It all started for Tara Shapiro when her family was driving upstate for her son’s graduation, and her mother-in-law started choking. Dr. Shapiro’s husband jumped in to do the Heimlich maneuver, saving his mother’s life. Which, it turned out, made her furious. “Don’t ever do that to me again,” she told the shaken-up family. She was 81 and had a degenerative muscle disease, and had already decided that she was ready to die. That night, she and Dr. Shapiro started talking about looking for a doctor who would help her end her life.
When her death did come, that summer of 2023, the family could agree it was all very Janice Shapiro. It was on her terms. The family decided to drive up to Vermont, which had just made medical aid in dying legal for people traveling in from out of state. The Shapiros booked an Airbnb. Just before departing, they invited over a rabbi, but Ms. Shapiro didn’t like him and he was sent away. Then a priest came, whom she liked much more.
They played “My Way,” by Frank Sinatra. Dr. Shapiro recalled mixing the powders in a cup with apple juice, bringing out some sherbet to dull the taste, and handing it to her mother-in-law, who gulped the lethal combination down. Then she told the family that after she died somebody should take the sweatpants she was wearing, which were awfully comfortable. Within 20 minutes, she was dead.
Dr. Shapiro is a palliative care doctor, and she has witnessed hundreds of deaths over her more than 30-year career, but this one turned her inside out. There was, as she expected, the crushing sense of grief. She mourned the person who had been more like a surrogate mother, who treated her like a princess and called incessantly to make sure all was OK after mammograms and who hosted mahjong parties on the deck. But there were also new questions for Dr. Shapiro.
After three decades of working in hospitals, what did it mean to go from fighting off death to speeding it up? What did this mean in terms of the Hippocratic oath, that ancient and often misquoted text meant to guide the profession, with its unsubtle command to “give no deadly medicine”?
Dr. Shapiro has been wrestling with these questions. New York has just made legal the practice known as physician-assisted suicide — those in the field prefer the gentler “medical aid in dying,” or MAID. Since around February, Dr. Shapiro has been working with a group of doctors, nurses, psychologists and other clinicians to create what is believed to be the state’s first practice devoted to helping patients die on their own terms. It opened on Aug. 5, the first day that medical aid in dying was legal in New York. (It doesn’t have an office, because the team will treat patients at their homes.)
You can think of it as a start-up for better deaths.
They have created a one-stop shop, Quiĕtus, where people can get help meeting every legal and medical requirement for a death on their own terms. Patients get two medical evaluations and a mental health screening, as well as a prescription for the combination of drugs — sedatives, morphine, lethal doses of cardiac medication — that will kill them. Medical aid in dying is legal in 13 states, and New York has among the strictest regulations, including that patients must be state residents, have six months or less to live, and wait five days between getting the prescription and filling it.
As you might imagine, the tasks involved in creating this enterprise, with very few precedents, are complex. There are questions about insurance, money and liability. There are also questions about whether Quiĕtus is inviting protest from neighbors or criticism by peers.
Quiĕtus comprises an eclectic crew of nine clinical professionals. There is Dr. Shapiro, who radiates suburban ease but whose own life has been punctuated by a pair of deaths — her 2-year-old sister, her 21-year-old nephew — that have made her quietly obsessive about comforting the dying.
There is David Atkins, a hospice social worker who used to be a Buddhist monk and found that caring for the dying felt like a way of continuing his Buddhist practice.
There’s Cristian Zanartu, a palliative care doctor who also treats trauma patients with ketamine therapy while dispensing wisdom about which parts of their mind ought to be embraced (“Your inner critic: Can you be sweet to her?”).
There’s also Daniel Cogan, the leader of Quiĕtus, a soft-spoken nurse practitioner who treats chronic pain and dreamed of creating this practice after treating aging patients who asked him to be put out of their misery.
For months, these doctors and nurses and clinicians met to figure out what it would take to set up their aid-in-dying practice, taking on seemingly unsayable questions. How on earth would they spread the word about their new clinic? Did they need business cards? How much should a patient have to pay?
(The total cost to die with Quiĕtus is just under $12,000. This covers medical consultations, psychological evaluations, logistical support, drugs and help for the grieving family after the death. The team also says it will care for people who cannot afford the cost.)
There is a strange reality surrounding medical aid in dying: Doctors as a whole overwhelmingly support it, but few want to be personally involved. One national poll from 2019 found that 60 percent of physicians favored the idea of legalizing assisted death, but only 13 percent wanted to help patients do it. Some argue that embracing medical aid in dying erodes the foundational ethics of the whole profession, or as the prominent medical ethicist Lydia Dugdale has put it: “We are committed to health, restoration of health, helping our patients flourish even as their bodies decay.”
Dr. Shapiro and her team don’t share this conviction. If doctors believe that patients deserve to get a prescription for a cocktail that allows them a smooth and controlled death, shouldn’t some be willing to step up and prescribe it?
“The Hippocratic oath says do no harm,” Dr. Shapiro said. “And I don’t think we’re harming anyone by doing this. I think we’re actually being compassionate and relieving suffering.”
April: The Logistics of Death
Mindful of their Aug. 5 deadline, members of the team gathered late one afternoon in April, squeezing onto the small gray couch in Mr. Cogan’s office, which was sparsely decorated with a bookshelf that had a copy of the best-selling “The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma.” It was right next to a copy of the not-so-best-selling “The Body Does Not Keep the Score: How Popular Beliefs About Trauma Are Wrong.” (For the Quiĕtus team, which spends a lot of time thinking about trauma, pain and contrarian medical views, this counts as a hilarious gag.)
They were dressed in the sensible apparel of clinicians off the clock: crisp white shirts and slip-on sneakers. Dr. Shapiro, between work shifts in a palliative care unit, called in over speakerphone.
From the very start of the team’s meetings, it was clear that doing the profound — changing the way people die — requires a lot of attention to the banal.
At this particular meeting, the topic was how to obtain the large quantities of drugs their patients would need.
Mr. Cogan had called a handful of pharmacies around New York State. Some became flustered when he said what he was calling about: “Medical aid in dying?” They demurred, said their pharmacies weren’t involved with that sort of thing. (Even in the months just before assisted suicide became legal in New York, many of the hospices and hospitals contacted for this story seemed uncomfortable talking about the new law, saying they hadn’t yet figured out how they would discuss it with terminally ill patients.)
Dr. Rob Siegel, another member of the group, eventually found a family-owned pharmacy in Midtown, one that sells specialty medications like those for egg freezing, that was willing to supply the lethal doses of drugs. (This pharmacy’s owner, when contacted, pleaded not to be named because he was worried about facing protests or losing business.)
Everyone at the meeting had questions about ordering these shipments. “What exactly is the sort of lead time or turnaround time for these drugs?” asked Mr. Cogan. He spoke with a focused intensity, a founder’s energy, as if he had mapped out the whole conversation in his head and knew where the group ought to go.
They were facing questions that few medical practices ever had to consider. Like, how do you arrange for the delivery of potentially deadly drugs? “We’re dealing with the city,” Dr. Siegel pointed out. “There’s doorman buildings, there’s people who you can’t even buzz in — so FedEx is going to leave it on their doorstep.”
And yet the team understood that this logistical hurdle was a crucial part of the process. For some very ill people, the arrival of the medication on their doorstep would be its own balm — bringing the knowledge that if they needed to end their pain at any moment, the option was within arm’s reach.
The practical decisions involved in creating the practice seemed inexhaustible. What should they pack in their bags for appointments: gloves and a rectal tube, certainly. Nonfat ice pops? A measuring cup? A spoon?
Would patients need death doulas? What about psychedelics? What if there were awkward family tensions the morning of a scheduled death? What if a patient choked on the concoction?
But there were also deeper questions about what a comforting death ought to look like.
Mr. Cogan felt strongly that taking responsibility for a person’s death meant being available. He imagined a scenario in which a patient suddenly began to feel piercing pain in the night and wanted to die. Shouldn’t the doctors leap into action to deliver on their promise of a controlled death?
He made his case, leaning toward his camera, articulating a situation that had been gnawing at him. “The family calls and says something like, ‘My wife, I know that she was scheduled for ingestion two weeks from now, but things seem to be changing and we want to do it tomorrow,’” he said. “I do not want to miss that call. ”
Dr. Zanartu, the ketamine therapist, felt they would end up burned out if they kept this breathless pace. If they wanted their work to be tender and intimate — all the qualities a good death should have — they needed to preserve their energy. Maybe a good death shouldn’t be available on demand.
Let’s imagine, Dr. Zanartu began, that a patient started thinking about drinking the medicine in the middle of the night. “Can they wait until 8 a.m.? I think they can,” he said. “I hate to say it, but we’re going to have to establish some boundaries.”
Accustomed to embracing patients who were weeping under the influence of ketamine, Dr. Zanartu tended to slip into the poetic. “You’re dialoguing with life and death at the same time,” he said. “God. We have to be nuanced!”
The meeting lasted an hour, but they hit an impasse. Mr. Cogan had made it clear to them he’d envisioned this operation being 24/7, their own psychic well-being be damned, but he realized they weren’t going to resolve the question in a day.
For Dr. Shapiro, these debates about dying sometimes shook loose painful memories, especially of her baby sister, who was born with trisomy 18, a fatal genetic condition.
She remembered as a child having the sense that her sister was different, but not that she was going to die. Her sister used to giggle, spit up her food and grind her teeth — to this day, Dr. Shapiro can’t bear the sound of grinding — but she was also like a little doll, and Dr. Shapiro loved taking care of her. Her sister’s death, when she was 2, came as a shock. Dr. Shapiro, 11 at the time, went to the wake and cried, but only because she saw everyone around her doing the same.
“We were told she went to heaven,” she recalled. “But I didn’t really have a sense why.”
Everyone in her family seemed to process the grief in different ways. Her father became a deacon in the Catholic Church. “There was no preparation, no explanation about why this happened — it put me on this journey to figure out why,” Dr. Shapiro said, later adding: “I don’t think I would’ve been a doctor without that.”
August: ‘The Solution and the Nightmare’
In the weeks before New York’s law took effect, the Quiĕtus team members found themselves at once ready for the change and also uncertain. For one thing, they didn’t know how many patients they could expect. When New Jersey legalized medical aid in dying in August 2019, only 12 people got prescriptions for the drugs that year; as of 2023, that figure rose to 101 people, 91 of whom used them. Mr. Atkins, the social worker, wondered aloud about the risk of quitting his full-time job. They all channeled their unease in different ways.
Mr. Cogan was a whirlwind of activity, refining the Quiĕtus website, adding a unified color scheme and font (the neutral public sans) to make it look professional, less amateur.
Mr. Atkins had given notice at his hospice job, and he invited a Buddhist monk and a nun friend over to his home to offer a blessing for his new chapter. (The monks were sometimes called to chant for the opening of new businesses, like the nearby H Mart.) Over dinner, the monk and nun talked inquisitively about their thoughts on medical aid in dying, asking how it fit with the Buddhist ideal of causing no suffering, even to a fly.
Dr. Shapiro flipped through photo albums with pictures of her mother-in-law — moony-eyed in the seat of a car after her wedding — as she wondered what Janice Shapiro would have said about this professional turn she was taking.
During one video meeting, Dr. Shapiro said she’d been warned by advocacy groups that pushed for the law that they should be cautious about the calls starting to trickle in from potential patients. “It’s a lot of people who don’t qualify,” she said, meaning, for example, some patients who had Parkinson’s but whose doctors said they had more than six months to live.
Mr. Cogan imagined a situation in which someone who was very sick but not terminally ill called up the team. “If somebody is like, I’m paraplegic and the doctor says I might live for years but I want to kill myself, can you help me? — the short answer is, I have tremendous sympathy for your situation, and tell me more about what’s going on, but these are the terms of the law,” he said. Quiĕtus would have to turn him down.
On Aug. 5, Dr. Zanartu visited their first patient, a middle-aged woman with terminal cancer. He packed a bag with his stethoscope and laptop for taking notes, along with a clip-on microphone so he could help the patient make a video documenting the request to die, a legal requirement. (“This is so silly, I hate to put you through this, we have to do this,” he practiced explaining). In the car on the way over, he felt a stark awareness of the darkness in the role he was taking on.
“You’re representing relief, but you’re also representing horror,” Dr. Zanartu reflected. “You’re the solution and the nightmare.”
The next day, the Quiĕtus meeting took on a newly urgent, down-to-business feeling. They talked about the cognitive assessment they would have to administer for patients, along with a test evaluating for depression, counterintuitive as it seemed to assess a dying person’s will to live.
For Dr. Shapiro, the summer was laced with memories of her past selves. As she got ready to see patients, she realized that she doesn’t think about death with all the mystery the word carried for her when her baby sister died. She feels confident in the notion of a heaven on the other side.
When Dr. Shapiro was preparing to travel up to Vermont, packing a light bag for Janice who knew she wouldn’t need a change of clothes, she asked her mother-in-law a pointed question.
“Ma, what happens after you die?” Dr. Shapiro remembers asking.
“Nothing,” her mother-in-law said.
“On the chance that you’re wrong, would you mind contacting me and making it obvious?”
About a year after she died, Dr. Shapiro said, she saw her mother-in-law appear in a dream. They were sitting in a banquet hall, feasting, and Dr. Shapiro asked if they were in heaven.
“Everything’s OK,” her mother-in-law said in the dream. “Just go get something to eat. You’ll know when you’re ready.”
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