- Associated Press - Saturday, December 19, 2015

SALEM, Ore. (AP) - It had been nearly a month since Dr. Peter Rasmussen started hospice care, and it had become clear that he was on a downward spiral.

“Is there any way I can stand up?” he once asked.

His caretakers said, no, he was too weak and the risk of injury was too high.

That sealed the decision for the retired oncologist, who had been living - and dying - with grade 4 glioblastoma for a year and a half.

His wife, Cindy Rasmussen, invited his out-of-state siblings, stepchildren and close friends to his East Salem home.

Peter Rasmussen filled out the written request for his doctor, the next step in the Death with Dignity process he had started weeks prior.

Within days, a fatal dose of legally prescribed medication would arrive at the home.

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It didn’t take long for Rasmussen to discover his calling was working with terminal patients.

After several years of working as a general internist, he returned to school at the University of Miami to complete his oncology fellowship. He set up shop in Salem in the 1980s, founding the practice that is now Hematology Oncology of Salem.

When he wasn’t caring for patients, he volunteered to help improve the health care system for dying patients.

He helped found Willamette Valley Hospice, served as the president of the Salem Hospital Medical Staff and led the Salem Hospital Medical Ethics Committee.

When, in the 1990s, Oregonians were pondering a ballot measure that would legalize physician aid-in-dying, the ethics committee hosted forums to help educate voters.

But while plenty of doctors were willing to speak against the Oregon Death with Dignity Act, no one volunteered to speak in favor of it. For the sake of the debate, Rasmussen stepped up.

His advocacy grew from there and never stopped, despite verbal attacks and patients leaving his practice.

Ultimately, Rasmussen became a well-known name in the movement as he fought the federal government to protect the integrity of Death with Dignity, which, by then, voters had approved twice.

While Rasmussen believed dying patients should have the legal option of ending their own suffering, he also believed good hospice care could greatly improve their quality of life.

Early in his disease progression, he hoped that when death was near, comfort care would be enough. Death with Dignity was the last resort.

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Rasmussen was diagnosed with the malignant brain tumor in the spring of 2014.

Some say he should have been immune from cancer, considering his 30-year legacy of caring for patients of his own. It felt unfair, somehow.

But Rasmussen, an atheist and pragmatist, would have said that actually, his familiarity with cancer gave him an advantage in coping with the diagnosis.

Rasmussen’s initial treatment regimen, which included surgical removal of the tumor in the spring of 2014, earned him more than a year of relatively comfortable life.

But when the end came, it was quick and sudden.

Disabled on his left side after a second surgery to remove his recurrent tumor, Rasmussen dedicated himself to rehabilitation, preparing for a new way of life.

His neurosurgeon hoped the second surgery would give him until May - the second anniversary of his diagnosis.

Rasmussen was determined to make this new phase a fulfilling experience.

One day, he was practicing getting around in a wheelchair. Moving from the chair, to the bed, to the toilet and back. Then repeat.

The next day, he was seriously ill.

The tumor was back. It had spread to the center of his brain.

Rasmussen decided against further treatments, and hospice took over his care.

“He has been warning me since the beginning that this is what happens with glioblastoma,” wife Cindy Rasmussen said, days after her husband returned home to live out his last days. “When it comes back, it can come back suddenly and with a vengeance.”

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On average, Death with Dignity expert and Rasmussen’s friend George Eighmey said, the entire process takes about 45 days.

It requires two oral requests, one written request, two physicians’ approval, one physician’s prescription, one pharmacist agreeing to fill the prescription and two mandatory waiting periods.

An adult Oregonian with a terminal diagnosis with six months or less left to live initiates the process by making an oral request to the prescribing physician.

Then a second physician consults with the patient to confirm the patient’s prognosis and mental competence.

Fifteen days after the first oral request, the patient must make a second oral request to the prescribing physician.

The patient also must fill out a written request form any time after the first oral request. This allows the physician to order the medication 48 hours later.

Then a pharmacist voluntarily fills the prescription, which, in Oregon, is typically 9 to 10 grams of secobarbital or pentobarbital. Both are sedatives that slow down brain activity.

The final legal requirement is that the patient take the medication without assistance. This means the patient must be able to swallow, to hold the medication and to bring it up to their mouth.

For people who are quickly declining, the timing is tricky. Die too soon, and there’s a risk of losing some quality days. Wait too long, and the patient could lose their chance to end the suffering.

Since the law passed in 1997, a total of 1,327 Death with Dignity prescriptions had been written as of 2014, and 859 patients had died from ingesting the medications.

Last year, 94 out of 155 patients who received prescriptions died using the law. An additional 11 patients died after ingesting medications prescribed in previous years.

Patients can die anywhere from within minutes to a couple of hours.

Rasmussen’s last weeks were tearful, but there was also plenty of laughter.

In his first week home, his stepchildren and their significant others traveled from Seattle and New York, and his older brother, John, flew in from Chicago. A niece took time away from school at Oregon State University. They all slept on the floor around Rasmussen’s bed, fearful he might die overnight.

Other friends flowed in and out of the front door of the East Salem home, bringing coffee and snacks.

At one point, one October morning, 18 or so people milled around the living room, chatting in small groups, forming concentric circles around Rasmussen, who dozed in and out of consciousness.

Rasmussen’s stepson, Keith Brandtjen, stuck by his stepfather’s bed, stroking his hair, reading to him and swabbing his mouth with water.

Brandtjen and his sister, Gretchen Higgins, reminisced about Rasmussen’s animated readings of Hans Christian Andersen stories when they were children.

“Peter’s always the best at accents,” Brandtjen said.

“And somehow they always end up with Irish accents, too,” Higgins said.

They laughed.

The family decided it was time they returned the favor.

Rasmussen chose a tale called “Little Claus and Big Claus.”

“Alright, Peter,” Brandtjen said. “I’m not going to be nearly up to your standards of excellent reading and storytelling. I hope it’s OK.”

He began the story, and a small crowd tuned in. It was a bizarrely violent story, starring a scheming Little Claus who was at best conniving and at worst murderous.

As casualties of the winding narrative mounted, the laughter in the living room grew.

“This is horrible,” Cindy Rasmussen teasingly said to her husband.

In a raspy, barely audible whisper, he replied, “The best is yet to come.”

John Rasmussen later explained the odd choice, saying the brothers’ father read the story to them when they were children.

Rasmussen’s last days continued like that for about a month.

Every morning, he started the day by having coffee with his older brother, who swabbed small amounts of coffee in his mouth.

On good days, they watched Pink Panther movies and listened to music. He cracked jokes and even enjoyed a little bit of his favorite drink, gin and tonic.

On bad days, he struggled with pain and side effects from medication. He had difficulty speaking and staying alert. He had seizures.

A week after Rasmussen made his first request for Death with Dignity with his primary care doctor, his oncologist visited him at his home to complete the consultation visit.

Then Rasmussen halted the process, deciding he wasn’t ready to die just yet, Cindy Rasmussen said.

“I feel like we gave him so much love and so much good care; I don’t think he wanted to leave that,” she said.

As Halloween approached, Rasmussen’s condition began declining rapidly and it became clear that he wouldn’t ever recover enough to enjoy a sufficient quality of life.

“I think he just started realizing that it’s time,” Cindy Rasmussen said.

On Nov. 1, with about 16 people gathered around Rasmussen, a Unitarian pastor officiated a memorial service. Rasmussen had planned to end his life this day, but a seizure left him too weak to take the fatal medication.

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On Tuesday, Nov. 3, Dr. Peter Rasmussen was ready. He had recovered enough from the seizure to take control again.

Five loved ones encircled Rasmussen in his bed in the living room, morning light flooding in through the large windows that framed a sloping, picturesque backyard.

Soft piano music flowed out of the speakers, helping set a peaceful mood.

Rasmussen swallowed a cup of papaya, mango and orange flavored juice mixed with a deadly dose of barbiturates - 90 capsules’ worth in all.

Loved ones held each other, stroked his body and murmured loving words to the 70-year-old man as his tired body drifted into a deep sleep.

As they waited for the medication to take full effect, they expressed how much they loved Rasmussen and what he meant to so many people, near and far.

His breathing became irregular and weak, as his body held on to the last thread of life. His heartbeat was more of a flutter of butterfly wings than a rhythmic thump.

“The peacefulness that came over everybody while we watched him slip away,” said Joan Stembridge, a longtime family friend, describing the memories of the morning. “The fact that we all knew that it was exactly what Peter wanted. And a gratefulness that we could all do this as a team.

“It was a sense of relief that Peter wasn’t suffering. He was clearly free.”

And then he was gone.

This was the way he wished to die. This was the choice for which he advocated his whole career.

About the series

Dr. Peter Rasmussen became a known name in the Oregon Death with Dignity movement in the 90s and 2000s as voters legalized physician aid-in-dying and state and national politicians attempted to nullify it after it became law. The Salem oncologist was an intervenor in the successful U.S. Supreme Court case defending the policy. When Rasmussen was diagnosed with a grade 4 brain tumor, he agreed to allow Statesman Journal reporter Saerom Yoo and photographer Danielle Peterson document the end of his life. This is the final installment of the yearlong multimedia project. Rasmussen died after taking Death with Dignity drugs on Nov. 3.

Previous stories, videos and photos are available at stjr.nl/rasmussen.

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Information from: Statesman Journal, http://www.statesmanjournal.com

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