Home » Death and Dying » Dying the Best Death – It’s Not Cancer

Dying the Best Death – It’s Not Cancer

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dying flower

Richard Smith wrote a New Years Eve opinion on The BMJ blog titled Dying of Cancer Is the Best Death. Early in the piece, he asks, “How do you want to die? You must think about it.”

As a metastatic lung cancer patient, I have spent significant time thinking about my death, which will likely come sooner rather than later.  I believe it’s important for people to accept death as a part of life and discuss end-of-life preferences with loved ones while life is still pleasant.

But Smith’s piece is not about awareness of death and treatment options.  It is about the best way to die.  And Smith gets it entirely wrong. I cannot accept his conclusion that cancer is the best death.

In Smith’s admittedly romanticized vision, a dying cancer patient “…can say goodbye, reflect on your life, leave last messages, perhaps visit special places for a last time, listen to favourite pieces of music, read loved poems, and prepare, according to your beliefs, to meet your maker or enjoy eternal oblivion …it is achievable with love, morphine, and whisky. “

The reality is that death from cancer often does not conform to Smith’s vision.  Death by cancer happens when tumors cut off your air supply, compress your heart so it can’t beat properly, block your gut so you can’t eat, cause organ failure, erode your bones, press on nerves, or destroy bits of your brain so you can’t control your body or think properly.  Sound painful?  Without pain medication – sometimes even WITH morphine and whisky – it is.  Yet according to the European Society for Medical Oncology, the majority of people in the world who die of metastatic cancer are NOT given the option to receive pain medication such as morphine. “Among patients with terminal cancer, 80% are estimated to experience moderate to severe pain due to inequitable access to medicine.” And this isn’t happening only in third world countries.

Not all forms of cancer give patients the luxury of time to set their affairs in order, resolve family issues, or tackle that bucket list.  In my too-familiar world of lung cancer, the majority of patients are diagnosed when the disease has already spread to the brain or other organs.  Among the lung cancer patients I’ve come to know online through their own posts or those of their caregivers, death can claim patients before they have established financial security for their family, raised their children, finished college — or even had time to recognize that they are dying. Many linger after they’ve lost the ability to do what they love, communicate, or think clearly. Most will eventually find themselves dependent on others for their basic needs while still aware of the emotional and financial stresses their illness imposes on their loved ones.

This is not the death I would prefer.

And then, Smith tacks on his ulterior motive: “But stay away from overambitious oncologists, and let’s stop wasting billions trying to cure cancer, potentially leaving us to die a much more horrible death.”

Wow.  If you follow this reasoning to its logical conclusion, we need no medical profession.  You’re going to die at some point, and being cured of one disease just means you’re going to die of something nastier later.  When you get sick, just take the morphine and whisky and get it over with.  Too bad we wasted our resources discovering antibiotics that cured the top three killers in the USA in 1900:  pneumonia/influenza, tuberculosis, and gastrointestinal infections.  Now people must die of heart disease or cancer instead.

**Deep breath**

I’ve lived long enough to know what different kinds of death look like.  A parent died from dementia over a decade.  Friends were struck down quickly by accidents or sudden sickness.  Other friends have dealt with organ failure, cycling in and out of good health.  And too many in my online and real life community have died of cancer.  Some metastatic cancer patients pursued clinical trials and aggressive treatments in search of a cure, while for others, solely palliative care was a brave and appropriate choice.  Ultimately, only the patient can decide which approach to treatment is the best for them.  Thanks to cancer research, most have some options, and some (like me) live comfortably for years.

Few of us know for certain how or when our death will come.  It would be lovely if Richard Smith’s idyllic vision of cancer death were true:  we could all know when death was near, take time to prepare, then take a pill and die comfortably.  Those who live in states that support death with dignity can actually make that choice, but most just have to wait for the credits to know how their story will end.

If I could choose my form of death, I would live each day with full awareness, do and say what’s important while I can, enjoy life and my loved ones as much as possible, and die quickly in my sleep.

I would not choose cancer.  If I could choose.

25 thoughts on “Dying the Best Death – It’s Not Cancer”

  1. Having lived in NYC and read about deaths in the local paper, I think I ould like to be returning from drinking a Frappucino at Starbucks and be ht on the head by a falling window air conditioner.

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  2. Smith’s essay is a classic example of “You should want what I think I want, having read about somebody else’s experience somewhere else.”

    What I learned working as a paramedic is that people do not, for the most part, get to choose “the best death.” Or who is with them when they die (if anyone). But none of my friends or family members who’s died of cancer would have chosen that death: they said so. I don’t think anyone can pronounce on “the best death” or “the worst death.” The cancer deaths I’ve seen have been generally slow and agonizing, with the loss of everything that person valued…but I’ve also seen deaths from non-cancer diseases: renal failure, liver failure, COPD, neuro-degenerative diseases. Slow isn’t necessarily merciful. “Time to make arrangements” doesn’t make pain less, or the loss of what the person loved doing less. And quick isn’t always quick enough to count as merciful–though we can do a lot with trauma, brain injuries and spinal cord injuries and some internal injuries lead to a longer, slower, more miserable death.

    Nor do we all agree on “the best/worst death”–nor need we. And still…for most of us it will come in a form that–if we’d been asked five years before–we would not have chosen. Our families would not have chosen. We see younger lives as cut short–but an old person may value their remaining years as much, still have unfulfilled ambitions, things to do and people to love.

    Death is the one absolute certain result of being born. And yes, we have to face that fact somehow. But we don’t have to agree with Richard Smith.

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    • Elizabeth, thank you for your thoughtful reply. I appreciate hearing about your experiences. Like each case of cancer, each death is unique. Culture, belief system, personality, and individual preferences all help define what is the “best death” for each of us. No one can dictate what is the best death for another.

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  4. “I would not choose cancer. If I could choose.” Amen.

    Life is 100% fatal, but Smith seems to be trying to rush some folks off the stage early, with little evidence to back up his opinion other than his “feels.” Morphine and whiskey? Great combo. What if the morphine and whiskey render you vegetative, making it necessary for your family to decide what to do? How … helpful. Not.

    Powerful rejoinder to a very poorly thought out BMJ post. Wonder who the editor was who let that slide into print. Not their finest hour, but this post is sure one of yours, Janet.

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    • Thanks, Casey. I’m glad so many people — especially those who have been touched by cancer — seem to relate to this post.

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  5. Thank you for writing this. I am still in shock, I think, from having cancer, and I think I might have a rough road ahead. Yes, my will is written and my medical proxy and DNR are in place, I’ve retired, and things seem to be going pretty well right now, but there is no way I would have chosen this. Nor would I choose it for Dr. Smith.

    Meanwhile I think of my dear friend Vivian, who died suddenly and in her sleep several months ago with no warning. She was partying with her family and friends the night of her death, living her life to the fullest like she did every day. Her death was a great shock to everyone who knew and loved her, and no one I know would have wished anything different for her. Certainly not cancer! Meanwhile, cancer research and a good oncologist mean that Vivian’s beloved daughter is still with us and raising her two young children, instead of dying from lymphoma. No one I know would wish for her to instead put her affairs in order and slip away into a good death.

    We are all on shaky ground when we think we know what is best for other people, aren’t we?

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    • Yes, “knowing” what’s best for another is fraught with peril. I’m glad you’ve had time to get your affairs in order; I wish more people would do so without waiting to be prompted by a potentially fatal illness or condition. For those who are interested, here’s a good place to start:
      http://theconversationproject.org/

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  6. Janet, This is an excellent writing. Thanks for all you do for lung cancer patients and their loved ones. It doesn’t go unnoticed. mj

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  9. So well said, Janet. I was struck by the 100+ comments in the BMJ in response to Dr. Smith’s essay, and among them even more struck by the overarching issue of inadequate symptom control in end-of-life care.

    The European statement on moderate-severe pain that you quote here is chilling, but as you say, this is not simply about pain. Pain is the symptom we most often dread, but extreme nausea and terrifying shortness of breath and other debilitating symptoms can be equally cruel companions at the end of life. Effective symptom management is where palliative care specialists excel, and where oncologists so often fail.

    I worked for many years in hospice palliative care, where we’d often admit people to our in-patient unit who had been suffering truly unbearable symptoms for weeks and even months despite being “cared for” at local cancer hospitals.

    The word “suffering” is one that’s often discussed among those working in end-of-life care. As you so accurately describe here, suffering also includes watching the stricken faces of your children watching your decline, or worrying if there’ll be enough money to keep the house after you’re gone, or despair at leaving a young family, or the omnipresent unfinished business of life.

    At hospice, we often spoke about the concept of “Total Pain” – which means a patient’s physical pain, but also means emotional pain, mental pain, spiritual pain and so much more. We can provide opioids for physical pain, but they’re not going to touch many other types of suffering.

    Dr. Smith is yet another physician (i.e. not sick) who speaks from the comfy pulpit of healthy privilege. When physicians do become seriously ill themselves, they invariably become newly-informed wide-eyed evangelists about how awful it is to be a patient – as if the reality of being the one lying in the bed is news to them, no matter how many years they’ve watched all those other people lying in bed.

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    • Thanks for sharing your thoughts about end-of-life care. It’s something most of us avoid considering until it’s too late. I hope this discussion gets more people thinking about it and discussing it with family members and caregivers.

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    • I’m glad my words helped voice your thoughts. We tend to take breathing for granted until we can’t do it easily, don’t we? Best hopes for peace and comfort on your Mesothelioma journey.

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