Medical Matters: Our every impulse is to fight – but can you live longer if you stop trying?

The much-loved British actor Lynda Bellingham died recently. The 66-year-old star of the ITV series Loose Women, who also appeared in a long-running TV advertisement for Oxo, was diagnosed with cancer of the colon last year. Despite treatment, the cancer subsequently spread to her liver and her lungs.

She was very open about her illness and had been candid about her decision to stop her chemotherapy some months before she died. She told viewers that she wanted to take back some control over her life.

“I just sat down when I was in pain – there’s no getting away from it with chemo: the ulcers in your throat, the thrush, plus the fact that I’d had major lifesaving surgery for a perforated colon. When you’re in terrible pain you make decisions,” she said.

Similar decision

I have looked after a number of cancer patients who have made a similar decision, sometimes in the middle of a course of radiotherapy or chemotherapy.

Some had reluctantly accepted further treatment, concerned that not to do so would cause offence to the doctors and nurses who were treating them.

Others had decided on a single course of chemotherapy and were adamant they would not undergo further treatment.

I think the issue is a broader one than “the cure is worse than the disease”. For example, Bellingham speaks of being in terrible pain. But was this the physical pain from the cancer, or perhaps psychological pain to do with her life ending prematurely? It may even have been a type of deep spiritual pain that drove her decision to give up active treatment.

Quandries

Being Mortal: Medicine and What Matters in the End is the latest book by the acclaimed surgeon and author Atul Gawande. It examines some of the quandaries facing healthcare professionals, patients and their families when they are faced with the limitations of medicine at the end of life.

“When there is no way of knowing exactly how long our skeins will run – and when we imagine ourselves to have much more time than we do – our every impulse is to fight, to die with chemo in our veins or a tube in our throats or fresh sutures in our flesh,” Gawande writes.

“The fact that we may be shortening or worsening the time we have left hardly seems to register. We imagine that we can wait until the doctors tell us that there is nothing more they can do.”

One of the many thought-provoking questions to emerge from the book is how well or how poorly doctors are able to communicate this ultimate truth.

Surprising, for one who writes so sensitively, is Gawande’s admission that until his father died he hadn’t really thought much about what went on in hospital geriatric units or that hospice care was more than just morphine infusions.

The author describes how he learned to initiate difficult end-of-life conversations with his patients with questions such as “What are your fears?”, “What are your hopes?”, and “What trade-offs might you be prepared to make?”

As a newly minted advocate of palliative care, Gawande lauds its focus on freeing the dying patient from pain and anxiety. He references a 2010 study that divided patients with incurable lung cancer into two groups: the first group received standard oncology treatment; those in the second were also treated by a palliative care specialist.

This second group stopped chemotherapy earlier, experienced less suffering at the end of their lives and lived about 25 per cent longer than those given standard care.

This outcome leads him to conclude that you can live longer when you stop trying to live longer. Rather than aiming for survival, patients need encouragement to set personal goals and maximise their wellbeing for what remains of their lives.

Both Bellingham and Gawande offer a similar take-home message: perhaps the only way to gain control towards the end of life is to relinquish it.

mhouston@irishtimes.com

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