How long do you continue to fight when death is certain?

How long do you continue to fight when death is certain?

Not long from now, the last cancer will be defeated, and even today most with the dread disease survive.  However, many still fall.  This leaves us with one of the toughest questions of life.  How long do you continue to fight, when death is certain?  When does striving become vain hope which drains quality and creates only suffering?  What makes struggle worth the pain; when is it time to yield?

This is a highly personal decision, which each of us can decide only for ourselves.  I have met young people who when faced with incurable disease, immediately decide that life was over, and accepting only comfort, make no attempt to delay death.  I have known frail very senior patients, who faced with an incurable disease, demand every treatment, the end of their lives announced by the compressions of CPR.  Is either path right or wrong? I do not know. Nevertheless, the certainty of these decisions demands that we consider this future, as best we can, before these events occur.

In talking to patients with chronic fatal disease, one image which seems to help, is that of climbing mountains. If you have cancer, you face a series of medical and emotional events. The first will be the symptoms that announce the disease, such as pain, swelling or bleeding. The next event will be undergoing tests to get a diagnosis.  Then, the first treatment.  Each of these is a hill or mountain over which you will need to hike and each follows the other.

As you get over one rise, and recover from that climb, in front of you stands the next hill.  Often the ascent in front is higher and harder than the one just completed. You must climb it, even though the mountain behind has depleted you.  Sometimes there will be a wide valley or plain between the mountains, where you can rest and heal.  During other parts of the journey, the foothills of one mountain will stumble immediately into the next rising slope.  At times, you will reach the top, just to realize it was a mirage and the real summit is higher still.

When cancer relapses or spreads, the treatment may demand more sacrifice. The side effects are more severe, precious energy lost, time away from family increases, and the opportunity to simply live is taken away. More mountains rise in front of you.

Having a fatal disease means that with time the mountains will get closer and higher, the climbs more savage, and the toll on your life and body will get worse.  We may fool ourselves that even though the disease has relapsed that if we scale the next Himalayan crag, we will finally get to rest.  But since death defines human life, at some point there will come a mountain which is so steep and so hard and causes us so much suffering, that we will die on its rocky side or plummet into a ravine.

I would not pretend to know when for each disease, each person, each life, the time has come to take off the hiking boots, and sit by the fire.  The range of rising mountains reminds me that the path we tread, at the end of our lives, is a balance between hope’s struggle, and the comfort which some may find in acceptance.  The analogy can test how we measure choices in treatment and in daily life.  For each of us what is important and gives meaning to our lives, is balanced with what we sacrifice.

The question is whether we will have the wisdom to recognize that the time has come not to climb, but to rest in the warm valley.  The peak of Everest is a crystal pure image of awe, power and beauty, but for most, it is a place of fantasy, where there is no air and the wind is as cold as death.

James C. Salwitz is an oncologist who blogs at Sunrise Rounds.

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  • PulmCCM

    Agree with the spirit of this very well written post. But “Not long from now, the last cancer will be defeated?” Hard to justify this statement or even guess where it came from other than a creative imagination. Cancer mortality has hardly changed in 30 years, and probably isn’t going to anytime soon. The suggestions otherwise (constantly overhyped in the media) play well in TV news segments and on fundraising drives, but sadly are not borne out in reality.
    http://www.preventcancer.com/losing/nci/manipulates.htm

  • ceblen

    I would hope the oncologist who wrote this hopeful post would acknowledge that he often knows that it is “false hope” because don’t the academics who specialize in prognostics know and predict with a high degree of accuracy just how long cancer patients will live?
    The prognosis of the cancer by the treating oncologist should be shared with the patient truthfully and supported with neutral data that the physician uses to make the prognosis.
    Unfortunately, oncologists and all physicians were not put under the provisions of the 1991 Patient Self Determination Act and have no legal obligation under this federal law to SEEK informed consent from elderly Medicare/Medicaid patients with life threatening cancers, etc.. for either Curative Care OR palliative care/transition to Hospice, whichever the patient and the physician agree are in the best interests of the patient.
    Over treatment of the elderly/disabled (hopeful? treatment) on Medicare/Medicaid has been a huge problem for Medicare and the private insurers who want to reduce end-of-life costs of dying by encouraging patients to use the Hospice/palliative care entitlement to “rest in the warm valley” —but treating oncologists who offer curative care that is non beneficial have to cooperate with this public policy goal, don’t they?
    And, of course, many do not! as illustrated by the fact that the Department of Justice in cooperation with the Department of Health and Human services just recently charged a Michigan oncologist with over treatment for the profit motive and fraudulent billing —the first case of its kind, I believe!

  • petromccrum

    Doctors MUST be more honest and open with terminal patients. The patient should have ALL the information regarding their prognosis, treatments, and side effects so they are able to make the best decisions for themselves. Stop giving false hope.

    • http://www.newatlantean.com/ Robert Hewes

      When I lived in Japan a friend’s aunt was in the hospital in the end stages of cancer. Not only did her doctor not share her diagnosis with her, but none of her visitors were allowed to even say the word cancer. I can’t imagine her despair as she died in agony, not even allowed to know what was going on.

      I’m not in the medical industry at all, but damnit, if my doc isn’t honest with me he better be ready for a firm kick to the lap. That’s true in all things, but especially should it concern end-of-life issues.

  • D.J. Md

    Well, I enjoy your optimistic out look that soon the last cancer will be defeated. Which, I suppose is all relevant to when you decide time started. If one was to look at it that way then sure, soon would be a good term to use.

    As far as your struggling to answer a question, that very well may be different for each person. When do you accept defeat and just not try anymore.

    That is when ever the patient decides to give up. Not your call. There is no happy medium. But realistically, it is a money question, How much should someone spend? Or how much do they have to spend.. Bottom line..

  • Jessica Rice

    I enjoyed this article and was able to identify both with the mirage of mountaintops near as well as the need to stop, remove my boots, and warm my feet by the fire – even if only for a while.

  • Bart Windrum

    I prefer the analogy of a glidepath to peaceful dying. Orienting towards that route requires advance study to get the “lay of the land” regarding 21st century dying realities (that’d be identifying, exploring, and overcoming the 7 primary obstacles to dying in peace) and practice at the controls (that’d be contemplative aging).