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I hadn't spoken of the PAS to anyone except my mother and daughter. Although completely legal, I feared potential judgment, and possible intervention, due to the controversial nature of PAS. No matter how much Kirsten and I wanted to confide in our friends for comfort and encouragement during this difficult time, we kept silent. My mother did not disclose her intentions to anyone at the AL facility, especially the management. I regretfully lied to the local friend, saying the passport was needed to take my mother on one last trip to Poland, her birthplace. Reinstating the passport became the first of several lengthy, arduous undertakings due to complicating factors, including that her driver's license, needed for identification, had recently expired. After four trips to the DMV, she finally had a current passport.
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Dignitas' reply came at the end of August. They requested minor revisions to the lettersâ€"easy. They said the medical reports were not in the correct format and different ones would be neededâ€"difficult. And, because one of the older reports mentioned depression, they required a letter attesting to her mental competence and signed by a psychiatristâ€"nearly impossible.
First the easy part. Tweak the letters and re-submit. Then the harder part. Figuring out what was wrong with the medical information I'd spent months compiling. After several emails where I sought clarification on the medical 'certificates' required, Diana, the case worker, said I had gone to unnecessary effort compiling hospital and specialist reports. My older primary doctor reports were acceptable. Only one comprehensive recent report was still required.
I made an appointment with a geriatric physician to obtain a new primary doctor's report. I traveled back east to take her to the appointment, as well as several other medical and dental visits. I gasped at the extent of her decline; barely able to walk, even with a walker, consistently out of breath, failing vision and hearing, and anxiety about being left alone even for a few minutes while I pulled the car around. The dental appointment offered a reprieve; the dentist's manner kind and comforting, sharing stories about her dogs to distract my mother from having a tooth pulled.
The geriatric specialist became skeptical when I informed him of the specific information required for the evaluation. If I told him about the PAS, would he refuse to help? He didn't know our diligence to assure legalityâ€"what if he feared being implicated? Or had religious or cultural reasons to object? Steeling myself, I fabricated a story that we needed the report to transfer my mother to an AL facility in California near my home. He seemed not fully convinced, stating that they usually deal directly with the facility, but agreed.
After the appointment, we got in the car to return to the AL facility. I turned to her and helped her with her seatbelt. "You're sure you still want to go to Switzerland, right?"
She tested the belt. "Yes, I'm sure. But it will never work."
I looked her in the eye. "Mom. I've been speaking to you practically every day. You know we're almost done with the process. Please stop worrying."
She stared back through rheumy eyes. "If you say so."
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By mid-October, almost seven months since we joined Dignitas, I was back home tackling the psychiatric reportâ€"the final hurdle. Or so I thought.
Dignitas' review of my initial submission contained a concern with one of the older medical reports. It stated that the report's mention of antidepressants could be interpreted as a sign of reduced or impaired judgment in relation to my mother's wish to die. Although there had been no previous relevant guidance from Dignitas, and the antidepressants were prescribed by a primary doctor without making a diagnosis, we would now need a psychiatric determination.
I emailed Diana:
Dear Diana,
I understand, but in my mother's case, she has never been diagnosed with depression. A year and a half ago she told her GP she was unhappy, and the GP prescribed Sertraline to see if it would help. The medication did not help and was discontinued. Our most recent report from the geriatric specialist confirms she does not exhibit signs of depression.

Dear Michelle,
Unfortunately, to complete the medical file and request for an accompanied suicide, Dignitas requires a medical report signed by a psychiatrist, and no older than three months, confirming capacity to understand, and decision-making ability. The decision-making process should not be influenced by third parties, medication, or psychological impairment.
I couldn't believe it. I was now expected to find my mother a psychiatrist, wait several months for an appointment, figure out how to get her to frequent visits, and wait however long for the doctor to become familiar enough with her to write that she was not depressed and was of sound mind and capable of making her own decisions. Meanwhile, the geriatric report would expire in a couple of months.
I had to speak with Diana. She only worked mornings, so I set my alarm to 2:00 a.m., 11:00 a.m. Switzerland time, and called her to discuss the issue. "My mother has never sought psychiatric care. The more recent medical reports show she was not experiencing depression, only anxiety. Since a GP prescribed, and shortly discontinued, the medication in the first place, can't another GP affirm it's not needed?"
Diana heard me out, but said "Unfortunately, the government rules are non-negotiable."
After a long stress-and-frustration-induced cry, I wracked my brain and recalled that a psychiatric nurse had made rounds at the AL building, visiting with my mother. I phoned the nurse who remembered my mother, consulted her notes, and agreed she had full mental capacity. Still afraid to share the real reason for the request, and needing to justify specific wording required, I reiterated the previous story of finding my mother a living facility closer to meâ€"one that did not accept residents with mental impairment. Lying never got easier, but what choice did I have?
The nurse provided me with a signed statement. Tension flowed from my body as I emailed the letter to Diana and got my first good night's sleep in weeks. The next morning, I opened my email
Dear Michelle,
Unfortunately, in Switzerland, nurses' reports have no value. A physician's signature is required.
Trying not to panic, I contacted the nurse again and asked if a psychiatrist in her office could also sign the letter. She tried, but the doctor refused, stating he was unfamiliar with the patient. My fingernails dug into my palms. Didn't he trust his own nurse's evaluation? Even if we pursued another psychiatrist, would they agree that a ninety-year-old woman having suffered from two strokes and of normal age-related mental capacity, was of sound mind?
I again set my alarm for 2:00 a.m. and called Diana. I argued that trying to place my mother under psychiatric care, to prove that she doesn't need it, would be quite prohibitive. Was my mother really going to lose her right to die based on having once tried an antidepressant that was shortly discontinued? Diana discussed our case with her supervisor and responded the next day.
My hands shook as I opened the email.
Dear Michelle,
Unfortunately, the letter signed by a psychiatrist is required.
I sat with my head in my hands feeling helpless and wishing for someone to talk to about all this. Desperation tempted me to consider forging the psychiatrist's signature beneath that of his nurse. I paced the kitchen floor. Would I fail at fulfilling my mother's last wish, and perpetuate her torment, or commit a forgery that no one would ever know about?
I called the nurse and beseeched her to try once more to get the psychiatrist's signature.
"Just a minute, he's here. I'll ask him."
My heart pounded in my ears, my mind racing to come up with options. Maybe the psychiatrist would agree my mother was technically already a patient of his practice, see her without the long waiting period and corroborate the nurse's determination? But would he sign based on a single visit? And if he refused and I forged the signature? Did the Swiss government call to check on these things? A dull headache pounded at the base of my skull. I paced some more on shaky legs.
The nurse came back on the phone.
My every muscle stiffened.
"He signed. I'm emailing it to you now."
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The first week of November 2022, I was elated to receive Diana's next email.
Dear Michelle,
All documentation is in order. Requesting 4,000 CHF for next steps. Attached: checklist of original or reissued documents needed (specific to country of origin).

The checklist requested several forms of identification for the patient and spouse, deceased for over 40 years in my father's case. I would now need to provide my mother's birth certificate and my father's death certificate, neither of which I had.
Dear Diana,
My mother emigrated to the U.S. when she was four years old. Her family fled the Nazi invasion of Poland, and her birth certificate was lost. She has always used her Naturalization papers instead. I'm assuming I can send those?
Dear Michelle,
Unfortunately, no. A reissued birth certificate is essential for identification purposes. Attached is a list of Polish attorneys who can assist you.
Great. I contacted one of the Polish attorneys, and for a reasonable fee of about $150, she initiated a search for the birth certificate. If found, one would be reissued, and if not, a legal statement that it had been destroyed would suffice. The process could take up to six weeks. I only had seven more weeks until the psychiatric note and latest medical certificate expired. The attorney agreed to expedite for a small additional fee, with no guarantees.
If only Dignitas had given me a heads-up, I could have started working on the birth and death certificates months ago. The organization provides only the information needed at each stage of approval since an applicant may not choose to proceed or may fail to provide the necessary documents. The difficulties I experienced locating older documents will not apply to everyone. But I believe there is no downside to supplying the full requirement list up front and have made that suggestion to Dignitas.
Neither my mother nor I had my father's death certificate, issued in 1980. I remembered the name of the funeral home only because it was a fixture in the town where I grew up. I contacted them and learned that records from the 1980s had not been saved electronically. They directed me to the County, who informed me that retrieving a copy was not a problem and shouldn't take more than five weeks. My ID and my paternal grandparents full names, including my grandmother's maiden name, were required as proof of the requestor's identification.
Retrieving the death certificate presented two problems. First, I had expedited my mother's birth certificate to prevent other documents from expiring and now I was right back with the same issue. Second, I never knew my paternal grandfather, and my paternal grandmother had long since passed. I found their full names on my parent's marriage license, but my grandmother's maiden name was not listed. My mother didn't know it and there were no living relatives on his side of the family. I was stuck.

Dear Diana,
Is there any way around this requirement? I can't believe my mother will lose her opportunity to die with dignity, even after all our efforts over the past six months, because we cannot produce the maiden name of a woman born abroad over one-hundred years ago, changed her surname twice through marriages, and who died half a century ago."

Dear Michelle,
In the case of a widow/widower, proof of the spouse's death is unfortunately required.
I grabbed a pillow from the couch and screamed into it. My mother needed me to do this one thing for herâ€"help her carry out her final wish. I'd tried my best and failed. After half a year of stress, trouble sleeping, and difficulty concentrating at work, I couldn't take one more "unfortunately."
I braced myself to tell my mother the PAS was not going to happen. It's one thing to have a "failure-is-not-an-option" attitude, and another to know when you're beaten. I reached for my cell and it rangâ€"a woman from the County. She had the funeral home on the other line and among the three of us managed to verify my grandmother's maiden name. The relief of the last obstacle falling away flooded my body. Two weeks later I had both my mother's birth certificate and my father's certificate of death.
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In late November, I received a few more basic forms to complete. A separate letter stated that the Swiss government had past difficulties identifying the deceased from photos alone, and therefore requested dental records. I recalled the kind dentist my mother and I had seen during my last trip to New Jersey and didn't hesitate to request the records.
The dentist phoned me the next day. "Has your mother found a new dentist? Where should I send the records?"
I sighed. "Please just email them to me in the format I requested, if that's okay."
"That's very unusual. We never send this type of record directly to the patient. What do you need them for? Perhaps I can send you something else?"
I hesitated. Exhaustion weighed heavy on my mind and body. But this had to be the last hurdle. "As you know, she's not doing well." I swallowed. "My daughter and are taking her to Switzerland for an assisted suicide. They need dental records for identification."
"I'm so sorry. I'll send these right over."
"Thank you so much for understanding. I've been afraid to tell any of her other doctors, or really anyone."
She clucked her tongue. "We give this consideration to our pets when the time comes. It's a crime we don't show people the same kindness."
I wiped a tear from the corner of my eye. The warmth of her solidarity brought me hope and confidence that others, too, would understand and support my mother's decision.
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A few days before Christmas, we received "conditional green light" approval; all the documentation and payments had been accepted. I booked travel for my mother (round trip, in case she changed her mind), my daughter, and myself, and scheduled the required Swiss physician's appointments. Our first appointment was one day before our most recent medical document would expire.
I phoned my mother, anticipating her relief. "We're all set. I booked our trip for January sixth. We've got an Airbnb that looks very nice. Kirsten and I will pick you up in New Jersey and we'll fly out there together."
She hesitated. "I don't know about this."
"I'm confused. What don't you know about?"
"All of it. I don't think we're really going for an assisted suicide."
"What are you talking about? We've been working on this for nine months. Where do you think we're going?"
"I believe we're going to Switzerland. But what if they don't accept us and you abandon me there?"
My gut tightened. "Why would I possibly want to do that?" I knew her anxiety and the weight of helplessness was flaring, but how could she believe me capable of abandonment? And that her granddaughter was in on it? "Would Kirsten agree to that?"
"No, I guess not. But I don't think I'll go. Besides I don't have anything to wearâ€"nothing fits me."
My limbs felt heavy. "You have clothes. Kirsten took you shopping, remember? But it's okay if you've changed your mind." If we missed this opportunity, her physical, and potentially mental, decline would mean there would be no second chance. I knew she'd regret it. But if any part of her had reservations, it wasn't for me to talk her out of them.
"I haven't changed my mind and I want the assisted suicideâ€"if I believed it."
My shoulders slumped. "Okay. What do you want me to do?"
"Send me a copy of the round-trip tickets. And I'd like your emails with Diana. I can read with a magnifier."
She no longer used her computer, so I made copies of the airline tickets and emails and mailed them to her by overnight air.
I phoned her the next day. "Did you get the stuff I sent?
"Yes."
"Do you still want to go?"
"Yes." Her voice caught. "Thank you for doing this."
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My phone rang. I saw it was my mother and got ready to explain again: Kirsten and I will fly there, help you pack, and drive to the airport. We'll be with you the whole time. I answered the phone.
She didn't pause to say hello. "I told them."
"You told who what?"
"I told the assisted living manager."
My stomach dropped. "What exactly did you say?"