Vatican City is an anxious place. Clergy keep their phones by their pillows. Reporters, crammed in the Holy See press office, open emails with trepidation. Faithful have begun to gather expectantly in St. Peter’s Square.

All await terse bulletins from the Vatican on the condition of Pope Francis, who remains critical after being taken to a hospital 11 days ago with bronchitis that developed into pneumonia in both lungs. On Monday afternoon, hours before the Vatican reported a “slight improvement,” the phones of Vatican officials buzzed with texts falsely reporting Francis’ death.

Francis, who now has the beginnings of kidney failure and infections, may yet recover. On Tuesday morning, the Vatican said in an 8-word bulletin that he had rested well through the night. But the prognosis is not promising, doctors say. For veterans of papal transitions, the daily health bulletins, the influx of global media, the rampant speculation and the special prayer services have a familiar and ominous feel.

“These are delicate moments,” said Duban Corredor, a 27-year-old seminarian from Colombia, who came to St. Peter’s Square on Monday night to pray the rosary for Francis, who he noted had always concluded his conversations and remarks with an appeal to “pray for me.”

The seminarian said he had assisted Francis during a Christmas Eve prayer service and saw him deeply tired, but also at peace. “I don’t think it will be long — I think he’s preparing for a moment of tranquillity, knowing that this is the end of his life.”

On a damp Monday evening, Cardinal Pietro Parolin, the Vatican’s second-in-command, who is a fixture in the increasing speculation about who might replace Francis, led cardinals, bishops and a few thousand faithful in front of St. Peter’s Basilica in a rosary prayer for the pope’s health.

Under an intermittent drizzle, the cardinal knelt before a portrait of the Madonna and child and addressed the crowd, made up largely of priests, nuns and pilgrims.

“For 2,000 years the Christian people have prayed for the pope when he was in danger or sick,” said Cardinal Parolin, adding that now the time had come to pray for Francis “in this moment of illness and trial.”

Francis is the 266th pope to lead the Roman Catholic Church, and for much of the church’s history, especially when the papacy acted as a monarchy directly and indirectly governing large swaths of land, the death of a pope could transform the fortunes of powerful aristocrats, change the direction of a powerful state, or even determine where the church had its headquarters.

“The upheaval that follows the death of the pope today is incomparably different from what might have happened” centuries ago, said Agostino Paravicini Bagliani, a church historian. He said that in some cases a pope’s death would be kept a secret, for fear that a papal entourage, or at times even the population of Rome, might ransack the Apostolic Palace. “A papal death provoked all sorts of problems.”

In the modern era, long after the pope lost his temporal powers, transitions have run more smoothly. Now a change at the top, while having great consequence for the priorities, vision and ideological complexion of the church, is unlikely to have much geopolitical impact. Still, the last days of a pope attract pilgrims, and news media, from all over the world to Rome, and they focus the faithful’s attention on their spiritual leader.

Cardinals said the rosary before the passing of Pope John XXIII in 1963. It was during a similar prayer session in St. Peter’s Square in 2005 that Cardinal Leonardo Sandri, then the under secretary of state for the Vatican, announced the death of Pope John Paul II after his final days of agony.

The once vigorous Polish pope had long suffered from Parkinson’s disease: He had lost his ability to speak clearly and often appeared hunched and ailing. His failing health had been a subject of morbid attention for years.

“It was so weird,” said Father Paul Alger, a 42-year-old priest from Augusta, Ga., who studied theology in Rome and recalled those years as a perennial papal death watch.

Francis, who initially speculated that he would have a short pontificate, has instead led the church for a dozen eventful and busy years. For the first years, he crisscrossed the globe, met with world leaders and played an active role in championing the issues he cared most about, especially on behalf of migrants and the marginalized.

But a bad knee and sciatica began to physically slow Francis down more recently. He began to depend on a cane and a walker and then a wheelchair.

Francis had colon surgery in 2021 and was operated on again two years later for a hernia that developed because of that surgery. Throughout, he kept up a demanding schedule, but his breathing became belabored, as he struggled with respiratory infections and now an explosion of pneumonia and infections that has put him in critical condition.

The faithful and clerics in attendance on Monday preferred to focus on Francis’ life rather than what seemed the end of it. Bishop Manuel Nin, the apostolic exarch to the Greek Byzantine Catholic Church, called it “unhealthy” to fixate on something that was ultimately “in God’s hands.”

But some clerics worried this latest downturn could be Francis’ last.

“They say he had a good night, he is resting, but at the same time it is clear his prognosis is not good,” said Bishop Earl Fernandes of Columbus, Ohio, who also attended the rosary in St. Peter’s Square. “It’s the beginning of the end.”

Bishop Fernandes, who said he follows “the news about the pope in multiple languages every day,” speculated that even if Francis were to get better, it would be harder for him to be around people, something Francis “always loved,” he said.

“That itself would kill him,” the bishop added.

A solemnity pervaded St. Peter’s Square, rain slicked the cobbled stones and the faithful chanted invocations to the Virgin Mary. A pair of swooping gulls cawed. In the surrounding palaces, private speculation about who might replace Francis began, ideological camps taking shape. But the event provided a public forum for the church’s leaders, of all political persuasions, to rally around the pope in his time of need.

Among the cardinals beside Cardinal Parolin on the steps of St. Peter’s Basilica on Monday evening were prelates who often appeared on short lists to replace Francis, including Cardinal Luis Antonio Tagle of the Philippines. But there were also cardinals with whom Francis has clashed for a decade, including the American Cardinal Raymond Burke, the de facto leader of the opposition to the pope’s agenda.

“When someone is dying, all that is said and done,” Father Alger said, comparing the church to a family that rallies around a dying father no matter the divisions at home. “He is the Holy Father and he is in trouble. Death has a way of making clear what matters.”

As the commander of a rebel group allied with Al Qaeda during Syria’s long civil war, the man known by his nom du guerre, Abu Mohammed al-Jolani, welcomed foreign jihadists, dispatched suicide bombers to blow up military posts and vowed to create an Islamic state.

A decade ago, he told a journalist that Muslims should not enter Parliament to swear on a man-made constitution because they had to respect “the rule of God Almighty.”

The same commander became Syria’s new president after a rebel alliance he led ousted the strongman Bashar al-Assad in December. He broke with Al Qaeda years ago and now goes by his real name, Ahmed al-Shara. He has swapped his military fatigues for suits and has embarked on a charm offensive to convince foreign leaders and his fellow Syrians that he can repair his shattered country and lead it toward democracy — or something like it.

“If democracy means that the people decide who will rule them and who represents them in the Parliament, then, yes, Syria is going in this direction,” he told The Economist in an interview published this month.

The sharp contrast between Mr. al-Shara’s jihadist past and his pragmatic, nationalistic present has left Syrians and foreign officials wondering what he actually believes and how he will govern a critical country in the heart of the Middle East.

On Tuesday, his interim government is holding a national dialogue with hundreds of attendees that organizers say seeks to build consensus around the nation’s political and economic future. But some key groups, like the U.S.-backed Kurdish militia that controls the country’s northeast, were not invited.

Many Syrians, exhausted after 13 years of civil war, say that whatever he does will be better than the misery and destruction wrought by Mr. al-Assad. Syrian critics who distrust his Islamist approach charge that beyond his conciliatory rhetoric lies a sinister past that he has not clearly renounced.

Since he emerged as Syria’s new leader, senior Arab and Western officials have visited him in Damascus or hosted him in their capitals to press him on issues they care about, including combating Iranian influence, limiting Russia’s military presence, shutting down illegal drug exports, cracking down on violent jihadists and ensuring the rights of women and religious minorities.

Some of those officials have said privately that they are impressed with Mr. al-Shara’s inclusive messaging. But few have promised what he needs most: financial aid to bolster Syria’s economy and kick-start reconstruction, and the lifting of harsh sanctions imposed to punish Mr. al-Assad. On Monday, the European Union agreed to suspend restrictions on Syrian banks and energy and transport sectors, as well as to extend measures to facilitate humanitarian aid.

One factor hindering foreign engagement with his government is that the United States and other countries, along with the United Nations, still classify the rebel group he led, Hayat Tahrir al-Sham, or H.T.S., as a terrorist organization. Some countries still classify him as a terrorist, too.

Barbara A. Leaf, a senior State Department official for the Middle East during the Biden administration, was among the first U.S. officials to meet Mr. al-Shara in Damascus, the Syrian capital, in December. She said in an interview that he had clearly come prepared to hear what the United States had to say — and to respond.

“I found him to be a very methodical thinker with a strong degree of pragmatism,” Ms. Leaf said.

She said it was unclear how much his jihadist background still shaped his views as the leader of a newly liberated country desperately seeking international recognition and support.

“Either he is just a great actor or he has a kind of spongelike personality that takes on both experience and the context that is shaping the larger environment and adjusts his own thinking to it,” she said.

Mr. al-Shara faces tremendous challenges. The war killed more than 500,000 people, according to most estimates, forced millions more to flee abroad and decimated entire communities, leaving many refugees with no homes to return to.

His government is seeking to create a national army to absorb Syria’s many militias, but some are resistant to joining and control significant territory and resources like farmland and oil.

Many Syrians were widowed, orphaned, maimed or traumatized during the war, and war monitors have reported vengeance killings across the country. To salvage what he can of the state, Mr. al-Shara has called on civil servants to keep working, but salaries are meager, the economy is feeble, and electricity is limited in many homes.

Even before he was named president last month during a closed-door meeting with allied rebel leaders, Mr. al-Shara was working at home and abroad to rebrand both Syria and himself.

He has toured Syrian provinces and met with representatives from the Christian, Alawite and Druse minorities. While Islamist in outlook, his government has not banned alcohol or imposed dress codes on women.

On foreign trips, he has catered his message and attire to his hosts. To meet Crown Prince Mohammed bin Salman in Saudi Arabia, he wore a green tie; to meet President Recep Tayyip Erdogan in Turkey, he wore a red one — the colors of their flags.

Many conservative Muslim men keep their wives out of public view, but Mr. al-Shara’s spouse, Latifa al-Droubi, appeared with him for the first time during a pilgrimage in Saudi Arabia. On a subsequent trip to Turkey, Ms. al-Droubi met with Mr. Erdogan’s wife, Emine.

He has spoken cautiously of Israel, which has occupied territory in southern Syria, calling on it to adhere to a decades-old truce along the countries’ shared frontier, and of Russia, even though its military backed Mr. al-Assad and heavily bombed rebel communities. He has lashed out at Iran, which also backed the former regime, but has said that Syria will pose no threat to its neighbors.

His contact with the Trump administration appears to have been limited. But in a recent interview for the podcast “The Rest Is Politics — Leading,” he praised President Trump for his interest in “peace building” and his “positive approach to both the Middle East and future U.S. policy in the region.”

Mr. al-Shara’s critics accuse him of telling whoever he is meeting what they want to hear while eliding his extremist background and some of his associates’ violent records.

One of the rebels who appointed him president, Ahmad al-Hayes, was a commander accused by the United States of overseeing the torture and killing of detainees, the trafficking of women and children, and ransom and extortion schemes.

Another supporter, Mohammad al-Jasim, stands accused by the United States of commanding forces who displaced residents to seize their property and kidnapped people for ransom, “likely generating tens of millions of dollars a year.”

In 2017, Mr. al-Shara’s rebel group set up a “Salvation Government” to administer territory it controlled in northwestern Syria. After Mr. al-Assad’s fall, Mr. al-Shara brought that administration to Damascus to serve as the country’s interim government until March 1, when a new government is supposed to take over. Elections cannot be held for three or four years, he has said, because Syria is in such disarray.

The current government is made up of Mr. al-Shara’s loyalists. Some members have been with him since his jihadist days, and the health minister is his brother.

Many Syrians have been horrified by videos shared on social media of the justice minister, Shadi al-Waisi, presiding over the street executions in 2015 of two women for prostitution and “spreading corruption on earth.”

The media relations office of the new government did not respond to request for comment.

Extremists still influenced the government only a few months before it moved to Damascus.

Last August, hundreds of athletes gathered to kick off a local version of the Paralympic Games in northwestern Syria, and the organizers lit a giant torch. Ultraconservative clerics accused the participants of worshiping fire, a sin in Islam, and the local government suspended the games, citing “transgressions” that “violate our culture, customs and traditions.”

Fuad Sayed Issa, the founder of Violet, the group that organized the games, said in an interview that officials in the government had apologized for the cancellation but that they were afraid of what the extremists would do if they went forward.

Mr. Issa was optimistic now that the government was in Damascus and Mr. al-Shara was expressing more openness.

“We now feel that things are going better,” he said. “The leader has an open mind-set and they are taking Syria to a better place.”

Mr. al-Shara’s allegiances changed repeatedly during the war. He came to Syria from Iraq with the support of the Islamic State, but later broke with the group. He pledged allegiance to Al Qaeda before announcing a break with it, too, in 2016.

His original group, the Nusra Front, battled and allied with other rebels over the years and rebranded itself twice, becoming H.T.S. in 2017. In the years since, Mr. al-Shara has focused on governing the country’s northwest and has cracked down on extremists believed to be plotting attacks outside Syria.

Orwa Ajjoub, a doctoral candidate at Malmo University in Sweden who studies H.T.S., said Mr. al-Shara’s history suggested he was guided less by rigid convictions than by a quest for power.

“He has changed a lot, and he is genuine in this change,” Mr. Ajjoub said. “On one hand, there is a pragmatism that is encouraging and it gives you some hope. But on the other, the lengths to which he is willing to go to stay in power are scary.”

Three and a half decades after reunification, a line runs through Germany where the Iron Curtain once stood. Instead of barbed wires and dogs, that line now divides Germans by measures like income and unemployment — and increasingly by the willingness to vote for extremist parties.

If East Germany were still its own country, the hard-right Alternative for Germany, or AfD, which has been linked to neo-Nazis and is being monitored by domestic intelligence, would have scored a convincing win in the elections on Sunday, with nearly one in three voters there casting ballots for it.

Only two of 48 voting districts outside of Berlin in the former East Germany were not won by the AfD. In a handful of districts in the east, the AfD got nearly 50 percent of the vote.

That division — and the sense that Germans still to some degree inhabit two separate worlds, east and west — has become a persistent feature of Germans’ voting habits. It is one that was manifest not only on Sunday but also when Germans voted in elections for the European Parliament last June.

The divide, analysts say, reflects not only a failure to fully integrate the east, but also its unique problems and culture, shaped by decades of Communist rule during the Cold War and close alignment with Moscow and the former Soviet bloc.

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Soon after Russia invaded Ukraine, Taiwan’s leaders joined the United States and its allies in declaring solidarity with the victim. Taiwan and Ukraine were fellow democracies, they said, each imperiled by its hulking, authoritarian neighbor.

Now, President Trump’s turn against Ukraine could fan debate in Taiwan about whether it can count on American support in the event of a widening conflict with China, which claims the self-governed island as its territory.

“Taiwan spent the better part of the past three years making the case for how the fate of democracies is intimately tied and what happens to Ukraine affects Taiwan,” said Russell Hsiao, the executive director of the Global Taiwan Institute, which is based in Washington.

“With the seemingly abrupt change in the U.S. position on the Ukraine war,” Mr. Hsiao said, “this could have the effect of causing some in Taiwan to question whether the United States could pull the rug from underneath them.”

For decades, Taiwan has faced the possibility of invasion by China, which now sends fighter jets and warships nearly every day to probe its defenses. Taiwan’s ability to deter a potential attack hinges on whether the United States stands ready to help and even send forces. The island’s leaders have made closer ties with Washington a pillar of its foreign and defense policy for nearly a decade.

But as Mr. Trump executes a dramatic reversal of U.S. policy toward Ukraine, abandoning Western efforts to punish Russia for the invasion and insisting that Ukraine is to blame for the war, the United States’ partners, including Taiwan, are being forced to assess their own positions and weigh how to secure Mr. Trump’s support.

In Taiwan, Mr. Trump’s stinging comments about Ukraine could feed a current of public opinion arguing that the island has been repeatedly abandoned by Washington and cannot trust its promises.

“The prospect of the United States trying to make a deal with Russia over Ukraine, without actually giving Ukraine a seat at the table, will reinforce the sense of American skepticism in Taiwan,” said Marcin Jerzewski, the head of the Taiwan office of the European Values Center for Security Policy, which tries to foster cooperation between European and Asian democracies.

Some anxiety has surfaced on social media, with a few Taiwanese commentators suggesting that if war between China and Taiwan should erupt, Mr. Trump might take a similarly transactional approach. (Taiwanese officials have said that the Chinese government covertly amplifies skeptical online talk about Washington in Taiwan.)

On Sunday, dozens of Ukrainians and Taiwanese gathered outside the de facto Russian embassy in Taipei. “Russia is the aggressor,” one organizer said — a message tacitly, yet pointedly, aimed at Mr. Trump.

“If today he could abandon Ukraine — and I don’t know if he’s really going to abandon Ukraine — then could he also abandon Taiwan?” said Huang Yu-hsiang, a 23-year-old technician who was at the protest. “If they don’t care about values, that means they could abandon Taiwan, a consistent supporter of democracy.”

Mr. Trump does not appear to have a strong commitment to Taiwanese democracy. That has contributed to concerns that he might put Taiwan’s interests at risk if he negotiates a big trade deal with China’s leader, Xi Jinping, who has told Mr. Trump and previous American presidents that Taiwan is a key concern in their relationship.

For now, Taiwanese officials have been sounding a positive note about relations with Washington, taking care to avoid an open rift with Mr. Trump. At a security forum in Taipei last week, President Lai Ching-te cast Taiwan as a key player in democracies’ struggle against authoritarian powers like as Russia, China and Iran. But Taiwan’s statements of support for Ukraine have been measured lately, avoiding specifics about Mr. Trump’s decisions.

What does Taiwan think of the possibility that the United States might cut off support for Ukraine or force it to accept peace terms that favor Russia? Joseph Wu, the secretary general of Taiwan’s National Security Council and a former foreign minister, sidestepped the question at the same security forum.

“Serving in the Ministry of Foreign Affairs for six — for more than six — years, I know there are things I can say, and there are things I cannot say,” Mr. Wu said. He emphasized that Taiwan understood that it needed to strengthen its military. “Our own fate is controlled in our hands,” he said.

When President Vladimir V. Putin sent Russian forces rumbling into Ukraine in a full invasion three years ago, Taiwanese leaders had already been worried that Mr. Xi might feel emboldened to try something similar on their soil. He had overseen a harsh security crackdown in Hong Kong and a rapid buildup of China’s military.

Tsai Ing-wen, Taiwan’s president at the time, and her officials drew rhetorical parallels between Taiwan and Ukraine as they sought to raise public support for their policies, including more military preparations and the strengthening of ties with other democracies.

Invaders must not go unpunished, Bi-khim Hsiao, who is now Taiwan’s vice president, told reporters in 2023, when she was its chief representative in Washington. “We must ensure that anyone contemplating the possibility of an invasion understands that,” she said, “and that is why Ukraine’s success in defending against aggression is so important also for Taiwan.”

It was clear to Taiwan that Mr. Trump’s return to the White House would inject uncertainty into the relationship with the United States, even before his recent statements about Ukraine.

As a candidate for the White House and after taking office, Mr. Trump said Taiwan was spending far too little on its military and was too complacent about the United States coming to its rescue in a war. He also accused Taiwan of unfairly gaining dominance in the manufacture of advanced semiconductors for smartphones and other technology.

But Taiwanese officials and experts have said that, pressure from Mr. Trump notwithstanding, Taiwan is very different from Ukraine and more economically important to the United States. They argue that the Trump administration sees China as a more pressing challenge for the United States than Russia, and that Taiwan can be a loyal partner in that context.

Mr. Lai, Taiwan’s president, has been trying to head off any serious breach with Mr. Trump. This month, he announced that Taiwan would increase military spending to at least 3 percent of its economic output (up from about 2.45 percent this year). He also said the island — which has more semiconductor fabrication plants, or “fabs,” than any other place in the world — would come up with proposals in response to Mr. Trump’s demand that more such plants be built in the United States.

“From additional arms purchases and energy imports to semiconductor fabs in the United States, the Lai administration will have to come up with an optimal mix that can catch the attention of President Trump and make haste,” said Mr. Hsiao, the researcher in Washington. “Time is really of the essence for Taipei.”

Syria’s interim president called on Tuesday for unity and the rebuilding of his fractured nation during a two-day conference meant to chart a path forward after decades of dictatorship.

Hundreds of participants attended the long-awaited “national dialogue” to bring together the country’s many religions and sects in the Syrian capital, Damascus, on Monday and Tuesday. But at least one major player was absent: The Kurdish-led militia that controls much of Syria’s northeast was not invited.

“Syria calls on you to stand together in unity and cooperation to heal its wounds, soothe its pain and support its recovery,” the president, Ahmed al-Shara, said in an address to conference participants.

What is the national dialogue?

Arab and Western leaders have urged Syria’s new rulers establish a representative government that is inclusive of all religious sects and ethnic groups before they can fully restore ties with Syria.

Mr. al-Shara, whose rebel coalition overthrew the longtime dictator Bashar al-Assad and seized control of Syria in early December, had promised to hold a national dialogue to discuss the formation of such a government.

Syrian leaders have promoted the conference as the first step to drafting a new constitution for the country, which is likely to be a long-winded process that Mr. al-Shara has said could take as long as three years.

While the conference was long awaited — especially since the government had set a March 1 deadline to begin the process of forming a representative government — it was hastily arranged.

Invitations for the conference were sent out on Feb. 23, just one day before it began, to hundreds of participants, including community leaders, academics and religious figures.

Journalists, businessmen, activists, former detainees and some of the families of those who were killed or wounded in Syria’s 13-year civil war were also invited.

What about the Kurds?

Mr. al-Shara has spoken of the need to unite Syria’s many diverse groups to build a new nation. Syria is a Sunni-Muslim majority country, but has many religious and ethnic minorities including Alawites, Druse, Christians and Kurds.

Many in Syria, however, remain skeptical of the country’s new Islamist leaders, with some criticizing the lack of minority representation at the conference.

Attempts to unify all of these communities have already met significant challenges.

Some Kurds, who make up some 10 percent of Syria’s population, were invited to the national dialogue. But the Kurdish-led Syrian Democratic Forces, a U.S.-backed militia that controls much of Syria’s northeast, was not. Syria’s interim government has demanded that the militia disarm, and join a unified national military force, as a condition of joining the dialogue.

At the conference on Tuesday, Mr. al-Shara reaffirmed the need to bring the country’s web of armed groups under state control.

“There are those who seek to undermine the achievements of the Syrian people, and we must firmly confront anyone who attempts to tamper with our security and unity,” he said, without naming any particular group.

The committee organizing the conference has previously said that the Syrian Democratic Forces do not represent all Syrian Kurds.

Turkey, a close ally of Mr. al-Shara’s rebel group, has for years sought to curb the power of the Syrian Democratic Forces, maintaining that the militia is linked to Kurdish separatist insurgents inside Turkey.

What will come of the dialogue?

Many Syrians are skeptical about what a national dialogue may bring, especially in a deeply divided country where sectarian tensions are already spilling over into revenge killings.

Syrians are also wary of the promises of inclusivity coming from a government led by Mr. al-Shara’s Islamist group Hayat Tahrir al-Sham, which has given government and ministerial positions to its own loyalists. It has yet to include other rebel groups, which helped oust Mr. Assad, in the government.

The conference organizers have said that there is no direct link between the formation of the new Syrian government and the dialogue, though they are happening at the same time.

Conference participants are expected to issue recommendations on the new government, as well as on the writing of a new constitution and laws. But it appears those recommendations will be nonbinding.

“Recommendations from the National Dialogue will not be mere advice and formalities, but will be the basis for the provisional constitutional declaration, economic identity, and institutional reform plan,” said Hassan al-Dughaim, the committee’s spokesman.

One recent evening, Sandra Demontigny tried to write down when she would die.

“I sat down in a corner with a candle next to me, just to create my own bubble, to think and to cry a little,” she said.

She had reflected on this moment for years, desperately hoped for it, fought tirelessly for it. But the words refused to come out. The form before her remained blank. How, exactly, does one decide when to end one’s life?

Canada’s French-speaking province of Quebec last fall became one of the few places in the world to allow a person with a serious and incurable illness to choose medically assisted death in advance — perhaps years before the act, when the person still has the mental capacity to make such a momentous decision.

And Ms. Demontigny — a 45-year-old mother of three, diagnosed in the prime of her life with a rare form of early-onset Alzheimer’s — played a pivotal role in lobbying for the change.

Some facing such a grave health challenge might have withdrawn. But even as Ms. Demontigny (deux-mon-tee-gnee) began losing her memory, she became the face of the campaign to expand the right to die in Quebec.

In front of health ministers and lawmakers, on talk shows, in countless interviews, she spoke of how she had inherited the Alzheimer’s gene carried by her family. She recalled how her middle-aged father, in the last years of his life, became unrecognizable and aggressive. She wanted to die with dignity.

Still, four months after Quebec expanded the right to die, she had yet to fill out the advanced request forms. Choosing death was agonizing enough, but Ms. Demontigny had to declare, in precise details, the circumstances under which the lethal dose would be administered. Should it be carried out when she needs care round the clock? When she no longer recognizes her own children?

“Even though it’s a subject that’s preoccupied me for years, it’s different now because I have to make an official request,” Ms. Demontigny said. “But I’m not changing my mind — that’s for sure.”

Under the new law, an advanced request for assisted death must meet a set of criteria and be approved by two physicians or specialized nurses.

Across the world, only a few countries — including the Netherlands, Belgium, Luxembourg, Spain and Colombia — recognize advance requests for assisted deaths, though, in some cases, not for people suffering from Alzheimer’s or other forms of dementia.

At her one-bedroom apartment, Ms. Demontigny spoke during a two-hour interview often punctuated by the cries of a very voluble siamese cat named Litchi. Her partner, André Secours, was visiting — helping her recall a detail, reminding her of a scheduled phone call in the afternoon or an appointment the following day.

Though only in her mid-40s, Ms. Demontigny moved into the apartment — inside a residence for older people in Lévis, a suburb south of Quebec City — as she needed more help a year ago. She chose to live alone, not wanting to burden her family. Her two older children were already adults, and her youngest went to live with Ms. Demontigny’s former husband.

Her front door was covered with reminder notes. A timer on top of the stovetop range cuts off power automatically. The dresses in her closet were methodically arranged and archived with photos on her smartphone. No system was foolproof, though.

“I’m doing something,” she said, “and Litchi walks past by me, and I follow Litchi and I forget what I was doing.”

Bright sofa covers — brought back from Bolivia, the Democratic Republic of Congo and other places where she had worked as a midwife — hinted at her life before her Alzheimer’s diagnosis at age 39.

Ms. Demontigny decided to become a midwife after the difficult birth of her first child. The obstetrician, she said, performed a procedure without warning her.

“It’s my body — can you at least tell me?” Ms. Demontigny said.

As a midwife, she wanted women to be able to give birth in a respectful and natural environment.

For Ms. Demontigny, there was a direct link between a proper birth and a proper death.

“Life and death resemble each other,” she said.

When Ms. Demontigny learned that she had Alzheimer’s, she slipped into depression but was not surprised. Several older relatives had begun experiencing symptoms of Alzheimer’s at a young age, though they kept the illness hidden as long as they could, out of shame.

Her father started losing his memory in his mid-40s and stopped working at 47. At home, he spent his days wandering, bumping into walls and collapsing from exhaustion. In his final years at a health facility, he licked the floor and acted menacingly, even threatening to kill his son, Ms. Demontigny’s brother.

Like many Québécois families, Ms. Demontigny’s parents had drifted away from the Roman Catholic Church, and Ms. Demontigny considered herself an atheist. And yet, when her father died after years of anguish, she said she felt his soul depart.

“I hadn’t seen him like that, at peace, in at least 10 years,” she said.

While her parents’ generation kept silent about Alzheimer’s, Ms. Demontigny set up a Facebook page in 2019 to describe living with the illness. The social media posts from a mother of three, not yet 40, who had to give up her career as a midwife because of a rare form of Alzheimer’s, resonated in Quebec. She became the spokeswoman for the Federation of Quebec Alzheimer Societies and wrote a book about her experience, “The Urgency to Live.”

Quebec legalized assisted death a decade ago, before the rest of Canada. Under the law, a person had to be in an “advanced state of irreversible decline in capability” and “must expressly confirm their consent immediately” before the assisted death. But the requirements presented a problem for those suffering from an incurable and serious disease like Alzheimer’s, who were likely to lose their capacity to consent.

Dr. Georges L’Espérance, a neurosurgeon and president of the Quebec Association for the Right to Die with Dignity, said Ms. Demontigny helped press to allow for advance requests after becoming the group’s spokeswoman in 2022.

“She played a primordial role,” Dr. L’Espérance said. “It’s fine to discuss these concepts in the abstract. But it’s different when you can link an illness to someone that people can identify with. And Sandra’s an open book and very credible.”

Mr. Secours, Ms. Demontigny’s partner, said fighting for the change had helped fill the void created by her diagnosis.

“She had never expected to commit herself to a cause,” Mr. Secours said. “But that saved her, that gave meaning to her life.”

In the half-decade since her diagnosis, Ms. Demontigny had led a busy life — speaking out, writing a book, becoming a grandmother. She had embarked on a romantic relationship with Mr. Secours, 72, who lived across the street from her old place.

“André talks to everybody, says hello to everybody, he’s very cheerful,” Ms. Demontigny said.

“We were friends, neighbors, in the beginning, then our affection developed,” Mr. Secours said.

Some people, though, asked him why he had chosen to get involved with someone with an incurable illness.

“Even my mother, who just turned 100 and sees very well, told me, ‘André, you’re really not making your life easier.’”

“She doesn’t say that anymore,” Ms. Demontigny interjected.

The couple vacationed in Costa Rica last year and were hoping to go on a safari in South Africa, they said, as Litchi now lay sleeping before the television.

Perhaps it was this, the life she was still able to lead and enjoy, that made it difficult for Ms. Demontigny to put down in writing, as required by law, the “clinical manifestations” that will lead to assisted death.

Because Ms. Demontigny is likely to become incapable of consenting as her illness progresses, the manifestations she describes will “constitute the expression” of her consent in the future.

In fact, she had written in her book that she wanted assisted death to be carried out when certain conditions were met, including being unable to recognize even one of her children and behaving aggressively toward her loved ones. But though she knew exactly what she was going to say as she sat over the documents on that recent evening, she could not bring herself to write it down, not yet.

“I’m not going to change my mind because for me, in my situation, that’s the best possible end,” she said. “But I don’t want to die. I’m not ready. That’s not what I want.”