Bob and Noreen Bishop sat on their sun porch, hands full of cards, playing a game of cribbage. Bob was wearing his pyjamas, Noreen a pink fluffy bathrobe and slippers. Their son Chris later remembered his mother looking like “a pink bunny rabbit.” The two had been playing cribbage nearly every day for decades, in an unending competition to skunk each other. The night before, Bob and Noreen had a family gathering at their home in Eagle Lake, Ontario, to celebrate their long lives. Their five children were there with their spouses, and they drank champagne, ate lobster, and danced to the music of their sixty-five years of marriage. It was Noreen and Bob’s last evening together.
The next morning, at eight o’clock, Chris and his siblings arrived at the house as their parents finished their game, and the family sat together, drinking coffee. They cried, but they also laughed. Soon the doctors arrived, and one of them, Dr. White, took Noreen and Bob aside separately to assess their mental states. At 9 o’clock, the two shuffled their way into the house, their kids behind them. At the last minute, Noreen called for a family picture, everybody laughing at the absurdity of the moment. The couple lay down on their bed, Noreen on the right and Bob on the left, and clasped their hands between them. They were given a moment of privacy to say their last words to each other, then, with their children at their feet, were first put to sleep, and then, after the family stepped out, the doctors helped them leave the world together.
Bob and Noreen Bishop were possibly the first couple to pass away together with MAID, or medical assistance in dying, in Ontario—and one of the few in Canada. At the ages of eighty-five and eighty-six, the two were deemed unwell enough by their separate physicians to qualify for assistance in dying and to begin the careful choreography of their own ends.
That same day, coincidentally, George and Shirley Brickenden, ages ninety-five and ninety-four, also died together with MAID. While Bob and Noreen died hand in hand around 9 a.m., the Brickendens died around seven that evening in their retirement home in Toronto, after nearly seventy-three years of marriage. Both stories, while eerily similar, illustrate a state of suffering and deep love and the complicated process of death. To both couples, and others across Canada, the end of life could be beautiful and dignified, and a choice.
Noreen and Bob Bishop met when they were nine years old, in Haliburton, Ontario, and began dating when they were fifteen, marrying at twenty. They raised five children and, in 1965, opened a ski resort, Sir Sam’s, with Noreen heading the food service. They also bought a nearby hunting-and-fishing lodge and turned it into an inn, so visitors to the area had somewhere to stay. Noreen took charge of the renovations, and Bob managed the hill. Despite the stress of running a weather-dependent business—they didn’t buy a snow machine until the late ’80s—they dealt with things as they came.
The Bishops were well known around Eagle Lake and nearby Haliburton. They were famously wonderful hosts, organizing dances and music events at the ski hill and meandering around the lodge in winter, asking their guests whether they were enjoying the slopes and liking the food. They saw their children often (four of them live in the Haliburton area, and one lives in Ottawa) and entertained friends when they could. But, in the last few years, they were seen at the ski hill less and less often.
In their early eighties, their health began to decline. Bob was diagnosed with renal cancer and had his kidney removed, but after a couple of hopeful years, doctors found it had metastasized to his shoulder and bones. Bob’s chemotherapy treatment left him fatigued and without an appetite, while the codeine and Tylenol that was treating his pain made him hazy. Noreen had congestive heart failure. When she wound up in the hospital for around five days with pneumonia, the family thought it was the end. She recovered but told her children later she would have wished she had died then, if not for the fact that her husband would be left alone.
For years they had told their children they wanted to die together, and as their quality of life dwindled, Bob approached his doctor and friend, Norm Bottum. “He just said, ‘Lookit, the one thing I want to tell you right now is that if I start having difficulties and the cancer is going to take me, I do not want to linger,’” Bottum remembers Bob telling him. Bob had watched his mother decline, with dementia that eventually claimed her life, and then his father die slowly from cancer that had similarly spread to his bones.
In June 2016, Canada passed a law that permitted adults to request MAID. The new legislation came after years of court battles and advocacy and was only drafted after the Supreme Court of Canada found the law that prohibited assisted death in Canada was in violation of the Charter of Rights and Freedoms. More than 6,700 Canadians have since received MAID, with the average recipient aged seventy-two.
By 2017, Bob had trouble sleeping because of the pain in his shoulder and found it difficult to do basic things around the house. Meanwhile, Noreen was on oxygen and had shortness of breath, which she said felt like drowning. She stopped going into town after a panicked experience of being in public and unable to breathe. She gave up her driver’s licence, so Bob would drive her around to do the things she enjoyed, like getting her hair and nails done. He called their trips “driving Miss Daisy.” They were both losing weight, and their ability to live independently was ending. Finally, in early 2018, Bob told his doctor that he and Noreen were ready to die.
By the time Bob approached Bottum, medically assisted death was legal in Canada, but the question of whether he and his wife could die together remained. When it was passed in 2016, Bill C-14, which legalized MAID, came with a plethora of criteria for how the procedure could be carried out. Among them is the requirement that the person must be suffering from an “irremediable” illness, disease, or disability and be in an advanced state of decline, such that natural death is “reasonably foreseeable.” The patient must also be able to consent to the procedure both on the day the request is made and the day it is carried out. In most cases, patients are required to wait for ten days after a request, before, depending on their province or territory of residence, a medical doctor or licensed nurse will assess their mental capacity, asking them questions and making sure they understand what is about to happen. The person can choose to be at home or in a hospital, with friends and family present if they wish, and can choose for the drug to be administered by the doctor or nurse or to ingest it themselves.
The law doesn’t make special considerations for couples, so dying hand in hand is only possible if both meet the requirements. Dying together can be further complicated because couples need to find two physicians or nurse practitioners to approve each them. Because of the need for physicians to remain independent, this could mean finding two separate physicians for each person. In small towns, this can be a challenge.
Bob was approved by Bottum on March 4 and Noreen by her own doctor the following day. The Bishops, who wanted to die at home, brought in a third doctor from nearby Bancroft, who was willing to help and was comfortable with MAID, who also approved them on March 6. “Then it was just waiting and hoping,” says Chris. “There were many times we thought they wouldn’t make it.” The biggest concern was that one of them would have a heart attack or become mentally incapacitated, and therefore unable to consent, or that one or the other would be moved to a palliative centre, which could be over an hour’s drive away. “Every day, you hear a story of somebody’s parents going into a home or [that they] just had a stroke,” says Chris. “Everybody’s lives just get turned upside down, and death becomes a disaster.”
One year after their parents death, three of the four children of Shirley and George Brickenden, the couple that died with MAID on the evening of March 27, 2018, sit on a couch in a bright Toronto apartment, food spread out on the coffee table. The family’s trademark banter and teasing filling the room as they enthusiastically share a stream of tales of their childhood and their parents’ eccentricities. When Pamela, seventy-two, Angela, fifty-six, and Saxe, sixty-one, reminisce about their parents, they are like children again.
The Brickendens’ story began sweetly. When George and Shirley met, in 1940s Halifax, she was in the air force and he was in the navy. They were both seeing other people at the time, but six days after meeting, George proposed. The couple lived in Montreal for a time, raising four children before moving to Toronto (one of their children now lives on the West Coast). George was a founding partner of an insurance brokerage, and Shirley was a talented watercolour painter who had her work displayed in art galleries in Montreal and in the Art Gallery of Ontario, in Toronto.
The children remember that Shirley and George had talked about the possibility of dying hand in hand for years, referring to it as when they would “fly away together.”
When MAID became possible, the Brickendens decided they wanted to share their story, despite being deeply private people. “The only reason they pulled the subject out of the shadows is because they wanted to pave the way for others,” says Angela. A week before they were scheduled to die, Globe and Mail reporter Kelly Grant came to their home to talk to them about their plans to die with medical assistance. The feature was published on the front page five days after they passed and included photographs of the cheery, smartly dressed elderly couple; in one image, George kisses Shirley’s nose.
The siblings were not ready for the torrent of opinions. Angela says, at one point after the story was published, she couldn’t go anywhere without hearing about it. She overheard conversations in line at a movie theatre about “that old couple who died with assisted suicide” and was approached by strangers, in as unlikely a place as Mexico, asking about her parents. The other side of the media attention hit them hard as well—Saxe spent days reading online comments, which he says varied from sentimental gushes to odd claims that his parents’ deaths were murder or a publicity stunt.
On the surface, the Brickendens didn’t quite fit the image of two elderly people nearing death. “They didn’t look at all unhealthy, even until the last bit,” says Saxe. But then he shows me a picture of Shirley’s hands. Rheumatoid arthritis had left her hands purple and gnarled, and at the end of her life, she wasn’t able to perform basic tasks, like doing up her pants. So George would help with her clothes and do her hair.
Despite the pain and discomfort, Shirley still made the effort to handwrite letters to family and friends, to be delivered the morning after their passing, to explain their decision and say goodbye. Like the Bishops, the couple chose to only tell their immediate family and closest friends beforehand about what they were planning to do. Shirley and George didn’t want to face any negativity, spend their last days consoling others, or have anything jeopardize their plan.
In 2016, the couple had attended an event run by Dying With Dignity Canada (DWDC), an advocacy group that supports Canadians with their end-of-life decisions, which include assisted dying. Afterwards, they approached CEO Shanaaz Gokool for advice on starting their own process. “They looked like characters off the show Dynasty from the ’80s,” Gokool remembers. “But they were just really beautiful people.” While it is tempting to romanticize their nearly three-quarters-of-a-century partnership, it’s important to remember they were also in pain. “It’s easy to get lost in the romantic nature of the story,” Gokool says. “But couples that age together, they also suffer together.”
DWDC supports people wanting to access MAID and advocates on their behalf. As the Brickendens navigated the process, Gokool would join them for dinner and cups of tea at the retirement home where they lived. She watched them finish each other’s sentences and joke with one another—a family trait. They would also flirt with each other like a young couple, Gokool recalls, with Shirley patting George’s chest, him calling her “darling.” She also witnessed their decline.
The ambiguity of the requirements for MAID were not in George’s favour. Shirley had multiple illnesses and was in a lot of pain, and she had been approved without issue, but one of the two doctors who assessed George was unsure whether he was sick enough to qualify. George didn’t have one specific diagnosis that would make his death imminent. What’s more, he had a sharp sense of humour. Pamela remembers the day the doctors visited the house for an assessment, and her father wandered over to a corner of the room and lay on his back, something he did often to ease his pain.
“What are you doing?” Shirley demanded.
George was rejected—and Pamela believes her father’s dry and macabre humour was a factor in the decision.
A doctor’s fear is well founded. Should a physician be found to have unlawfully aided in a suicide, criminal penalties are severe. Besides any emotional strain or moral qualms, physicians risk jail time in addition to civil legal actions and sanctions from the College of Physicians if the patient is later found to have not met the requirements for MAID. The vague definitions of the criteria for MAID therefore become the biggest source of uncertainty. A reasonably foreseeable death can be difficult to define.
In the case of couples, it is difficult to line up a situation where both partners are eligible. “That’s why it doesn’t happen as often, because of the eligibility criteria,” says Gokool. A couple’s ability to die with dignity side by side therefore comes down to luck. If one is not sick enough, the plan fails, yet neither must to be too ill so as to not be able to consent the day of. If one fails to qualify, the other must decide to continue to live in suffering or leave the world without their partner.
George’s rejection stalled the couple’s plan to die together. But he was still dealing with ongoing heart problems and was suffering from fainting spells. In early February 2018, Angela recalls receiving a text telling her that Shirley was in hospital with a broken hip, and the next day, she heard her father was in hospital with a potential heart attack. It ended up being influenza, and after he was released, the kids took turns sleeping on the floor of the retirement home apartment, giving George his medication every couple hours and helping him recover. Shirley was working doubly hard at rehab so she could get home to George. “She was in a panic,” says Pamela. After eight nights, it was the longest they had ever spent apart. Soon after, George was reassessed by another doctor, and the couple finally received the go-ahead to plan their “flying away.”
DWDC is advocating for more inclusive eligibility criteria, specifically, the organization opposes the rule that a patient must consent to MAID again moments before their death. They argue that allowing individuals the ability to give advance directives would stop Canadians from planning their deaths too far in advance out of fear they might lose their mental capacity any day.
More flexibility would make it easier to apply the criteria to a wider variety of situations but might further spook physicians by expanding the legal, and ethical, grey zone. The difficulty is matching what Canadians want for themselves and what legislators deem right for society. A 2016 poll conducted by DWDC found that 80 percent of Canadians believe patients with a serious illness should be able to make advanced requests for physician-assisted dying.
“What I hope,” says Angela Bishop, Bob and Noreen’s daughter, “is that there’s a card, like your donor card,” she says. “We sign a donor card—why can’t we sign a death card?” Canadians should have the option to plan to be given MAID after reaching a certain point of decline, she thinks, no matter their mental state. “Why can’t you have a box you check?”
The fear of dementia and losing the ability to choose such an ending, the exact circumstance that poses the most risks is, ethically, a focus of the public conversation around MAID. “What if you don’t seem to be suffering, you don’t seem to be unhappy, but you meet all the conditions you set out in your advanced request five years ago?” asks Jonathan Breslin, an ethicist and University of Toronto professor. The danger is in the specifics—what if, in this mentally feeble state, you start struggling as the doctors attempt to carry out your wishes? Can you trust a family member to make the moral call to go ahead with your past wishes? What exactly will the conditions on your advance directive be? When you can’t dress yourself? When you no longer recognize your loved ones? “Should we be putting people to death who aren’t visibly suffering and can’t say, ‘Yes, I’m ready, put me to death’ because of something they said years ago?” says Breslin.
While Canadians grapple with these questions, the stakes are high. Gokool has worked with individuals who have not met the criteria for MAID and have flown to Switzerland, where foreigners can legally access right-to-die services—for a steep fee. Others she worked with have taken their own lives after not being approved, and then there are people who lived after a suicide attempt. “Those are hard, hard cases,” she says.
The Bishops and the Brickendens were so resolved on leaving the world together that both sets of children were concerned about what would happen if they weren’t able to die with medical assistance. “I was always worried,” says Chris. “They talked about it for years, saying, ‘We want to go together.’ So I’m thinking, Well, the only way you can go together is if you do it yourself.”
Shirley and George Brickenden were also set on leaving the world together, and if one or both didn’t qualify, they talked about how they could do it themselves. “We had real conversations with them,” Pamela says. But there was always the possibility of things going wrong. “The eligibility criteria and the legislation is too restrictive,” says Gokool. People in severe pain can end up living decades because their illness, disease, or disability does not predict an imminent death, something she believes is unconstitutional.
At the least, Gokool believes we should advocate more for advance care planning. “Who’s going to be making those decisions if you can’t make them yourself?” she says. “How do we take all of this and empower ourselves?” One way is by speaking to family and friends about what we want and what we don’t want in our final days, including do-not-resuscitate orders and palliative care. Only a small number of Canadians will have access to assisted death, but we can all plan some of how we are going to die.
Two months after Bob and Noreen Bishop died, on a sunny Sunday in May, Sir Sam’s ski chalet was bustling with people who had come to celebrate the couple. “We needed to do something for us and for people whose lives they touched,” said Chris. They needed to look back. Old friends and neighbours chatted in groups, drank beer and wine, and milled about inside and on a deck that faces the ski hill, green with grass.
The Bishop children greeted guests and shared anecdotes of their parents. “They used to say, ‘If you’re going to throw a party, throw a PARTY!’” Chris said with a belly laugh before wrapping the next person in a hug and a greeting. People huddled around photographs of Bob and Noreen that date from before they were married until their final winter. They’re pictured in ski jackets and surrounded by their five children. An elderly woman pointed to a print of the two sitting on a bench, Bob’s arm around his wife as they laugh. “That’s my sister,” she said. “So strange they are gone, but what a lovely couple they were.”
People laughed and smiled and swapped stories about the pair and spoke about assisted death as an option. “Would you do it?” was a common question.
When the Brickenden children remember their parents, they often think back to the final days. On March 26, the eve of their day to die, at the same time as the Bishops were celebrating their own lives, Shirley and George Brickenden said farewell to a gathering of close relatives. They had a cake that read, “We love you” on the top. There were toasts and many group photographs.
Everything was prepared for the next day: a bed made, two flowing caftans altered to fit Shirley and George’s small frames perfectly, a playlist of their favourite songs meticulously designed by their son Saxe.
The next day, they spent time with family, eating more lobster and filet mignon and drinking champagne. As the sun went down, the two donned their caftans and looked at each other.
“Are you ready?” Shirley asked her husband.
“Whenever you are, darling.”