some newspaper articles that quoted the judge in the case as believing that the murderer/patient was malingering his mental illness.
When the patient (I'm going to call him Mr. C) arrived in Ely he was already on an antipsychotic medication, called Clozaril, that is frequently the medication of last resort because of a side-effect profile that can lead to the loss of key parts of the immune system and death from infections.
When evaluated at Ely, Mr. C was able to communicate reasonably well. He endorsed previous membership in the CIA. He expressed sorrow and remorse about having killed a young woman and an antidepressant was added to his medications. Mr. C remained at Ely for several months. He was seldom any trouble and he continued his Clozaril without incident. He spent several weeks in the infirmary over the years and I saw him frequently. There was no doubt in my mind that he suffered from Schizoprenia, but probably of the paranoid, higher functioning type.
Shortly before I left Ely, Mr. C asked to talk to me. He related that the Courts had overturned all pleas of Guilty but Insane and that the District Attorney had stated that Mr. C would be retried. If C pleaded guilty he would be given Life in Prison without the possibility of parole. The District Attorney said if Mr. C pleaded Not Guilty or Not Guilty by Reason of Insanity then the state would seek the death penalty. Mr. C asked me if I knew of any psychiatrists who might be willing to look at his case. At the time, Jasmine was board certified in Forensic Psychiatry. I gave Jasmine's work number and thought no more about it until about 2 years later.
In 2003 Jasmine received a phone call from a lawyer for Mr. C. He asked if Jasmine would meet with him to discuss a case. Jasmine was in Las Vegas every other weekend and so an appointment was set up using the office for my private practice. Two attorneys appeared. They summarized the case against Mr. C and then asked if either Jasmine or I were interested in participating in the case. Either Jasmine or I asked for the most damning information from the case and our jaws dropped open.
As a part of the plea of Guilty But Insane, Mr. C was required to identify the location of the body so that it could be autopsied and returned to the family. Mr. C provided a location and a forensic team retrieved the body. The problem was that it was a body other than the victim's.
Jasmine and I looked at the lawyers. "You've got to be kidding! How could anyone willingly provide testimony that might lead to Mr. C's release. Life without Parole seems like a rather light sentence for a person who appears to be a serial killer."

Uncertainty--the Goddess of the Universe

Ely State Prison 1

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March 8. It's 1 A.M. as I start this. I am four weeks past my last chemotherapy and today the fuzziness in my head seems completely gone. I'm having a little bit of difficulty with word finding. My mood is very good. Current meds are dexamethasone 4 mg daily (more than twice what the body generally needs), hytrin 5 mg once or twice a day to battle my prostate, omeprazole 40 mg a day to keep from making stomach acid and decreasing my risk of developing an ulcer from the dexamethasone, and Levaquin 500 mg a day to treat what is probably a pneumonia that has been around for a week or so.  I'm having some pain from the left diaphragm from tumor fluid and I took a short-acting fentanyl a few minutes ago.


Ely State Prison
Jasmine and I had met in 1997. Her fellowship in Forensic Psychiatry ended on June 30 of that year. She had originally planned to return to her home in Orange County but decided to accept employment at Atascadero State Hospital instead. I was already committed to Atascadero for the forensic fellowship. She moved in with me in Morro Bay and we had a wonderful first year of romance. For me it was an opportunity to observe a Zen master. For her it may have been something analogous to a Jane Goodall field study.
Unfortunately, "lived happily ever after" was not an option at that time--the world was rapidly changing. Although the youngest in her family, Jasmine is the matriarch of her family of origin and provides needed medical services to various family members. She had delayed her return to LA from 1997 until 1998. However, her 89 year-old father had stopped driving and was becoming more frail. Both her dad and step mother had ongoing medical problems and needed assistance on a regular basis. She believed that she had no choice but to return--out of love for him.
There is a phenomenon that I call the illusion of independence, where the elderly stay in their own home but require a mountain of assistance in order to do so. Her father was at this point in his functioning and it was not something that was going to change.
Atascadero State Hospital was changing, also. After the Polly Klass murder, the legislature had passed a statute that required certain types of sexual criminals, Sexually Violent Predators (SVPs), be committed to a state hospital for treatment upon completion of a prison sentence. Atascadero State Hospital had been designated as the treatment site for all of these cases until a new hospital, Coalinga State Hospital, could be constructed specifically for the needs of these "patients." Neither Jasmine nor I had any real interest in doing psychiatric work with that population.
I was unable to imagine myself living in the bustle of Los Angeles. (Jasmine would always tell me that she lived in Orange County, not Los Angeles--but it all looked the same to me.) Sometime in May I received a job offer from the old company, Correctional Medical Services. The position as psychiatrist at the maximum security facility for the state of Nevada was available. It was a job with medical benefits but no retirement plan. However, the contract offered twice the hourly rate as my position at Atascadero...it was an offer I couldn't refuse.
Jasmine and I scoped the job. We flew to Salt Lake City and rented a car and drove the 250 miles to Ely, where we took a tour of the medical facilities in the prison and had a meal with the medical and mental health staff. It was very convivial. The next day, I met the warden and I was impressed. He was an enormously big man--both large framed and carrying an extra 100 lbs. He was articulate and opinionated enough to make me comfortable that his decision-making was likely to be clear and decisive. I didn't see anything not to like.
The job required that I spend 35 hours at the facility per week when averaged over a month. This provided an opportunity for a great deal of flexibility in scheduling. However, a key to that flexibility was the relationship with the medical director, Dr. Eric Stokmanis, a young internist who had been at the prison for a couple of years. Given my background in Family Practice and prison medicine, I could actually provide him with medical coverage and permit him time away from Ely several times a year. It turned out to be a great arrangement. We were both capable of examining one another's patients and discussing the cases by phone in order to develop a reasonable treatment plan. We did this for the next four years.

Ely Nevada. Low resolution shot that captures the mountainous feel to the place.

Ely is in a beautiful location at about 6500 feet above sea-level with a high desert climate. The summer weather is next to perfect with very dry days in the mid-80's with intense sun. Although it was not unusual for night-time winter temperatures to dip to zero, the average daily temperature during the winter months was in the 40's. I found it much more comfortable than Billings MT.
http://en.wikipedia.org/wiki/Ely,_Nevada

Aerial View Ely State Prison: The 8 squares are housing units.

On my second or third day on the job, I was still within the facility in the afternoon after the departure of Dr. Stokmanis. I was called to one of the housing units. When I arrived, there was a man lying on his back outside of a cell. There was a very ragged cut that extended from one ear almost to the other. The man on his back was dead and had been for a while because the body was cool.
On the floor alongside the man was a coffee can lid with sharp edges. It had been folded over and rolled slightly to provide a handle. Home made prison knives are called "shanks." Most are constructed to "puncture" and penetrate rather than slash. Generally shanks do their damage by piercing vital organs in blows to the neck, spine, and chest. The shank I was looking at was more sophisticated and specifically intended for use as a blade to slash the trachea, jugular veins and other vessels in the neck, like the carotid arteries.
Inside of the open cell, a naked inmate was on his knees, cuffed in the back, and pressed against the wall by two correctional officers. This was the cellmate. The body had been discovered during the afternoon "count." (Several times a day, a count of all prisoners is performed--to ensure that all that should be there, are in fact there.)
About an hour after pronouncing the man dead, the warden invited me to a conference room where a recorded telephone conversation between the dead man and his mother was played. The victim had been scheduled for release on parole within the next days. His mother was a card dealer in Vegas who spent several minutes informing him how important it would be to obtain credit.
It was suspected that the victim had been unwilling to comply with a request from a gang.
Despite the murder in the first week of work, I have never felt safer working in a prison.  Movement of inmates was strictly controlled. Patients brought to the medical unit were shackled at ankles and wrists. There was also a "belly" chain to which the shackled wrists were attached. And then there were either one or two escorting officers who walked beside the inmate and maintained a  hand grip on the upper arm.

Oregon Assisted Suicide

March 6..

I promised to look into the Oregon Physician Assisted Suicide situation. I don't mean to complain but it seems like such a very small step forward in the direction of providing as much assistance as my dog, Archie, will be able to receive to help him with his terminal illness and pain. If somehow I attempt to take a lethal dose of oral medication, like Seconal, and I am unlucky enough to vomit too much of it and survive, there is no legal way in the U.S. for a physician or anyone else to start an IV and give me the lethal dose that I need to exit.
To benefit from the Oregon law, one must be 18 years of age, a citizen of the state, and have a documented terminal illness. The patient must be competent to make medical decisions. The patient must request assistance in writing. I'll just provide some of the information from the statute. The complete statute is here:
http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Pages/ors.aspx

127.805 s.2.01. Who may initiate a written request for medication.

(1) An adult who is capable, is a resident of Oregon, and has been determined by the attending physician and consulting physician to be suffering from a terminal disease, and who has voluntarily expressed his or her wish to die, may make a written request for medication for the purpose of ending his or her life in a humane and dignified manner in accordance with ORS 127.800 to 127.897.

127.810 s.2.02. Form of the written request.

(1) A valid request for medication under ORS 127.800 to 127.897 shall be in substantially the form described in ORS 127.897, signed and dated by the patient and witnessed by at least two individuals who, in the presence of the patient, attest that to the best of their knowledge and belief the patient is capable, acting voluntarily, and is not being coerced to sign the request.

(2) One of the witnesses shall be a person who is not:

(a) A relative of the patient by blood, marriage or adoption;

(b) A person who at the time the request is signed would be entitled to any portion of the estate of the qualified patient upon death under any will or by operation of law; or

(c) An owner, operator or employee of a health care facility where the qualified patient is receiving medical treatment or is a resident.

(3) The patient's attending physician at the time the request is signed shall not be a witness.

(4) If the patient is a patient in a long term care facility at the time the written request is made, one of the witnesses shall be an individual designated by the facility and having the qualifications specified by the Oregon Health Authority by rule. [1995 c.3 s.2.02]

127.815 s.3.01.Attending physician responsibilities.

(1) The attending physician shall:

(a) Make the initial determination of whether a patient has a terminal disease, is capable, and has made the request voluntarily;

(b) Request that the patient demonstrate Oregon residency pursuant to ORS 127.860;

(c) To ensure that the patient is making an informed decision, inform the patient of:

(A) His or her medical diagnosis;

(B) His or her prognosis;

(C) The potential risks associated with taking the medication to be prescribed;

(D) The probable result of taking the medication to be prescribed; and

(E) The feasible alternatives, including, but not limited to, comfort care, hospice care and pain control;

(d) Refer the patient to a consulting physician for medical confirmation of the diagnosis, and for a determination that the patient is capable and acting voluntarily;

(e) Refer the patient for counseling if appropriate pursuant to ORS 127.825;

(f) Recommend that the patient notify next of kin;

(g) Counsel the patient about the importance of having another person present when the patient takes the medication prescribed pursuant to ORS 127.800 to 127.897 and of not taking the medication in a public place;

(h) Inform the patient that he or she has an opportunity to rescind the request at any time and in any manner, and offer the patient an opportunity to rescind at the end of the 15 day waiting period pursuant to ORS 127.840;

(i) Verify, immediately prior to writing the prescription for medication under ORS 127.800 to 127.897, that the patient is making an informed decision;

(j) Fulfill the medical record documentation requirements of ORS 127.855;

(k) Ensure that all appropriate steps are carried out in accordance with ORS 127.800 to 127.897 prior to writing a prescription for medication to enable a qualified patient to end his or her life in a humane and dignified manner; and

(L)(A) Dispense medications directly, including ancillary medications intended to facilitate the desired effect to minimize the patient's discomfort, provided the attending physician is registered as a dispensing physician with the Board of Medical Examiners, has a current Drug Enforcement Administration certificate and complies with any applicable administrative rule; or

(B) With the patient's written consent:

(i) Contact a pharmacist and inform the pharmacist of the prescription; and

(ii) Deliver the written prescription personally or by mail to the pharmacist, who will dispense the medications to either the patient, the attending physician or an expressly identified agent of the patient.

(2) Notwithstanding any other provision of law, the attending physician may sign the patient's death certificate. [1995 c.3 s.3.01; 1999 c.423 s.3]

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Well, that was my promise to provide more info about Oregon. At the end of this process, you will receive a prescription for a lethal dose of a medication. It would be nice if there were a refill available in case you screw up and vomit the first try. The law does make it easy to receive other medications that will be of help--for anxiety and for nausea.

There is an ongoing, active, negative campaign by opponents of end-of-life rights as exemplified by this Fox News article: http://www.foxnews.com/story/0,2933,392962,00.html

For this particular case above, I would like to see the original letter that the patient received. To notify the poor patient of a rejection of insurance coverage and in the same communication to offer assisted suicide is poor form, to say the least.

The safeguards outlined in the Oregon statute appear reasonable when considering that we intend to end a human life. The capacity to make the decision must be established. Pain must have been addressed aggressively. Depression should be ruled out or treated vigorously. Second opinions are a minimum precaution. Stretching out the process over two or more weeks reduces the probability of an impulsive decision.
Hopefully these safeguards become the foundation of a system that provides more in the way of help. No matter how carefully an individual prepares for the moment of departure, there is the possibility of a misstep or error, in which case a backup of actual euthanasia administered by an experienced practitioner would be highly desirable. So--Oregon seems like a "start."

Rationing

In another post I have mentioned rationing. It has always existed in the delivery of health care and to begin a serious conversation about the future of health care costs without recognizing its presence dooms the discussion at the outset.
I like the thoughtful presentations of Daniel Callahan in Setting Limits. Throughout human history, survival of the family, group, and clan depended upon pooling of resources and, at times, decision-making about the distribution of resources, like available calories immediately available to the group. I believe that one of his vignettes depicted an Eskimo family in which the grandparents decide that they are too much of a burden to make the next "hop" in their hunting and they stay behind as the family leaves without them.
In our own society, how should health care resources be distributed? If we all agree that a heart transplant at age 40 is reasonable and that a heart transplant at 100 is not, what about the ages in between? Is there a magic age? As fewer of us pay for health care out of pocket, how will health insurers, including governments, make decisions about the distribution of benefits? We have 300 million different value systems to apply to such questions but serious discussion is hidden behind sloganeering.

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My enrollment in hospice has been completed. In the past 5 days I must have gotten 25 phone calls from various disciplines in the hospice agency including nursing, social work, pastoral, administration, etc. Apparently Medicare requires that each offers me their services.
The hospital bed was delivered on Monday and set up in the middle of living room.

View from the head of my bed

The picture is before sunrise. The sea is out there but I guess you are going to have to trust me. The most distressing symptom is severe shortness of breath when I change positions, like getting up out of a chair and walking to another room.
There is a lot of fluid and crud in the base of my left lung. It is lying on the diaphragm, the dome-shaped muscle that does a lot of the work of breathing. The diaphragm is a structure that migrates during the fetal period. The nerves that innervate the muscle come from the cervical spine, C3 and C4. The epaulet area of the shoulder is also innervated by C3 and C4, where I am sometimes experiencing breakthrough pain, like right now as I write.
Today Kirk and I were busy. He spent the morning editing a cooking show while I worked on refinancing and taxes again. Then we took the RV to the beach. I took in the sun while Kirk and Archie had a great walk. Then a lunch at a restaurant on the water. I wasn't hungry so I drank a beer and ate some sourdough (I am really living it up!). Then a drive to Los Osos to the pharmacy to pick up some supplies. Then to Autozone to get replacement bulbs for headlight and rear running light...then replacement of bulbs courtesy of Kirk...then a nap. A great day. Somewhere in there we bought a very expensive single malt whiskey.
This was a treasured day. I hope yours was as well.

I recently wrote about my increased interest in observing human faces--I noticed that I was smiling back in response to seeing smiles both in my environment and on television. When I mentioned it to David, a psychiatrist friend, he threw out a comment about mirror neurons. Such neurons might be a key to empathy and permit us to walk a mile in another's shoes without leaving our living rooms.
http://en.wikipedia.org/wiki/Mirror_neuron

March 4

February 28
Yesterday I called Dr. Palchak's office and opted out of my chemotherapy session set for Friday. I don't think that it is doing much for me. I was very fuzzy-headed for quite a spell after my last session and I want to be as clear as possible for the next phase of illness.
One of the things that I have noticed is a tendency on my part to enjoy watching people smile--this can be in real life or on television. I am also much more aware of length of life when it is mentioned in a news brief. Yesterday, I came across an article about George Kennan who lived to be 101. I thought.."wow...another 30 plus years beyond mine...what would that have been like?"
Dana is my youngest brother, born in 1959, 16 years after me. He is incredibly smart and started his own newspaper when he was 19. The paper was called "It" and was initially directed at students and faculty of the University of Maryland and expanded to other colleges and night spots around the D.C. area. The paper was not a successful commercial venture but was an important failure for his professional growth. He had some time after the demise of the newspaper and I invited him to visit me in Billings to write a manual for a software program that I was developing with Ed Puckett. We spent two or three weeks working and hiking together. We got close and have stayed close ever since.

Dana and Wife, Therese

So, we've had two long rides of about 8 hours each in the past week with the opportunity to talk about a number of things, particularly our current sense of impending loss.
Our Las Vegas reunion included 7 families who came from New Jersey, Maryland,  Virginia, Colorado, San Francisco, Berkeley, and Mazatlan. My brother, Kirk (b. 1956) was a primary chauffeur and made several airport runs.
It was wonderful to have all of my siblings and their children together at the same time.

The Sohr Kids: clockwise Sue, Dana, Kirk, Geoff, Eric--September 2006

Las Vegas was an amazing value. The Station Casino buffets at Green Valley Ranch and at Boulder Station were remarkable for the variety and the price, particularly if one acquires a "rewards" card. The Bellagio buffet on Saturday night was also bargain when factoring in variety and quality. I particularly liked the Sushi, the variety of seafood, exquisite pizza, fresh vegetables and fruits, and pastries. (As you can see, the only thing that is working for me these days is my Alimentary tract.)
There were a couple of moments for tears. On Sunday morning I was sitting at the breakfast table with 20 family members and I was watching all of the wonderful interaction. I thought how much my mother and daughter would have enjoyed being there with everyone--and I was experiencing my loss at seeing most of my family for the last time.
Other good times over the weekend were spontaneous with folks piled into one hotel room or another shooting the breeze and telling family stories--several of which you would have recognized from previous posts. I have accumulated a couple of dozen bottles of wine over the years. If I do drink, it is never more than about 1/2 glass. Jasmine doesn't drink. So it's open a bottle of wine; use no more than a drink;  then cook with it and wait for it to turn to vinegar. My wine cellar for the past few years has been cardboard containers under my bed so as not to waste space in cabinets. This trip allowed me to create space and fight the dust bunnies.
As the room filled with people, the bottles of wine slowly disappeared, voices were raised in merriment, and laughter supervened.
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As you might imagine, as my time ticks down I am increasingly focused on my plans for the last few hours of life.
"What do you want done with your ashes?" It doesn't seem crucial to me. The nicest place to scatter them would be the graveyard on Smith Island.
"Do you have any requests for your service?" To quote Bob Hope when asked where he wished to be buried, "Surprise me!"...but no, I don't have any requests right now.
There are some apologies I owe where there is no longer any possibility of making amends. I do have to get started on some of those.
There are letters I need to write to others and I'm still hoping for some honest conversation with family and friends.

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In addition to last few days, I have concerns about last few minutes and last few breaths. This brings up the issues of right to die and euthanasia.
I happen to take the position that we have the right to be in control of our passing from this life. Although I think that there can be value in suffering, that value is diminished when in the embrace of a terminal illness. I fully believe that some safeguards to prevent action in depression or in pain be in place, provided the safeguards are not constructed exclusively by those who are opposed to the right to choose the timing of one's death..
For those who do believe that we are justified in exercising that control over the future, we have to make certain decisions about the timing. If we are planning on an assisted-suicide, there is less need to be concerned about our physical abilities because we are ceding control to another. However, if we are intending to act without assistance in pulling the trigger (a preferable way in most states to avoid possible charges of assisting another to die) we need to pick an exit time when we still possess the necessary physical strength and mental ability to be successful. We'd like to only have to do this once.
My knowledge of the literature on the topic is limited to Final Exit by Derek Humphrey and To Die Well by Wanzer and Glenmullen. Plugging these titles into Amazon will bring forward some other candidates.
Naturally, I was most interested in the chapters specific for self-directed departures. The focus in both books was on two methods--lethal medications and inert gases. Barbiturates are the medications that have a long history of "successful" use as a toxic agent. The short acting agent secobarbital (Seconal) is increasingly more difficult to find. It is an old-time sleeper and has been replaced by newer sleeping agents that are much less toxic. The lethal dose is as variable as human genetics. 9 or 10 grams is considered a certain lethal dose.
A possible scenario for obtaining Seconal is to "start early" in acquiring a supply. I would approach your physician with an inquiry about his/her stance on your right to determine your time of departure. If an equivocal response, network among other cancer sufferers to find a more open physician. You might want to check out the physicians associated with your local hospices. Your next move is to request medication for sleep. I would mention that in the past you had used a few sleepers and that Seconal appeared to work the best for you. The physician is more likely to ask you to try something safer and to prescribe a few alternatives. Smile and accept all the alternatives. Wait 72 hours and call the physicians office for another appointment because the sleepers didn't work. Hopefully, after two or three tries, a prescription for seconal is forthcoming. As for a month supply. It will take three months of 30 tabs of 100 mg to acquire the lethal dose. The copay for seconal is especially heavy at $50 a clip with my insurance.
The books recommend that one eat pills as fast as possible in order to get 90 down before falling asleep. An alternative is to open the capsules and mix the powdered drug with applesauce and to down the small amount of applesauce in lieu of swallowing pills. This makes more sense.
Here is the procedure I would follow for seconal.

1. Mix 9 grams of seconal powder with applesauce--I'd give 4 oz a try.
2. 2 hours before departure time, use an anti nausea med (antiemetic preparation). I like Odansetron (Zofran), or Phenergan or Compazine.
3. 1 hour before lift off, use a dose of lorazepam (Ativan) 1 mg for uninitiated--your usual dose if it's something you already take like valium or serax. 
4. It is well known that Alcohol increases the effectiveness of barbiturates. One hour before might be a good time for cocktails with your supporting group. Don't drink so much that it increases your risk of nausea.
5. At 1 hour before departure, you might consider a little more opiate, like morphine or whatever you are currently using, but not so much that you increase vomiting risk.
6. Remember that our goal is to get down a lethal dose of seconal without any reflex vomiting occurring after you have fallen asleep from the medication effects. You need to keep down the lethal dose.
7. At departure time, eat the applesauce. Don't dawdle because you will go to sleep fairly quickly and you need to get the medicine all down.

The above mentioned books provide many more details about Seconal. Both also cover the use of "inert gases" primarily helium which is readily available in disposable tanks intended for balloon filling. As part of my research, I ordered 2 tanks online. With shipping, etc. each was about $64. The authors of Final Exit and To Die Well describe the use helium as representing a potentially painless way of exiting. Their argument goes like this--our respiratory drive is associated with our sense of smothering. If we look at the information on waterboarding, it only takes a few seconds before the smothering supervenes. The sense of smothering is triggered by sensors in the brain that detect carbon dioxide and oxygen, but that it is primarily carbon dioxide that accumulates rapidly and initiates the sense of smothering. The authors claim that low oxygen does not cause distress. As long as one can continue breathing, it blows off the CO2 and prevents its accumulation. So the breathing of helium replaces oxygen without disturbing CO2 and allows the brain to shut down from oxygen lack in a minute or two without distress. As one continues to breathe helium, the brain suffers from anoxia, consciousness is lost quickly and brain death occurs within about 15 minutes. There are diagrams in the books demonstrating a helium hood that can be fashioned from readily available materials.

Well, I really liked hearing about the helium method. After reading the books, I decided that it would be my first option should I see it to be necessary. That's why I ordered the gas. However, since both of the authors were still alive, I decided to check out the painless claim with a friend. We gerry-rigged a tank to my cpap machine and did a trial run. The goal was for me to demonstrate oxygen deprivation by failing to maintain a hand signal and to do so without experiencing air hunger. I failed--the air hunger kicked in within 20 seconds. Both authors who recommended the method were still alive. I decided to try again using a medication for anxiety before the trial. I was unable to find any ativan. So I used additional fentanyl quick-acting. I doubled my breakthrough dose and waited about 25 minutes and tried the helium again. Maybe I went a bit longer, but the result was the same--absolute terror. Conclusion: this method leaves a lot to be desired for me.

After my experiment with helium, I decided that I'm going to give a call to folks in Oregon tomorrow in order to find a place where I might go to get some help. I'll do my best to keep people posted. It appears to me that there might not be a fail safe method for me that doesn't potentially compromise my friends. Given the current situation, I would have to elect to use seconal. However, if I were not dead within an hour or two, I would want to add the second method--i.e. the helium. I will be far below sufficient consciousness for my respiratory drive. The use of helium to eliminate the oxygen should end things very quickly. However, it would take someone else's hand--and that is too much to ask because of the possible legal burdens.

March 4. It has been a very tough weekend. I awoke on Friday with a fever and a headache. My pulse was generally around 130. My oxygen saturations were in the high 80s. My brain was very fuzzy. The most likely cause of a fever for me is a pneumonia. I felt so crummy I was hoping that this would be a terminal event...no such luck...just a miserable couple of days. The fever went away on its own and I decided to take an antibiotic. I could live pretty well with my days from last Wed and Thu. On Friday I ended up stuck in my recliner in recline and was too weak to get up when the doorbell rang and rang and rang. I was finally able to get up for the hospice nurse and she went through the intake procedures and  left a comfort kit of senna for constipation, morphine for pain, lorazepam for anxiety and nausea, phenergan for nausea, and decadron as a steroid. A hospital bed and walker and were ordered for me.
Today Luis and Desiree came by with the baby and moved furniture around in the front room to accomodate a hospital bed. It will be nice to have everything I need on one floor. Generally I use the TV room, bathroom and bedroom downstairs for recreation, work, toileting, and dressing--but that has gotten harder to manage...
Jasmine has been overworked handling her day job, doing errands, filling rx's, getting me food and drinks, rearranging furniture, etc. She asked me to ask my family for help--to have someone around when she is at work because she worries. We called my brother Kirk and he said he would be here tomorrow--pretty amazing! Thank you, Kirk, and thank you for letting him go for awhile, Claudia. This is so helpful.
My canine partner has decided to wind down from the busy week.