False Prescriptions for Dying

I try to start most years not thinking too much about dying. It’s a resolution of sorts. But on the first day of this year I came across this much shared piece by Dr Richard Smith over at the BMJ blogs (also mentioned in news coverage here). Cancer is apparently “the best death”. We should stop with the “overambitious oncologists” and “stop wasting billions trying to cure cancer”. Well there’s a different perspective.

While on first reading it appears that it can only have been written by someone stumbling out of a hobbit hole into the sort of bucolic surroundings that anaesthetise all sense of the larger world, it certainly did the job of provoking discussion. It’s just that I can’t help but think that the whole topic of death isn’t what this thinker thinks it is.

A blog post doesn’t always provide much scope to explore a topic and it would be unfair to suggest it should contain the entire world of a subject. But what starts with an interesting excursion through the mind of a dying surrealist sleepwalks straight past the very questions it poses on the topic of death,

“Will you be ready? Will I be ready?”

Big Questions

Those are very big questions. So to have anyone bring them up can only be a good thing, right?

Except that from someone who has “endlessly repeated” a taxonomy of death what follows is complete neglect of the individual in the experience of death. Add to this a complete neglect of the reality experienced by the majority with cancer and that’s a pretty big hole in the middle of his short treatise.

The Four Ways To Die

Things start promisingly enough once we’ve moved beyond 1983. Sudden death is dismissed as the pinnacle because of the impact on those nearby, not any consideration for the dead individual. And the exhortation borrowed from an inspirational desk calendar to “live every day as your last” has its own merit.

Dementia does many horrors for both the individual losing themselves and those close to them watching them wisp away. And I’d grant that the redeeming possibility of saccharine movies with notebooks being subsequently created don’t offset that at all. Death from organ failure also has the potential to be awful, no contest.

But cancer is presented as a death of warm afternoons with a beloved pet. The glasses aren’t just rose-coloured. They’re 5 inches thick and blurring reality.

Some Real World Information

How could I be so dismissive of love, whisky and morphine as a cure for all end-of-life ills?

I’m not. But that cocktail doesn’t apply to many people. In two glib paragraphs the writer assumes that almost every individual with cancer is well enough to say their farewells, reflect on life’s splendour, tie up all loose ends, go touring, nourish the mind and soul, reconcile their death with all their beliefs and relax in a blissful fog of alcohol and morphine.

Perhaps some (and only some) points for consideration. In May 2014 the 67th World Health Assembly ratified an agreed resolution on palliative care. This highlighted the needs of the 40 million or so people every year who need palliative care globally. Of course even in Australia, which has pretty excellent services, somewhere between 50-70% of those who would benefit from palliative care can’t access it.

And morphine? Well around 6.5 million people per year die without access to any pain relief often because access to this class of medicines is extremely limited. This is a terrible and avoidable burden because Dr Smith is right in saying that opioid medications do provide excellent pain relief for the majority of patients.

But not all. A little under 1 in 10 patients won’t get significant relief from their cancer pain, particularly if it involves pain started or maintained by nerves. And for some patients using opioids will give them side-effects like decreased pain thresholds or pain in response to seemingly harmless triggers and around 1 in 20 will have to stop those same pain medications because they can’t tolerate the side-effects (here’s a summary of a review (but only one), which also highlights there are actually lots of problems with the quality of research on the topic).

But I guess if you ignore the fact that your basic assumptions about the nature of death with cancer don’t apply to the vast majority of those dealing with it, you can make a pretty strong argument to quit it with all the trying to find a cure malarkey. You just have to forget that whole bit about cancer causing suffering.

With this visual hint, I am pointing out that the writer has chosen to focus on the tree third from the right, and ignored that pesky forest (via ilovebutter at flickr under CC 2.0)

With this visual hint, I am pointing out that the writer has chosen to focus on the tree third from the right, and ignored that pesky forest (via ilovebutter at flickr under CC 2.0)

The Individual

Both personally and professionally I have seen people facing up to a death announced by messengers a long time in advance. For some there are elements much as Dr Smith describes. Some have no pain to deal with, or find our many clever medical options of great assistance. Some never have to lean on those around them but hold them up with their own good spirits.  Some find all the peace and existential wellbeing you could wish for.

But I have seen others have their sense of all they were certain of destroyed. I have seen people reduced to someone they could not recognise and would not dine with, given the choice. I have seen those with no time to ponder any nourishment of the self as they desperately try to keep living for others however they can.

I have seen patients wake, sleep, eat and weep with fear. I have seen families entwine and tear apart. I have seen people die alone. And I have seen patients reduced by their suffering, their body a cage that locks them up with pain when our efforts don’t work.

Dr Smith asks a most vital question. We should all ponder death, and doctors more than most. But death deserves more respect than this. Death is a part of life. And there is a place for everyone to consider what place it will take within their lives. But why suggest that the experience of it is any less complex than life itself?

If we assume that the many tangled arcs of life are bound to dazzle by their sheer number, why not agree that there will be just as many stories of death and what it means for all of us?

And when did accepting that death is shared by us all become a reason to stop looking for ways to stop people suffering?

As a sidenote, it’s worth reflecting on the fact that most oncologists are not “overambitious” drug merchants trying to extend suffering. Read this if you like as just one example. 

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