I read a blog last December on “cancer being the best way to die” (by Richard Smith, MD.) He achieved resounding cries of “foul” by many for making this statement and also recommending people stop the merry-go-round of aggressive cancer treatment and go enjoy the time left rather than suffer through endless hours of torture from cancer “cure”. I believe this is a crucial dilemma for all who face a life threatening illness. I already hear, quite often, that someone had to “give up and go on hospice”. I want to reiterate something I have said many times: deciding to forgo treatment, choosing hospice, is not necessarily “giving up” but it IS making a decision. Living life is a continuous battle regardless of the choices.

As a person who has witnessed countless deaths from cancer, I have been on a quest, for many years now, of sharing with people their need to stop and consider before they arrive there; what do they want their final days and weeks to look like, how do they want to die? This should not be decided by a medical team! Considering things like: what are their priorities, what is important to spend time doing now? Who begins the discussion and how does a person find a balance, somewhere in the midst of chemotherapy to extend life, becoming Don Quixote madly chasing after the imaginary, and recognizing life is ebbing, choosing to make the very most of the time left with quality of life becoming the focus? (And what does “quality of life” mean for each of us?) Those of us with knowledge about the aftermath of treatment, (that includes the oncology doctors)…do we share honestly about all the likely scenarios? The whole truth should be told so a person whose time is limited can actually make an informed choice.

No one can answer for someone else, what is important and brings meaning to their life. Each of us must find our unique answer. Yet nearly every patient whom I have asked about their priorities as they consider dying, tells me this: they do not want to burden their family; they do not want to suffer tremendous pain; they do not want to lose everything they hold dear; they hope to die peacefully when the time comes.

I was visiting one of my patients with end stage cancer. We had completed the nurse tasks at my visit, and she asked me to sit next to her, while she recounted the losses experienced in her daughter’s life. My patient knew her own death would be a cap stone to all that had happened before for her daughter. She told me she wants to live, yet her questions were poignantly searching and wondering about how it would be as she physically died, and she asked me that question I have heard so many times, “How long will it take, when I am actually dying? What will it be like?” Cancer is robbing her of her energy, pilfering her concentration, and replacing her joy of life with advancing pain. Yet she does find joy, and meaning, and cherishes her time left. And she is brave enough to ask the hard questions and consider her response now, knowing that death is in her near future. She is pleased to have already outlived the prognosis of her oncology doctor, though she chose to forgo the additional “palliative” chemotherapy and declined additional “palliative” surgery.

Her actions are in stark contrast to an acquaintance, whose determination to survive included every imaginable treatment offered for her cancer, undergoing extensive surgery to remove tumor growth, then several additional surgeries to remove cancers growing elsewhere, countless rounds of palliative chemotherapy and radiation, and finally receiving nutrition the only way her body could accept it, intravenously, having lost over a third of her body weight. There were many conversations over the last year and a half, and I only hope her consistent plan of care for continued treatment was one based on complete understanding of the pros and cons of each decision. She is now dying in the hospital setting as a “palliative care” patient, her family convinced that her medical care is too cumbersome to die at home with hospice.

So different, these two women, yet in reality expressing the same desire: to live. How they die, the treatment they have pursued, the plans they have already completed, they have had to consider each bend in the road and determine how they want to continue their journey. Indeed you could say that cancer gave them the opportunity to take time to make these decisions, but I am positive neither of them would wish this for anyone else.
Unlike the movies, dying is not easy and rarely comes with a few well-chosen words and a couple of gentle last breaths. For so many, it is the daily loss of yet one more ability; the excruciating decisions to do more, or less, with the allotted time; the gritty reality of a body that is deteriorating. Dying slowly is fraught with suffering and loss.

The best deaths that I have witnessed are premeditated…the “thief in the night” has been scrutinized and lights in the house are turned on in preparation. And whether it happens in a sudden burst or there are many days and weeks to consider the outcome, I am convinced of this one thing; we mortals will all have to come to terms with our end, and make choices… or have them made for us.