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Harriet Maclean at her partner's bedside in the ICU ward at Sunnybrook Hospital. Rheo Eybel was diagnosed with Glioblastoma, an aggressive form of brain tumour. (Moe Doiron/(Moe Doiron/The Globe and Mail))
Harriet Maclean at her partner's bedside in the ICU ward at Sunnybrook Hospital. Rheo Eybel was diagnosed with Glioblastoma, an aggressive form of brain tumour. (Moe Doiron/(Moe Doiron/The Globe and Mail))

Critical care: Spending 10 weeks with patients facing death Add to ...

This is part of the Globe's in-depth series on the agonizing decisions surrounding end-of-life care in the 21st century. For the complete series, click here

Rheo Eybel was singing Brown Eyed Girl, gazing at his own brown-eyed partner on the dance floor. He was trying to ignore the karaoke singer on stage belting out the Van Morrison song – he’d gulped down enough liquid courage to get up and dance, but there wasn’t enough beer in the world to get him in front of a microphone.

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Later that night in July, Mr. Eybel and his girlfriend, Harriet MacLean, walked back to the income property they were renovating that summer in Guelph, Ont., a half-hour north of their home in Fergus.

Mr. Eybel’s neck had started to ache. Whether he had hurt himself working on the house or at his job making truck parts, he couldn’t be sure. But a week later, the legs that had been dancing with abandon were going numb. By the month’s end, he wasn’t feeling a thing when he urinated.

“I knew then,” he said later, “that I was in trouble.”

That trouble was confirmed in a biopsy in Toronto on Aug. 1, when spine surgeon Joel Finkelstein opened Mr. Eybel’s neck to find “the most aggressive tumour possible of the spinal cord.”

And just like that, Mr. Eybel, then 44, faced a death sentence: A glioblastoma had infiltrated his spinal column, rendering him a quadriplegic. There was no effective treatment, no cure.

Placed on a ventilator in the critical-care unit at Toronto’s Sunnybrook Health Sciences Centre, Mr. Eybel could not speak, yet decisions on how and where he was to die were being rushed at him with urgency. He had quickly given Ms. MacLean his power of attorney.

The news was devastating. “I don’t know what we’ve done so wrong,” said Ms. MacLean, a straight-talking woman with a blond bob.

Nurse Bill Bisley, with blond spiky hair and a gold hoop in his left ear, tried to comfort her. These events were random tragedies, he told her, not the patients’ faults – he had seen that, in this unit, time and again.

So had everyone in the critical-care centre at Sunnybrook, the hospital with more intensive-care beds – 120 – than any other site in Canada. Here, death is a constant, almost routine event, claiming one in five patients who enter. Yet few who come to units like this have given advance directions, written or verbal, about how they wanted to be cared for in the event of a crisis.

For two-and-a-half months, a Globe and Mail reporter and photographer were granted unique access to one 20-bed unit here. They followed the cases of four patients and their families especially closely, both in the unit and for months afterward: Some had made decisions in advance and others had not, but all faced choices they could hardly have imagined before.

It is an increasingly vital matter for all Canadians. Historically a place for those who’d suffered traumatic injuries, this kind of unit is becoming a more universal place of last chances. Cancer patients, the frail elderly and those with progressive, underlying diseases are going out not with a bang but with the bleep, bleep, bleep of machines – the 21st-century way of death.

Too few of us talk about the consequences of our tendency to seek high-tech interventions, even in the face of Canada’s aging population: How much treatment is too much? When do you withdraw life support – “pull the plug”? And who decides?

“I worry that as we have put medicine out there as a potential saviour and, in fact, almost a new religion over the last 100 years,” said Rob Fowler, one of about 20 critical-care physicians here, “people have increasingly bought what we’ve sold: that cancer can be beaten and every death is a preventable death – that every death is, in some way, a failure.”

In Mr. Eybel’s case, he had to decide whether to move to a palliative-care unit, where he would receive relief for his pain and other symptoms and be allowed to die a natural death. To do so, he would need to sign a Do Not Resuscitate order, commonly known as a DNR, agreeing not to be revived should his heart stop. Mr. Bisley took Mr. Eybel outside in his wheelchair, along with Ms. MacLean, to weigh this issue.

The subject seemed at odds with the sunny summer’s day. The cicadas and the midafternoon traffic were so loud, it was hard to hear. No one wanted to say the word “death” aloud. Ms. MacLean touched Mr. Eybel’s arm and said, “I know you know.”

He couldn’t speak, but he mouthed the words, “I have to put things in order.” He refused to authorize the DNR, and stayed “full code,” meaning he wanted everything medically possible to keep him alive while he pondered his future.

It may have been a question of too much too soon. “You are trying to accept your mortality,” Mr. Bisley said, “and it’s scary as hell.”

They returned to his room. Mr. Bisley had already obtained a doctor’s permission to give Mr. Eybel something he keenly wanted but thought impossible in a hospital – a cold beer. The nurse syringed liquid from a chilled can of Canadian, then pushed it through Mr. Eybel’s nasogastric tube.

Mr. Eybel was able to pick and choose which treatments he wanted – pain relief, a comforting beer – and which he would forgo, such as radiation. Others seek last-ditch medical efforts of little value, believing they may be the long shot that pays off. Even Mr. Eybel was seeking a second opinion.

No one can be sure how long they will live, not even doctors, and it is hard to give up hope.

Searching for a voice, through the respirator’s forced silence Each day, the physicians here go on medical rounds, discussing patients’ conditions in a shorthand of numbers, letters and vital signs.

Families can stay and listen, and sometimes witness life-saving acts of cardiopulmonary resuscitation. In person, this place can be more intense than any TV medical drama.

An electronic pass, a long corridor and three sets of stainless-steel doors take you inside, where doctors and nurses cut arteries and vessels in patients’ necks, heads, groins and arms and transform them into highways for monitoring and medication.

These patients are so ill, some of them so lacking in response that, unless a doctor shows you, it can be hard to tell if they are alive or dead.

A catheter in the groin helps the heart pump blood; a tube down the nose into the stomach provides nutrition. A tube monitors blood flow and another tracks swelling in the brain.

One machine universal to all is the mechanical ventilator, a breathing apparatus that distinguishes critical-care patients from all others.

Its use today might seem indiscriminate to the Danish inventors who created the first manual version in 1947-48, as the polio epidemic ravaged Europe and the United States.

Today, it can keep alive patients for months, even years, who would otherwise die without it.

A ventilator means living either in an institution or under 24-hour supervision. One patient at Sunnybrook remained in critical care for 1,176 days (more than three years) before death – the average stay in a Canadian intensive-care unit is just over four days.

Some patients are placed in open areas for easy access to the nurses’ station, while others are moved to the more spacious rooms with windows at the far end of a corridor.

Bonnie Isacovics, a patient with multiple sclerosis, was placed near the entrance. A loss of consciousness and fever had forced Ms. Isacovics, 54, into the hospital in late May. She came to the critical-care unit in July to be treated for pneumonia.

Before that, she had been living at home in North York, Ont., with her teenaged daughter, Beatrice, and her husband, Morty Goldmacher, along with two paid caregivers and her dog, Denis, who would sit at the foot of her wheelchair.

Long ago, in 2002, she’d had to leave behind a job she loved dearly and held for 15 years, running a rheumatology research laboratory at the Hospital for Sick Children.

But Ms. Isacovics had soldiered on with MS for 14 years, adjusting to a disease that had attacked every part of her body but left her intelligence intact.

Though locked into a body that no longer worked, she could still make treatment decisions. She could not speak on the ventilator, and MS had made her hands unable to write, but she could nod, mouth words or spell things out by pointing to the black alphabet letters on a white, plasticized board that was provided to her.

Dr. Fowler was at her bedside and discussed options. The main goal would be to have her live without the ventilator, but that was appearing less likely, as her left lower lung lobe was in the habit of collapsing every four or five days.

There was a program at another hospital that could train her family and caregivers to manage her condition, so she could eventually go home, but the waiting period to enter it was up to six months.

Would that be too many months to stay on the ventilator? She nodded. Was two months too long? She nodded again. One month? Ms. Isacovics shrugged her shoulders.

She was moved to a semi-private room on the third floor, and her bed was placed next to a big window that looked over hospital grounds; the tile ceiling above her was painted with a forest.

But no matter how inviting the hospital tries to make this unit, it is an institution. Staff members go home to their lives and families settle into visiting routines, but patients stay on their ventilators, sleeping or staring at the ceiling. It may not be much of a life, but it’s theirs.

To help doctors and nurses see these patients as something other than inert, mute bodies in beds, many have “Get to Know Me” sheets taped to the wall next to them: Ms. Isacovics’s form said she liked Bob Marley, ballet, bridge and swimming; she loved mystery novels and on TV, Dr. Phil, The Ellen DeGeneres Show and the medical show House.

Her family said she had adjusted admirably to the difficult MS diagnosis. She had a happy domestic life, although as in all marriages there were tensions: Ms. Isacovics always had made her job the priority, and couldn’t care less about food, bringing the same lunch to work for 15 years, a cheddar-cheese sandwich on whole wheat and an apple. While Mr. Goldmacher was a family lawyer, also a demanding job, he insisted on the home-cooked family dinners he made for the three of them every night.

Whenever he lamented that she had never cooked, she would remind him that she made meatballs in 1986 – or was it 1987?

Initially, Mr. Goldmacher had expected her to get over this hospital episode quickly and be home. Now, he didn’t know what to expect. “I had no idea that MS can have this kind of effect on your respiratory system,” he said.

But if life in the long term meant being on a ventilator, Ms. Isacovics wanted no part in it. When a reporter asked in late July what she wanted, she pointed to letters on her alphabet board: “D-E-A …” She paused.

“Are you trying to spell out ‘dead’ ?”

She nodded. A tear rolled down her left cheek.

In a report on end-of-life decision-making earlier this month, the Royal Society of Canada noted that although competent adults want to be involved in making decisions about their care, most fail to complete advance directives or communicate their preferences to family members or significant others.

That’s certainly what they see here at Sunnybrook.

“Among patients coming to hospital and to the ICU,” Dr. Fowler said, “it is much less common that patients have had the detailed discussions with their families and physicians needed, to help know the extent and for how long patients would want to receive aggressive, life-supporting care.”

At least Ms. Isacovics could make her own treatment decisions.

Still, there was no hurry: She needed to sit with it for a while, see her family and wait to find out if, just maybe, she could get off the ventilator.

What she hadn’t counted on was Linda Nusdorfer, an advanced-practice nurse, who roamed the corridors of critical and cardiac-intensive care,functioning as a fairy godmother – granting wishes to those who are on a ventilator, typically for 21 days or more.

By the time she gets to them, she said, most patients feel “very discouraged.” Some have lost the will to live.

Often, their requests are surprisingly simple: ice chips to suck, and eyeglasses or hearing aids to be brought in from home. Ms. Isacovics, however, wanted to feel the summer sun outside with her family – including her dog, Denis.

The plan would require a respiratory therapist to manage her oxygen, plus a personal-service worker to help push her wheelchair, along with Ms. Nusdorfer.

When the day came, Denis arrived in the lobby; his white, floppy ears looking almost long enough to mop the floors. When he was placed on Ms. Isacovics’s wheelchair, his excited, sloppy licks suggested a fond remembrance.

Outside, in front of the hospital, on a green area with trees near the cenotaph, Ms. Isacovics leaned back in her wheelchair, basking in the sun, a smile on her face.

Her daughter, Beatrice, 17, stood near her mother’s wheelchair, watching her, and said, “It feels like home.”

That was the day, it seems, that Ms. Isacovics decided that if she could ever get out of here, she wanted to live after all. A well-laid plan and a leap of faith Betty Pritchard made her choices for the end of life long before they were needed. Only three paragraphs long, her statement from Aug. 4, 1994, left no doubt about what loved ones should do if she wound up in a place like this, with an injury like hers.

“If at such time the situation should arise in which there is no reasonable expectation of my recovery from extreme physical or mental disability, I direct that I be allowed to die and not be kept alive by medications, artificial means or ‘heroic measures,’ “ said her typed, one-page letter, found in a purse in her Brantford, Ont., apartment.

“I do, however, ask that medication be mercifully administered to me to alleviate suffering, even though this may shorten my remaining life.”

On July 18, it was Ms. Pritchard’s third day at Sunnybrook. A heat alert had just been lifted, but the weather outside the window remained impossibly warm, at odds with the raw suffering of the patients inside. Hospital chaplain Klara Siber, a calm voice for many under duress, walked over to bed 40 and introduced herself. She had been sent by Ms. Pritchard’s son to pray with her.

“I didn’t get a sense of her response until I said the Lord’s Prayer,” Ms. Siber said. “I could see her nodding and trying to mouth the words.”

Ms. Pritchard was a religious woman with a religious son – a minister. She had told him she had known from the time he was in the womb that he was destined to be a man of the cloth.

She was a social woman too – a grandmother who stayed in touch with friends on Facebook, was on the executive of her seniors group, was active in her church and was excited to have passed her driver’s-licence renewal at the age of 86.

What had brought her here was a sideways fall down a flight of stairs at a relative’s home in Toronto, caused by a drop left foot due to the polio she had developed when she was a small child. Her fractured neck left her quadriplegic and on a ventilator, with an uncertain future.

That Monday morning, Dr. Fowler was about to begin leading medical rounds with a roving posse of specialists, specialists-in-training and medical students. Of the three paths to becoming a critical-care physician – two years of training on top of a specialty usually in surgery, anesthesia or internal medicine – he had taken the latter, ending up here at Sunnybrook, a long way from his primary-school years in a two-room schoolhouse in rural New Brunswick.

He stopped at Ms. Pritchard’s bed to hear the nurse describe her condition, then noticed the patient was awake and alert. Even though she was paralyzed and could not speak through the ventilator, she could nod her head and blink her eyes. He touched her arm and leaned into her face, telling her that he knew she could hear him, that he knew the tube was unpleasant and that he would try to make her as comfortable as possible.

Her son, he said, had told him what treatments she did and didn’t want. They would respect her wishes. Would it be okay for her son to advise him on that? She replied with a vigorous affirmative nod.

Around 5 p.m., her son, Rev. David Pritchard, minister of Grace United Church in Niagara-on-the-Lake, Ont., was in the critical-care meeting room, hurriedly flipping through his address book, calling relatives across Canada. He referred to this spot as the “room of tears,” the place where doctors break bad news. This time it was his turn: Life support, Mr. Pritchard told family members, was going to be withdrawn.

“To me, this isn’t a hard decision. If mom said that, then that’s what she wanted,” he said. “To be trapped in a body where she can’t express her feelings, that would be torture for her.”

Ms. Pritchard’s nurse, Lukshmi Perampalamoorthy, sat at a desk at the end of her bed, penning in vital signs on a huge sheet every hour. Before she left for home that evening, she had one more thing to prepare for the evening nurse – to measure out the morphine that, among other drugs, would be used to help ease the patient off life support.

She took her usual 30-minute walk home, thinking about Ms. Pritchard.

“I had personal feelings of anxiety, of not knowing is this the right thing, is this a good thing. There’s always that: What if things could have improved more?” she said, adding that even when a patient’s wishes are fulfilled and there is no disagreement, a death can still feel unsettling.

Family from Guelph, Niagara-on-the-Lake and Calgary gathered around the bedside. Tears rolled down Ms. Pritchard’s cheeks. The tube was removed. Her son, anticipating a long night, went back to the family room to call more relatives.

She died in 10 minutes.

The next morning, there was an empty spot on the white board next to bed 40, where Ms. Pritchard’s name had been erased. Ms. Perampalamoorthy sat at her desk, in front of the empty bed, looking forlorn.

Later, she would tell Mr. Pritchard, “I’ve never seen something handled so beautifully.”

Though Ms. Pritchard’s directive was crystal clear, many others are limited: They are written too abstractly, with family members left still wondering which exact treatments would be acceptable.

“Patients usually construct them in a state of health and perspective that can be very different from the one proximate to the final stages of life,” Dr. Fowler pointed out. “It is important that such directives not be static and final, but fluid and responsive to the changing situations that patients inevitably encounter.”

A century ago, heart attacks, strokes, kidney disease, flu and pneumonia took people swiftly. Today, cancer is the No. 1 killer, followed by heart disease. Many others die of accidents, chronic respiratory diseases and what could be called frailty, with multiple chronic conditions.

Fred Franklin came to Sunnybrook with a medical emergency. There was no time to debate the finer points of quality of life in a 90-year-old man with a suspected bowel obstruction and aspiration pneumonia – a condition that meant he was breathing in his own vomit.

“We had been very clear, we wanted no heroic technology,” said his wife, Ursula Franklin. “Our wish was that the quality of life would be the determining factor.”

For Mr. Franklin, the quality of most of his life had been measured by bridging differences and furthering social justice, bringing him in contact with refugees, prisoners and other disadvantaged groups. That was what mattered to him. By the time his son, Martin, got to the hospital that day, Aug. 7, this was not the active father he had seen just weeks earlier.

“When I left the bed and went outside, I basically fell apart. It was incredibly overwhelming when you see someone that active, then see them that non-responsive,” said Martin, a Grade 4 public-school teacher.

Over the next several weeks, he kept track of his father’s progress in a book, noting the most minuscule of improvements. One entry said he now required 80 per cent oxygen instead of 100 per cent; another stated his white-blood-cell count was up, suggesting that he was fighting an infection.

“There’s so much hindsight involved. If we knew then what we know now, our decisions might be different,” Martin said later. “Doctors are there to save lives – they are not there to give you a window of opportunity on when to end it.”

The Franklins had a physician help them craft a DNR that left no room for misinterpretation: If Mr. Franklin’s heart stopped, he would not be resuscitated, though he would be provided relief.

“I would think, given the choice, the family will prefer him to die with dignity,” Martin said, “rather than to be kept alive by machines and end up bedridden.”

Yet in a somewhat surprising turn of events, Mr. Franklin made a significant recovery in recent weeks. Today, he is at a rehabilitation hospital and expected to be discharged home in early December. He has been given a reprieve, at least for now.

“I can see that he’s happy,” Martin said. “He needs to work to live. It will be a success if he is able to be somewhat functional – if not, it will be a wasted life. I don’t think a life where you are sustained by machines is good for anyone, not the patient and not the family.”

Intensive care takes a long-term toll Quality of life is a personal measure. It is a moving target that changes with time and circumstance. Brian Cuthbertson, chief of critical care at Sunnybrook, studied 300 patients who had been admitted to a hospital critical unit in Britain, and discovered that compared with others their age, even five years later they had higher death rates, remained notably weaker and had more trouble carrying out daily-life activities.

And yet they weren’t very old (the median age was 60.5 years) and hadn’t stayed very long (the median was 6.7 days). What Dr. Cuthbertson concluded, in a paper published in the journal Critical Care last year, was that a stay in an intensive-care unit should be treated as a lifetime diagnosis, requiring ongoing health-care support.

“The mistake some people make is [to think]that there is no human cost of going to intensive care and having all these treatments,” he said.“When we’re talking about whether someone is going to get better, it’s not just about will they survive to leave an intensive-care unit, to leave the hospital, but will they have a quality of life that they want and will accept.”

Some patients suffer from depression, anxiety and post-traumatic-stress disorder long after they have left. Being in the ICU usually means “a very slow, prolonged recovery period,” Dr. Cuthbertson said, “and indeed many patients will never get back to the quality of life that they had before they were critically unwell.”

That’s why, instead of keeping critical patients heavily sedated, they are now kept more awake, sat up in bed and exercised more, in hopes of offsetting those long-term effects.

It’s also part of why many people are asking which interventions are worth making, and which come at too great a cost.

“One of the great challenges of modern medicine,” Dr. Cuthbertson said, “is not saying, ‘Can we?’ but ‘Should we?’ “ The issue of how much treatment is too much is debated in medical journals, but it is also a pressing issue of national importance.

Intensive-care beds are extraordinarily expensive to operate, about $1-million a year in many hospitals. Such costs threaten the very sustainability of our health-care system if not kept in check.

Those who have not given written or explicit verbal directions to relatives may find themselves in critical-care units, unable to stop very aggressive treatments of marginal benefit, as families push for them simply because they feel it’s the safest default position.

Yet few of us expect that moment to come, except perhaps elderly people with complex chronic conditions.

Traumatic brain injuries are another common reason patients land here – car accidents, falls or other traumas. Physicians such as Damon Scales see in a day what many may not see in a lifetime, and the job has given his family new rules for living: “There’s no ladder climbing over age 50. At our cottage, everyone jumps in feet first,” not head first, he said. “There are no motorcycles, no drinking and driving.”

But for Ki-Don Kang, 54, it was the mere everyday act of going down the stairs to a restaurant-basement restroom, after a night of singing karaoke, that led to a fall and a brain injury that rapidly progressed to brain death.

Now his son, Jeffery, had a problem: His brother and mother were in Korea and he wanted them to see his father, even if he was only being kept biologically alive through the use of machines.

“How do I keep the body here one more day? That was the main thing,” Jeffery said. Then he figured out a way: organ donation. He signed his father up, not meaning actually to go through with it.

The following day, Aug. 21, Mr. Kang’s wife was able to see him, just as the son had wished, lying in bed amid monitors and machines flashing red numbers of vital signs.

But the organ-donation issue remained. The family talked for hours, and finally agreed that Jeffery’s loving, giving father would have wanted to donate. His heart, two kidneys and liver were removed to be transplanted into other patients.

Hours later, Mr. Kang’s youngest son, Justin, arrived from Korea: ”I just looked at him. He was really cold. I touched his hand, then I started to bawl my eyes out like crazy,” Justin said. “I really, really wanted to at least say my goodbyes.”

A superbug setback, but the will to go on remains A few weeks after her day in the sun, Bonnie Isacovics faced new trouble, in the form of a antibiotic-resistant superbug called NDM-1 that was making headlines around the world.

Andrew Simor, head of microbiology and infectious diseases at Sunnybrook, labelled it a “bad player” – in hospital patients, it can cause significant urinary-tract and other infections, as well as pneumonia and bloodstream and wound infections that are very difficult to treat.

Endemic in India, there are about two dozen cases across Canada; Ms. Isacovics is currently one of two patients at Sunnybrook who is carrying the organism, though she is not infected with it.

This meant further isolation: Every one who went into her room had to put on mask, gloves and gown, so as not to spread it to other patients.

By this point, Ms. Isacovics had accepted that she would need the ventilator long-term, but was hoping she would need it only at night.

Because of the long wait for the program at the other hospital, Sunnybrook began arranging its own training for her family and caregivers, to teach them to suction a tracheotomy (a surgical opening through the throat into the windpipe). They’d need a hospital bed, suction, home ventilator and supplemental oxygen. But she could be home by late December or early January.

At a meeting in late August, Dr. Fowler reminded her that if she gets sick again, with a bad pneumonia, she would return to the ICU. He wanted to make sure she dictated the kind of treatment they would provide.

“Everybody fully appreciates you are able to call the shots here,” he said through his mask. “Even though your muscles aren’t so strong right now, your mind is super-sharp. We appreciate your direction here.”

Her husband, Morty Goldmacher, said he thought his wife could still find value in the life she has left. “She can still get some enjoyment, some pleasure.”

Earlier this week, Ms. Isacovics was excited to be on the path to returning home. She had come a long way from that day in July that she expressed a wish to die. She wanted to say something. The alphabet board was taken from the windowsill and placed on her wheelchair table.

Her two right fingers searched for the letters. She spelled out: H, then O, P, E.

What has been joined, let no one put asunder Rheo Eybel was eventually able to develop different muscles to help him breathe, and to get off the respirator, though he is still in a wheelchair, unable to walk. He described his three weeks on the machine as a living hell, in which he was trapped inside his own head.

“It’s just beyond words really,” said Mr. Eybel, now 45. “If I had to do that, even for another two weeks, I wonder if I would have gone insane. … I can’t even explain how lonely, lost and how very scared you feel when you can’t voice your opinion and you’re on these stupid machines.”

After some days’ contemplation, it became clear to Mr. Eybel what he should do, and that was to get as close as possible to home in Fergus, a place of rolling hills, a quaint downtown of grey stone buildings, a gorge and his family.

Even the small community hospital seemed an institution of decades past – an elderly, bespectacled gentleman with a blue volunteer’s vest stood in the lobby, studying a newspaper; a sign said the gift shop was selling ice cream for 75 cents; the cafeteria worked on the honour system.

It was at this hospital that Mr. Eybel met The Globe again this fall, dimples on each cheek framing a toothy grin, his long, thinning grey hair pulled back into a ponytail.

He was now able to move his shoulders and arms, and he could talk, though he kept his tracheotomy intact, just in case: He had been warned that his tumour could grow back and climb into his brain or go down to his diaphragm and stop his breathing again.

Remembering his panic and anguish when he was first diagnosed in August, he said, “My will to survive surprised me.”

He and Ms. MacLean had five kids between them – two from her past marriage and three from his. After his divorce, he had never been keen to remarry. But now, with a limited time to live, it was all he could think about.

There was also a practical reason: They had property and assets together, and he didn’t want any disagreements about who was owed what among relatives.

And so on Oct. 1, more than 50 people packed into their family home in Fergus. Trucks parked on the gravel side road. Some people gathered in the barn, others in the house, and a few on the deck looking out over the sprawling farm, where fall had brought bales of hay.

Ms. MacLean put on a dressy skirt and flowered suit jacket, and was having her makeup done just outside the kitchen so that Mr. Eybel could not see her. Friends made a cake, a sister brought a bouquet and others brought trays of meat, vegetables and pasta.

“To make her feel whole, that will make me feel whole,” Mr. Eybel said minutes before the ceremony, wearing a yellow dress shirt beneath his brown, fleece jacket with a white boutonniere. “She’s got something missing and I’ve got something missing; that ‘happy wife, happy life’ idea. … I expect that I will have better luck this time.”

His doctor has told him that he is stable and may live up to another year.

There’s a distant, even more positive hope too: Mr. Eybel was accepted for a clinical trial in Texas, with a targeted therapy for his cancer, although travelling would risk his health.

As for that pesky DNR, he got around to that too. “I had to sign something,” he pointed out. If he has a heart attack, he won’t be revived – but he has no plans to go, at least not yet.

“I just thank God every day. I just thank Him for another day,” he said.

And he thinks back to dancing with Ms. MacLean, his brown-eyed girl, and now his wife.

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