Some of our most important ethical decisions are made with the least analysis. At least that was the way it was for me this morning at 10:34, when my sister and I directed that my 89-year-old mom, Eleanor Coulouris Marshall, be taken off of life support.
The last time I had seen my mother was on Thursday, when I visited her in the hospital. She was awfully sick for sure, battling a persistent colon infection that was proving resistant to antibiotics, but she was a fighter, and nobody, especially her, thought that she was in any immediate peril. By Friday night, as I was trying to work my way back home from Winston-Salem in the midst of high winds and flight delays, the doctors were talking about removing her colon as the only way to keep the bacteria from poisoning her system.
They didn’t get the chance. Prepping her for the operation in the early morning hours, Mom’s heart stopped: they resuscitated her, and she was conscious, but there was no hope. Without the surgery, she couldn’t survive the infection, and all were agreed that the infection would kill her. When I finally got to the hospital, my mom was on life-support. She might wake up, I was told; my sister had spoken with her, briefly, an hour before. She wasn’t really aware of what was going on. My mother was terrified at the prospect of death, and always had been. I did not want her to be frightened or panicked, or to awaken only long enough to learn, if she could comprehend it, that the infection was killing her, and that nothing could be done.
The doctor said that while she could survive on life support for quite a while—days, perhaps, and maybe longer—stopping life support would end her life in a matter of seconds. My sister and I, who had written authority to make such a decision, didn’t hesitate.
“Do it,” we said.
And that was that.
What ethical considerations went into the decision? I can only speculate after the fact. I wasn’t thinking as an ethicist, but as a son who knew my mother very well, loved her, and who had her complete trust. She had a wonderful life for 88 of her 89 years; only the last was unhappy, primarily because her whole sense of identity and purpose was lost when my father, and her husband of 63 years, died in December of 2009. She was in a bad place now; she hated living alone, and she hated living with anyone other than family even more. I invited her to live with me, but she refused, for my father had always insisted that they should never be “a burden.” She was so depressed without Dad that she had trouble getting through the day, but she was always expressing hope that she would eventually get over her grief, eventually walk without pain, and drive again, and be able to travel—essentially be 40 again. Her fighting spirit kept her hopeful, but it also kept her from dealing with reality. She had been falling since November of last year because she refused–refused—to use a walker consistently. A serious injury was just a matter of time.
Had she lost her colon to emergency surgery, Mom would have been horribly depressed, but she would have preferred that to the alternative. She would prefer being an invalid to the alternative too, but would have been miserable beyond imagining. I couldn’t apply the Golden Rule, because my Mom was very different from me in this respect. I’d want to be taken off of life-support; give me a useful life, or no life at all. My Mom? She would be terrified, she would be in despair, she would be in denial, but I know that she would never be able to voluntarily go into a dark unknown that always frightened her. And she was going. Mom would often ask me if she would meet up with Dad after death, like the recent finale of “Medium,” where Allison dies of old age and is suddenly young and united with Joe in the Great Beyond. “I don’t know,” was the bravest answer I could give her, rather than the more honest and direct, “No.” “I think so,” she would say. That was the only way she could keep her fear of death at bay. “I hope so,” was my reply.
She didn’t believe it any more than I do.
Ultimately, I decided that “pulling the plug” was the kindest act, keeping my Mom safe from fright and worry, leaving her as much dignity as possible, for dignity was very important to her. I wanted so much to be able to look into her eyes one last time and tell her how grateful I was to her, how much her unequivocal, complete and unwavering love and affection had meant to me. But that was what I needed, not her.
It felt wrong to decide when a woman who never could accept the inevitability of death had to die. But I believe, I hope, that it was the right and loving thing to do.
I am indebted to my mom for everything; not least of which was a daily, 60 year course on the meaning of love.
I just wish there was some way to know if I passed her final exam.
Ethics Alarms 
Of course you passed her final exam, Jack. You loved her and took the best care of her that you could. ear of the inevitable does not stop the inevitable….only the conditions. A life of colostomy bags and strange home health aides and nurses completing those personal functions for her would have compounded her misery and further demoralized her more than even she could know.
Had she agreed to come live with you, the burden would have fallen upon your wife and son to either do her chores or have strangers in your house who would see your mother as another job in day full of jobs. You would have had your mother but not necessarily the mother you loved and who had loved and nurtured you through your life.
Did you do the right thing? I don’t know the answer to that. That Mrs. Marshall is no longer suffering is certainly a blessing and she died knowing how much you and your sister loved her is a comfort to her and you.
Geoff and Emma and I send you our sympathies and condolences for your loss. Geoff and i have only our mothers left and I contemplate the time when I will be an orphan and I believe it will be soon. Another one of life’s inevitabilities. but better the natural way than for your mother to have outlived one of her children.
My condolences to you and yours.
I can more than understand since I just lost my mom. She had strokes that affected her brain but physically there wasn’t a thing wrong with her. She required a lot of care because she wasn’t always aware, fell a lot, couldn’t prepare her meals etc. She was disgusted and wanted to die. In the end, she decided to starve herself to death. Watching that horror was beyond belief. Hospice came in as well as doctors and told us we should respect her wishes. It took weeks for her kidneys to start failing. When she would wake up she would start crying because she was still alive. You have spared your mom taking such a final-desperate act. My mom was 91.
What an awful resolution. I could see my mother getting to such a point of despair…her own mother essentially willed herself to death when she had to be moved to a nursing home, and died after two days.
Please accept my condolences. It is never easy losing a parent. She did not lose the battle of illness, but she won the battle of life.
My brother and I made a similar decision. We knew it was the right decision. No doubts.
Many blessings to you and your sister, Jack.
Jack, you are a good son, a very very good son, and Edith is a very very good daughter. Eleanor knew, as did your father Jack, that their children are the best that there is. Try to comfort each other, and all of those touched by the lives of your parents, with the knowledge that they passed into eternity, held up by the love of their children and many, many other people. I am so very sorry for the loss of your mother, so soon after the loss of your father. Eleanor and Jack Marshall raised wonderful children, and that is a magnificent legacy.
My sincere condolences to you, your sister, and the rest of your family.
–Dwayne
Jack, first let me say how sorry I am for you and your family–and how grateful I am for you sharing this intensely personal moment through this column. Earlier this year, I was asked to update my mother’s emergency medical instructions by the staff at the nursing home she entered three years ago. At that time she had chosen the highest level of intervention: resuscitation, breathing support, feeding–the full tubes-and-all combo. I declined to influence her otherwise because although her dementia was in play, I reasoned I must respect her right to make those choices. After spending those three years on a steadily declining course, and with each recent phone conversation growing more surreal and difficult than the previous one for both of us, I took the advice of the staff and modified that MOLST form with some more realistic choices. Not an easy decision, but a necessary one.
So many of us are on this journey at this point in our lives, but each of us experiences it in a unique way. And there are never easy answers along the way. But it seems to me that you and your sister made the best possible choice for both your family and your mom. You have my respect and my understanding.
Deepest sympathies and condolences to you, your sister, and the rest of your family. End of life decisions are very very hard and each family faces them in their own unique way. That your sister and you could face them together, united, says much about the parenting you received, the family you belonged to, and the rightness of your and your sister’s decision.
I’m so sorry about your mom. I was with my grandmother within hours of her death. She would come in an out of consciousness, couldn’t speak (but tried desperate to) and I could tell by the look in her eyes that she was terrified. I comforted as best as I could, told her I loved her and knew that she loved me too, but I’ll never forget how scared she was. I think you did the right thing.
I’m so sorry for your loss, Jack. For whatever it’s worth, it sounds like you did the right thing.
You made the necessary decision that only you could have made, Jack. And you did it for the highest reasons. It wasn’t because of “inconvenience” or monetary concerns. Your mother’s life was only being artificially prolonged by machines with no possibility of recovery. It’s a hard decision, nonetheless. I’ve never had to make it, thank God. Nor would I wish it on others, particularly if it comes with my own departure from this world. But it happens… and some one must decide. That’s one of the things that family is for. Speaking as a Christian, I can take comfort from the Lord’s promise that all travails are passing, as are all separations.
You made a decision based on love, which is the only inherently correct answer to these questions. I’ve been there, with both parents, and the one thing I can say with absolute confidence is that I will never, ever, criticize anyone’s choice about a loved one in such a situation.
My thoughts are with you and yours.
Dear Jack: Thanks for sharing your very eloquent expression of love, care and compassion in your essay above. I am deeply sorry for your Mother’s passing and your family’s loss. My condolences to you, your sister and your entire family. During our phone conversation on Thursday I commented on how fortunate your Mother was to have a son and daughter so fully committed to her care, so full of unconditional love and so totally devoted to ensuring her comfort, joy, grace and dignity. And how fortunate you and your sister are to have been blessed by your Mother’s wonderfully fulfilled life for nearly 90 years. I truly believe she is in a better place tonight , thanks to your and your sister’s decision to let her go peacefully and without pain. And yes, I believe she is resting tonight in the embrace of your Father, both of whom are eternally grateful for their son and daughter’s expression of pure and perfect love. You are in my prayers tonight my friend. My email hug to you and your wonderful family.
My condolences, Jack.
Jack: Thank you for sharing your very difficult but courageous story. Please accept my sympathy for your loss. All of us with elderly parents know the many issues that old age brings in terms of living with dignity and just living. and trying to balance continued life with a life of quality. Best, Karen
I am very sorry for your loss, heartfelt condolences. You and your sister were placed in an untenable situation. You both passed the test with
flying colors. Sometimes it sucks being the decision maker, been there, done that. Sorry for your loss and best wishes going forward.
Joe
Thanks Joe—that is very kind. Times like these remind me how supportive and empathetic our species is when it matters most.
I am so sorry for your loss, Jack. My deepest condolences. And I would echo Mark’s statement, and say that I, too, think you did the right thing.
Thanks, Franco. The reassurance helps.
My condolences Jack in the passing of your mother.
Consider this a long distance hug. This brought tears to my eyes.
Thanks, RN. I need it.
My condolences as well. My parents have been clear in that they don’t want to be kept on life support, but I can’t imagine having to make that decision.