What do chronic kidney failure, hypertension, degenerative arthritis, limited mobility, memory loss, hemodialysis, and 76 years of age have in common? Taken as a whole, nothing, but the dialysis part puts this melange into a unique situation: the ability to schedule one's own death.

I first met Dick 12 years ago. Dick had blood in his urine, small kidneys, and reduced kidney function. He had been dialyzed briefly in 1963 after an automobile accident and now had nephrosclerosis as well.

About 6 years after I assumed his care, Dick needed an inguinal hernia repaired. During that hospitalization, dehydration reduced his marginal renal function to the critical 10% level, and he was to receive dialysis forever.

He began coming to the outpatient facility three times a week for 4 hours each time. He had been an 18-hole, three-times-a-week golfer before dialysis and after a period of stabilization, was back golfing. He used his time on the machine wisely. He was a reader. In this way for 6 years, until just last week, I saw Dick and his wife, Ruth, every month. He had done very well.

During the last 8 to 12 months, however, Dick's course started to take a slow, downhill slide. He had difficulty walking without assistance, more bone pain, and an increased loathing for dialysis. I began to tell Dick and Ruth about their options. We could try twice-a-week dialysis for 4 hours or three times a week for 3 hours or they could stop dialysis altogether. Dick's eyebrows raised and with a twinkle he said, "Let's do that".

"You will not," said Ruth, who was never one to mince words.

"I was just kidding!" said Dick.

About October of last year, I began talking with them about a durable power of attorney for health care and advanced medical directives. Because I was on the Bioethics Committee at our hospital and with the recent passage of the Patient Self-Determination Act, I was attuned to patients' rights. Ruth would be Dick's surrogate should he ever be mentally or physically incapable of making health decisions. Dick decided that in the event of a catastrophe, he would want "do not resuscitate" (DNR) status. Dick indicated he wanted to continue dialysis. But on our next visit, he again expressed his dread about the dialysis unit. It was at this time that I began discussing what withdrawing from dialysis would entail.

"Dick, you can withdraw any time you want. You have a way out, a comfortable way out. Over a week or two you would just become sleepier. Eventually your potassium will rise enough to stop your heart".

"No pain?" he asked.

"No. You might be uncomfortable being in bed so long or you might retain some fluid and have a little difficulty breathing. But, I would have a hospice nurse see you from the moment you stop treatments to ensure comfort with oral morphine".

That was it for that visit. Two visits later Dick brought up the topic again. Ruth seemed uncomfortable with the idea. The next day she called.

"Dick's not going back".

"Oh, you've talked".

"Yes, Doctor Golden, he's made up his mind. You know all these years he says he's gone through with it for me. He's been afraid to leave me alone to fend for myself".

"But he must see how tough you've become by now".

"Yes, and that's made his decision easier. Oh, I'm OK now, but I know I'll go all to pieces when he goes".

"Do you want me to talk to Dick?"

"Hold on".

"Hi, Doc. Yep, I'm not going back. The kids are here, and we all agree".

Then Ruth wanted to talk again.

"Doctor Golden, you know that paper we signed awhile back?"

"The advanced medical directive".

"Yes. Since Dick checked your box desiring dialysis what do I do now?"

"Just cross out the "yes" and check the "no" and update the date. I'll then have Dick sign it and you or your daughters witness it. That's all you have to do".

"Will you come out to the house sometime before ... ?"

"Sure".

The answer came spilling from my mouth but just as quickly I realized that in 14 years of private practice I had never made a house call.

And so began the last 6 days of Dick's life. The weekend came, and I headed for the Merced National Wildlife Refuge to see the migrating waterfowl and clear my head of a week's worth of work.

At noon on Monday was the first chance I could drive out to their home.

As I pulled up in my jeep, Ruth was on the porch.

"Still driving that old thing! We were hoping you would get here soon. I think he's going fast. In fact, I don't think he'll last the day".

"Is he comfortable?"

"It's the strangest thing, Doc, but up until last night he was perfectly lucid and enjoying the grandkids. Then he started complaining of pain and a little hard breathing. The hospice nurse, Tippie, gave him his first dose of the liquid morphine last night, twenty milligrams. You just missed her. She just gave him his second dose, thirty".

She led me into their home, and I said hello to their two daughters. They had taken up a round-the-clock vigil with their mom. I went in with Ruth to see Dick. He was stuporous, and there was some upper airway noise like snoring but no pulmonary edema. My stethoscope aroused him.

"Dick, Doctor Golden is here".

The old gleam was in his eye. He cracked a smile.

"Where were you this weekend? Out with the birds again, huh?"

"You got that right exactly".

Then he drifted off. We went into the kitchen and sat around the table. Ruth told me that the day before, Dick had had the grandest time giving away some of his prize possessions to his grandchildren. A belt with silver buckle to one, a coin collection to another. Even the daughters were the object of his giving.

"And you know, Doctor Golden, he wants to give you his Doctor Golden sweater".

"I don't understand".

"You remember how you two always commented on each others' cardigans? Well there is one in particular that he called his Doctor Golden sweater, and he wants you to have it. Shall I get it?"

"No, let's wait until after".

I went back in the bedroom and just watched him. He looked like someone sleeping. He must have sensed me watching him. He opened his eyes and looked up at me.

"Well, Dick, what do I say? So long or good-bye?"

Then that half-smile reappeared, and the twinkle of the eye as he slowly outstretched his arm to shake my hand.

"How about you just get the hell out of here, and we'll leave it at that". And his eyes closed.

They offered me lunch, but I had to get back to the hospital so I hugged Ruth and her daughters and left.

As I drove back to the hospital, I felt that nothing else I did that day would mean as much as that 30 minutes. I felt pride for Dick whose heroism permitted a death with dignity.

When I got back to the hospital, the first patient I went to see was a young woman with pre-eclampsia. I spent what seemed a long time staring at her baby.

At 4:30 that afternoon Ruth called me at the office to tell me that Dick had just died.

"And you know, Doctor Golden, I'm fine. I thought I would fall apart but when I just now looked at him, he looked more comfortable than I have seen him look in years".