As a rural family physician, who delivers babies and cares for people from birth to death, I run in to all sorts of complex situations and people. I like working with end of life issues and dying patients. It isn't that they are nice or that they are fun; the patient may act out and the whole family may act out and usually does, but they are real. There is no social mask. The whole family becomes deeply themselves during extremity. I am one of those people who tends to not understand social masks and am clumsily disrespectful of them, so working with people in extremis is a huge relief.

One of the most extreme was a pregnant woman. She was not my patient. She belonged to my partner, but I was the one who was on call each time she came in. She was in her second trimester. She would come to the hospital bleeding. Not just a little blood, but, as we say, hosing. She would bleed enough in an hour that we would have to transfuse her.

But the baby was alive.

She was bleeding vaginally. The edge of the placenta had lifted and would spontaneously bleed. She would bleed suddenly, with no warning.

I was always the person on call.

The third time she came in, we were transfusing 4 pints of blood. She had bled heavily and quickly. The fetus looked completely fine on the monitor.

The fetus was also not quite 20 weeks. The earliest possible survival is 22-23 weeks and then the odds are extremely high of severe disability: cerebral palsy, blindness, permanent lung damage, all of the above.

I had had it. I called the perinatologist, knowing in the back of my brain what they would say.

"End the pregnancy."

"But she is second trimester."

"Doesn't matter. Send her to us. She has a huge chance of dying. End it. Transfer her now."

She wasn't my patient, but she knew me a bit by now. I went back in the room.

"I talked to the high risk obstetrics doctor about you. A perinatologist. I am very sorry, but they recommend ending the pregnancy. Terminating. If you don't end the pregnancy, you have a very high chance of bleeding to death and you will both die."

"You are trying to kill my baby! I won't kill my baby! I won't let you!"

"I am trying to keep you from dying. You have two other children. Are you going to take the risk of dying to try to keep this one?"

"No! I won't do it! You can't transfer me!"

"I won't do anything against your will."

"You can transfuse me!"

"No. We can try, but if you bleed at the rate you did today for more than half an hour, we would not be able to keep up. We can't put blood in you fast enough. You would die."

"Get out!"

I did. I went down the hallway. I knew I was telling her what she had to hear. Also, that she totally hated me and that that was sort of okay. I was telling her something awful. A deadly choice. It was truly her choice. What I wanted was to be sure that she was really choosing.

I waited and at last went back.

She glared at me. "You can't make me kill my baby."

"I just wanted to ask, to be sure you are making the right decision. How does this pregnancy feel to you?"

Her face stilled for a moment. Her eyes changed from glaring at me to an internal look. Slowly her face crumpled and her eyes filled. She started crying. "Terrible," she whispered. "Terrible. It feels wrong."

"Then WHY," a whispered snarl, "aren't you LISTENING to that?"

She just looked at me and at the same time was looking inside.

"Transfer me." She said, "Transfer me. I will end it. I don't want to die. My girls need me.

I called the perinatologist and the helicopter. I said goodbye. I cried a little when I hugged her goodbye. I told her she was brave. She was sure at that point. No question, no hesitation.

I do think it was the right decision. I was so frightened that she would bleed to death and I truly think she would have. Yet if she had refused, I would have documented and accepted it. I would have tried to transfer her to a bigger hospital and kept her on bed rest, but she could have refused that too.

She has since had another child.