Choosing When to Die

A woman in her 60s who has fought a battle with breast cancer presents with odd symptoms of an ascending paralysis. An unclear neurologic illness has slowly picked off her cranial nerves one by one to the point that she cannot even swallow, cough, or gag and has to be intubated to protect her from choking. A PET scan shows a concerning mass on the same side of her body as her original breast cancer, and after multiple tests, we determine that her cancer is causing this odd paraneoplastic paralysis. She is, however, still able to communicate by writing on a notepad.

The oncologists and neurologists sit down with the patient and her family to discuss options. They believe that with aggressive chemotherapy and radiation, they could suppress the cancer and would expect slow return of the patient's neurologic function. The patient, however, does not want this. She communicates completely clearly to us that she would not want to undergo chemoradiation, and in fact, wants palliative care. She has decided it is her time to pass on. She chooses to do it with dignity, without the uncertainty, fear, hair loss, pain, nausea, discomfort, and risk of chemotherapy. She says her goodbyes - hour-long heartfelt tearful farewells - and asks to be extubated. Although we did not think she would pass so quickly, she died in the next few hours. It was as if she had chosen to die.

We choose how we live, how we act, what matters, why we do things. Why should we not choose how we die? This woman surprised me because so many other patients want absolutely everything done to live. But she resolutely and stoutly chose not to try chemotherapy, even though it offered a chance at recovery. Her passing, and the way and timing of it, was entirely of her choosing.