Acceptance: when to say stop (Waging Peace in the War on Cancer)
When faced with a potentially terminal diagnosis, or one with serious implications for our health, people sometimes question themselves or their doctor: “what’s the right thing to do”.
Every person has the right to refuse any treatment – before or after starting it. In ethics, this is known as the principle of autonomy.
Many people don’t realize they have that right. To exercise that right though, and before making a decision, you should ask for relevant, up-to-date information that is understandable. Then, based on your personal values and goals, you can choose to accept or reject any option.
The story appended below, Waging Peace in the War on Cancer, by Dr. Thomas Edes, is about a woman who made a choice, after failing in her initial fight against the cancer, to accept her condition rather than to continue to do battle with something she could no longer defeat. In her acceptance, she found peace and comfort. Published in the Journal of the American Medical Association in 2008, this article helps explain this concept of treatment options/choices much better than I could.
The key point I want to emphasize is that these principles—of choice and of acceptance—can be applied to any life limiting disease or to any disease for that matter.
Waging Peace in the War on Cancer
MY DEAR FRIEND BONNIE IS DYING OF CANCER, AND living in peace.
She is eagerly awaiting news about her grandchildren, not about her laboratory results.
She is focused on the daily routines of her loved ones, not on a clinic schedule.
She is planning for a child’s birthday, not for a treatment regimen.
She is living in joy of every day, not in fear of the next sign.
She is pursuing what she loves, not the enemy in her bones.
Bonnie is at peace, not at war.
The metaphor “fight the war on cancer” may be appropriate for health systems to set their sights on a target, to focus their resources, to plan their research agenda, or to inspire their workforce to pursue a cure. The “war on cancer” may help organizations rally support, attract study participants, or raise awareness and funds. This “war on cancer” may indeed help many, by galvanizing efforts that lead to advances in treatment. However, as my friend Bonnie taught me, carrying this metaphor to each affected individual can be counterproductive, inappropriate, even destructive.
Bonnie approached her initial diagnosis with aggressive chemotherapy and radiation, as many patients do. She endured the countless prolonged visits to clinics, the long nights of retching, the long months of weakness, and the losses—of hair, of weight, of vigor, of time. And we can hope that Bonnie received more good days in exchange for those bad days.
Two years later, Bonnie was told that her cancer had returned—with a vengeance. She was advised that this aggressive cancer would require aggressive chemotherapy. Bonnie carefully considered her options. She decided she did not want to go through rescue chemotherapy, she did not want to trade in any of her good days for some chance of more days, she did not want aggressive treatment. She told this to her oncologist. He responded, “Well, if you just want to die, you might as well commit suicide.”
Bonnie was shocked. And when I heard this, I was horrified. But then we realized that this may be simply a starkly honest expression of a prevalent perspective—that when one is faced with cancer, the valiant action is to fight. It is our duty to take up arms, to go into battle, to join others in the fight. To do less is somehow less heroic, less honorable. We are at war with cancer.
What is the impact of carrying this metaphor to the highly personal decisions that we physicians or our patients make as individuals? When at war, you must focus on the enemy, not on the beauty of the world around you. When in battle, you must be constantly vigilant for signs of danger, not distracted by opportunities for joy. When preparing to fight, you must be disciplined and attuned to the mission, not relaxing with family. When personally waging the war on cancer, your time and energy are diverted to the war, and away from the things you love. What if you wish to devote your time and energy to something else, instead of fighting cancer? Is there any reason you should feel pressured, ashamed, or bad about your decision?
After having gone through chemotherapy and radiation, having the cancer return, and having decided to accept the cancer rather than to fight it, Bonnie found amazing strength and peace. She traveled to distant places, visiting family. She spent time strolling amidst the rustle and aroma of the pine woods, rather than the bustle and sterility of the clinic. And despite her widely metastatic disease, bone pain, and anemia, she went back to school to visit her teacher colleagues.
“I hate to gloat,” she said almost apologetically, “but they looked so stressed. So tired. So haggard. I am sure I am feeling better than they are.”
Bonnie continued over the next year to devote her energy and time to her family, to the things she loved. Yes, new pains appeared—as she anticipated—and her physician and hospice helped her bring them under control. Yes, she gradually became weaker—as she anticipated—and she adjusted her routines.
She met these signs with peaceful acceptance, not with fear. And in each day she found joy, not dread.
When faced with a terminal illness, some may choose to devote their time and energy to fighting the illness; others may choose to accept the illness and devote their time and energy to what they love. Whichever decision they choose, isn’t it equally courageous? Aren’t they equally honorable, equally deserving of dignity, respect, and support?
For awhile, Bonnie continued to enjoy a stroll among the pines.
Eventually, Bonnie could no longer walk. “I never thought I would get to the point where I’d let someone give me a bed bath,” she sighed. “My moth-eaten bones are just too brittle for me to stand. I’m confined to bed now.” She paused. “But you know, it’s not so bad. I am in my own home. I have these silk sheets. Someone comes along and gives me a nice warm bath and a gentle massage. I can watch my favorite movies any time I want. I don’t have any schedule I have to keep. . . .”
“Bonnie,” I interrupted softly. “You’re not gloating again, are you?”
She hesitated, then I could hear her smile.
“Well, I could be.”
Thomas E. Edes, MD, MS
Editor’s Note: Both Bonnie and her family reviewed the manuscript and granted permission for its publication.
A Piece of My Mind Section Editor: Roxanne K. Young, Associate Editor.
©2008 American Medical Association. All rights reserved. (Reprinted) JAMA, June 4, 2008—Vol 299, No. 21 2483