A Bitter End, part 1: The very old man who wanted to die

In print, this story was split across more than one issue because of its length. Online, we've split it into six chapters: 

1. The very old man who wanted to die
2. The hospice
3. The overdose
4. The pro-life coroner
5. The strange prosecution of Barbara Mancini
6. The legal land mine, undefused

Or you can read the story as a single page. 

Part 1: The very old man who wanted to die

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One thing that nobody disagrees about: Joseph Yourshaw wanted to die.

“He talked about it to anyone who would listen to him,” says his daughter, Barbara Mancini, 58. “He said he didn’t want to be a burden on my mom, he didn’t like living like that, he didn’t like being old, he hurt all over.”

Mancini, an emergency room nurse, lives in Roxborough, two hours away from her parents’ home in Pottsville. She helped her father with the official parts of the big decisions he made about his end-of-life care — helping him make a living will and a Do Not Resuscitate order (DNR) in 2010, when he was 91, and serving as his health-care power of attorney.

Her father would often tell her that he wanted to die, she says. “I usually wouldn’t say anything, I’d just listen to him. I’d say, ‘I know, Dad. I know you don’t like living like this.’ What am I going to say? ‘I know it’s hard for you.’”

The constant talk of death was rough on Yourshaw’s wife, Marguerite, who was 83 at the time. “But he needed to say it,” says Mancini. “He said it to me, he said it to anyone who came in the house.”

He certainly said it to employees of the Hospice of Central Pennsylvania — their notes on Yourshaw from periods in 2012 and 2013, when he was enrolled in their home-care program, read like a broken record. Under the heading Most Important to Patient Now, hospice workers wrote, over and over: “Pt [patient] wants to die,” “pt states he is ready to die,” “just wants to die.” His DNR is also noted in every entry.

Records from Yourshaw’s first hospice stay in spring of 2012 note that he was refusing to take any medicines for his high blood pressure or diabetes, and that “he is trying to ‘will himself to die’ by refusing to eat, take meds, etc. ... Pt. appears to be trying very hard to die a.s.a.p.”

But he couldn’t seem to die.

So he tried a little harder. A few weeks after his enrollment, HCP charts note that Yourshaw, a model diabetic who’d eschewed bread and spaghetti for decades, had “drastically increased his intake of sugar (in the form of candy) in last 1-2 weeks.” Most Important to Patient Now, April 4: “To have his wishes respected.”

But Yourshaw still couldn’t seem to die. In fact, his condition was deemed stable enough to leave hospice in June 2012.

So he tried a little harder. When Yourshaw returned to HCP care in mid-January 2013, he was doing a lot worse. Charts note that his diet now consisted of “mostly sugar foods such as candy and soda.” Soon, he was sleeping 18 to 20 hours a day, waking up to lug himself to the bathroom and to eat more candy. Jan. 30: “Again states that he doesn’t know why he can’t die.”

So he tried a little harder. And this is where people start disagreeing.

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On the morning of Feb. 7, 2013, after a year and a half of trying to die, Joseph Yourshaw was done waiting. While his wife was out to lunch, he told his daughter he was in pain, and asked her to hand him his hospice-prescribed bottle of morphine. She did. Yourshaw swallowed what remained in the small bottle. He and his daughter then talked for a while. Eventually, he fell asleep as she held his hand. “I just sat there with him,” says Mancini. “I was not about to call and take him to the hospital, because he never wanted to go to the hospital for anything. He made that clear to all of us.”

But, even then, Yourshaw couldn’t seem to die.

He woke up in an emergency room a few hours later. A hospice nurse had stopped by the house, and his daughter had briefed her on what had happened with the morphine. “I didn’t think I had anything to hide!” says Mancini. “It didn’t even occur to me to concoct a story, or not to mention it.”

Mancini had explained to the nurse that her father wanted to die, and that he had a DNR on file. To her shock, the nurse called 911, and the police and paramedics arrived. “I told them, ‘He asked me for his morphine, and I handed it to him,’ and they said, ‘Well, let’s go to the hospital,’” says Mancini. Despite her pleading, Yourshaw was loaded into the ambulance and taken to the hospital. “I said, ‘He’s suffering! He wants to die!’ And that got turned into, ‘She gave him his morphine so he could die.’” That phrasing appears many times in official documentation of what happened.

“So he gets taken off to the hospital; I get taken off to the police station,” says Mancini. As she was being booked on charges of causing or aiding suicide, her father was being given a dose of Narcan, a drug designed to counter heroin overdoses in addicts. The hospice records note: “Pt responded by awakening within 30 seconds of receiving the Narcan. He was able to talk and he kept saying over and over —‘Don’t let them hurt Barbara.’” The ER records note: “After Narcan given, pt. became very active, pulling off gown, trying to climb [out of bed], pulling at heart monitor, mitts applied.”

Says Mancini: “He’d obviously heard what was going on in the house. He was livid. My sister-in-law said she’d never seen him so angry in 30 years.”

Immediately after Yourshaw was revived, a hospice worker, for once, got a different answer from him than his usual wishes for death. Most Important to Patient Now, Feb. 7: “Wants to see Barbara and make sure no one hurts her.”

When Mancini was released by police and arrived at the hospital, though, she was barred from visiting her father in the ER. By the time she was able to see him that night, she says, “His eyes weren’t open; he wasn’t talking or anything. I mean, I said things to him; whether he heard me or not, that’s anybody’s guess.”

In the hospital, Yourshaw developed bedsores, a rash where he’d been catheterized and pneumonia. He hung on for four days — possibly the first time in a year he’d been trying to live rather than die, aware as he was that his daughter could be in serious trouble over his death.

Joseph Yourshaw finally managed to die on Feb. 11, 2013. But his daughter’s problems were just beginning. His death was ruled a homicide, and the state hit Mancini with felony charges that could have resulted in a 10-year prison sentence. And though the case against her was so flimsy that it was thrown out before it went to trial, the Pennsylvania Attorney General’s Office pursued it aggressively.

On Feb. 11, 2014, the anniversary of Yourshaw’s death, Schuylkill County Court of Common Pleas Judge Jacqueline Russell granted Mancini’s petition for habeas corpus. Her written opinion contained harsh words for Kathleen Kane and the Pennsylvania Attorney General’s Office: “As the case presented to the Court would not warrant a submission to a jury due to the lack of competent evidence elicited by the Commonwealth” and “reliance on speculation and guess serving as an inappropriate means to prove its case.”

But an extended prosecution can make even such a slam-bang ruling feel like a Pyrrhic victory.

“The case was dismissed, but I’m going to be dealing with the fallout from this for a long, long time,” says Mancini in an exclusive interview a few months after the ruling, as she was about to return to work after nine months of unpaid leave. “My defense cost $104,000. I’m a nurse, my husband’s a paramedic. We’re not wealthy.” Major death-with-dignity nonprofit Compassion & Choices contributed $20,000 from its legal defense fund, Mancini says, but it’s still a lot. “I’ve got a child in college and a 16-year-old who wants to go to college someday, so …” She gives a pained laugh. “I’m going to be 58 in a couple days, and my husband’s 57, and we think that we probably won’t retire, ever.”

But that’s not what bothers her the most. “I will be forever haunted by the way my father’s life ended,” she says. “He suffered tremendously in the hospital. Not only physically — the anguish that he died with knowing that I was in trouble because of him asking me to hand him his medicine. … I cannot imagine I’ll ever get over that.”

It seemed very much like Mancini and her lawyers had been prepared for an appeals-court battle challenging the constitutionality of the “causing or aiding suicide” statute under which she was charged. But the flimsiness of the commonwealth’s case against her caused the charges to be dismissed before it even went to trial. The vague wording of the law that caused Mancini’s hellish year is still unaddressed, which means everything that happened to Mancini and her father — the felony charges, the year of prosecution, the debt, the overruled DNR, the prolonged death, the horrible memories — could easily happen to another family.

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“He could build anything, and he could fix anything,” Mancini says of her father. “He could do anything. My mom likes to say that she never had to call a repairman for anything until the last year of my dad’s life. And he was really smart, very opinionated. Hated Ronald Reagan. He was a champion for the regular guy. Read a lot of periodicals.”

Joseph Yourshaw was, above all, fiercely independent. When he retired from contracting in his late 70s, he hadn’t had a boss in nearly half a century — his last one was in World War II, where he was awarded a Bronze Star for bravery for repairing bombed-out tanks on the front lines during the Battle of the Bulge.

Mancini says that her father got a little forgetful in the last few years of his life. But his mind was clear, and he’d never been diagnosed with dementia or anything that would make him incompetent to make his own decisions about his end-of-life care. In October of 2012, between his first and second stints in hospice, the Pottsville Historical Society interviewed him about his WWII Army experiences. “He described at length where he served, the tanks he worked on, all kinds of stuff, in great detail,” says Mancini. “I never understood that stuff, but if someone was mechanically inclined, they could spend hours talking about how all these engines worked.”

Even after retiring, he renovated and did repairs on a five-acre property the Yourshaws had bought in Florida. “He rebuilt the deck around the pool. He knocked out a brick wall and put these decorative windows in. He’d get up on the roof. He did the entire cement driveway by himself,” says Mancini.

“Here’s something funny that gives you an idea of what kind of guy he was — when he was 83, he was down in Florida and Mom was up in Pottsville, and he called her and told her she needed to come down and bring him some crutches because he’d fallen down a couple times and hurt himself,” Mancini says with a laugh. “So she gets in the car with my brother-in-law and they start to drive down to Florida with these crutches.

“So I call my dad, ask him what’s going on, and he told me he couldn’t walk right and had fallen down a couple times. I say, ‘Dad, you need to call 911 and get to the hospital, you might be having a stroke.’ And he’s, like, ‘No, no, I’m fine, I just need your mother to bring me the crutches.’” I tried and I tried to convince him, but he wouldn’t do it.” Eventually Mancini called his doctor, who was able to talk Yourshaw into calling 911. “He packed a suitcase, locked up the house, went out into the driveway and was sitting there with his suitcase when the ambulance got there. And he’d had a stroke. That was the kind of guy he was. He wanted to do everything himself. He didn’t want anybody’s help.

“He was convinced that he would be healthy because he was always very physically active and ate a decent diet and worked hard. He thought he was immune to getting anything because of his lifestyle. He didn’t have much regard for people who just sat around all the time,” says Mancini. Toward the end of his life, “when he physically became like that, it was very difficult for him. Some people wouldn’t mind that, but he minded it a lot.

“And he was also in pain — all those years of physical labor take a toll. He had arthritis throughout his body,” as well as complications from diabetes and problems with his kidneys and heart. But he still insisted on cleaning the oil burner until he was 91.

“He was 92 when he decided he wasn’t going to do this anymore,” says Mancini. Yourshaw went to his doctor in October 2011 and told her he was done with taking his diabetes and blood-pressure medications. His family was sad, but respected his decision. “I feel very strongly that a person should have the right to make the decisions that affect the intimate details of their lives,” Mancini says. “I probably feel that way because he felt that way, and my mother feels that way, and that’s what I was raised with.”

Though religion is a big factor in many people’s end-of-life decisions, it wasn’t in Yourshaw’s. For decades, he had been a staunch atheist. “He’d go on and on about it,” Mancini laughs. “He talked about his lack of belief a lot. … He was raised Catholic and had a very difficult upbringing — he was one of 12 children in a very poor family, and I think that was a big influence on how he felt about religion.”

When Yourshaw stopped taking his medicines, Mancini started driving the two hours to Pottsville more often to help out. “I would go up once a week, because I was working, I have two children.” After a flu in December prevented Mancini from driving up a couple weeks in a row, she brought up the idea of hospice care.

“I normally am a person who does a lot of research,” says Mancini, illustrated by the 4-inch-thick, neatly annotated binder of papers and records relating to her case on the table in front of her. “I’ve advocated for family members when they’ve had health issues, and I try to find out as much as I can about things beforehand. I didn’t do it with this.” Mancini often sounds furious or outraged about the past few years. Here, she sounds like she’s in real pain.

When she couldn’t find resources to judge the comparative quality of hospices — at the moment there’s no standard, and hospices use different methods of assessment that aren’t easily comparable — Mancini just went with the recommendation of her father’s primary-care physician. She suggested the nonprofit Hospice of Central Pennsylvania, one of the biggest in the state.

“I thought I was doing the right thing. And I just assumed that when we engaged a hospice, they were gonna do the right thing. That was a really bad judgment flaw on my part.

“I believe that this would not have happened at all if this hospice had done what they were supposed to.”

>>> Continue to part 2: The hospice.