THERE SEEM TO BE four subjects that folks are reluctant to discuss with acquaintances, friends, intimates and often themselves: money, sex, religion and death. A few months ago, I broached the subject of money, to wit, my investment history—territory well-trod by this readership.
I will now turn to the literal and figurative last item in the above lineup of forbidden subjects: death. As a physician, I have some knowledge about the death of others. But I’ve had no experience with my own death—until now.
My health news has always reflected a “bullet-proof Bob.” Over my 88 years, I’ve had the most unlikely run of incredible good health: no serious illnesses, no broken bones, a single missed day of work thanks to the flu 45 years ago, a single significant surgery involving a knee replacement, no cancer or vascular disease, no hospitalizations, and an astonishing family history of longevity.
This incredible run ended with sudden finality. Two months ago, in preparation for a procedure for an enlarged prostate, I had a prostate-specific antigen (PSA) test performed. It was off-the-charts high, with a score above 1,000. At that moment, in the blink of an eye, I knew I had metastatic prostatic cancer (PC) and that it was incurable. So began my odyssey.
After due diligence—reviewing the disease online at some length—I got lucky. A friend put me in touch with a colleague of his, a professor at a large academic center who was an expert in metastatic PC. This expert pointed the way. I had my roadmap.
The most significant and revealing test was a PET-CT radioactive isotope scan of my entire body. It accurately identified all of my prostatic metastases down to the size of a pea. It revealed extensive cancer involving almost all my internal lymph nodes, head to toe, but only a few small scattered bone metastases, and no organ involvement at all.
My reaction to this news was confusion. How so? For some time, I had been ruminating about my future decade as a nonagenarian. My vision of it filled me with considerable apprehension and anxiety. With my wife’s health quite fragile, I saw the odds favoring her demise before me, leaving me spouseless and alone without intimates or family nearby, since I live in Mexico.
My deafness is now profound and a source of social isolation, anxiety and severe disability. Worse, the next decade would see an inevitably increasing frailty, physical deterioration and fading cognition, all impacting my ability to care for myself and enjoy daily life. I have seen this process up close both in my own family and in my medical practice.
Worse still, I couldn’t envision many practical steps that would significantly alter this future. A lot of happy talk surrounds such issues in the public press. The realities, I think, are a poor match for such talk. Ahead of me lay a faded old man waiting for an uncomfortable death.
On the other hand, the case for a somewhat different aging scenario could be made. I have been entirely symptom-free. PC is frequently a quiet fellow who creeps along silently in the shadows, not drawing attention to pain or other symptoms. In my case, this lack of pain and other symptoms suggested a robust response to therapy and the best possible prognosis for metastatic PC.
I remain in remarkable health, enjoy life and have no other current diseases. Most important, I have a wife who truly loves and understands me, and who will willingly share and help me with the experience of dying. What few regrets I have had, I have set to rights as best I can. In short, my immediate future is relatively bright.
So, is the tolling I hear the knell of impending decay and death, or is it ringing in some comfortable years ahead? It seems to be both—some sort of cosmic Manichean happenstance. Of two minds am I. Should I embark on a treatment plan with probably tolerable side effects that offers prolongation of life into a feared old age? Or should I go without treatment, enjoy a life unfettered by medicine’s interventions, and accept a shortened lifespan? What sails to set to death’s foreign shore?
After some significant dreams, consultations with my subconscious, acknowledging my biases and listening—really listening—to confidants, I’ve decided on a middle way. I will take my prescribed medicines but pass on chemo, continue to assess my disease’s progress, weigh the treatment side-effects, and keep an open mind about changing course. Death has of yet only darkened my door. As his presence becomes more insistent and real, will I change my mind in some way? Life is ever-changing and fraught with surprises. What will it bring? Time will tell. Quien sabe? Vamos a ver.
And my “long-term” future? I have for many years believed in purposed lives, reincarnation and the soul’s permanence. That I will return to this earth many times to share lives with my intimates, in circumstances and roles different than in this life. And that such journeys will bring us closer to the perfection known as God. I arrived at this belief system over many years, not as a rationalization for death’s inevitability, but rather because it made sense to me, and my readings and experience supported it. Whether this belief system is valid, I will discover soon enough.
Robert Dailey is a long-retired emergency physician from California. He lives with his wife in the slow lane of Cuernavaca, Mexico, where he enjoys birding, investing, and travel with an assist from credit card miles and points. His previous article was For the Fun of It.
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My personal Cosmology obviates all fears concerning what comes After life, but I believe I’d like, more than anything else, to get Out of here with a minimum of angst and pain.
The late humorist, Michael O’Donoghue, presenting a “How to Write” satire in an early National Lampoon, described an ever-available ending—useful for any narrative that any writer couldn’t come up with a better way to conclude:
“Suddenly, everyone was run over by a bus.”
In countless situations since then—but most-often when talking about How to Go—I’ve thought back to O’Donoghue’s otherwise-unhelpful “How to Write” guide. The wife and I often debate which one of us should die first. I characterize us as living with an “Anti-Suicide Pact,” in which both of us swear never to die before the other. (Whenever I say this in my wife’s company, she disputes it vehemently. I’m not sure what aspect of this formulation disturbs her—and she ain’t sayin’.)
O’Donoghue died in 1994, at the ripe, young age of 54. If the Gods of Finance and/or of Comedy have ample generosity of spirit, they will reincarnate the late, great satirist, just in time to drive that “bus.”
____________________
May the remaining balance of your life course continue to reward the costs.
Regards,
(($; -)}™
Gozo
Buena suerte, jefe. On the same day that HD launched the impersonal AI article series, this moving statement was as honest and human as anything I’ve read on the site. Many thanks for sharing your thoughts.
In my career in internal medicine and geriatrics I had a number of patients with similar metatastic prostate issues.
Hormonal therapy is almost always the first step but there have been remarkable advances in treating castrate resistant PC in the last few years, and several randomized trials showing increased survival with various new drugs. I had several patients take them without a lot of side effects. Good luck!
Thank you Robert for talking about something not usually openly discussed.
My own PCancer was diagnosed in Dec 2020 and my Gleason score was 8 out of a possible high of 10. The Doc said I can’t just forget it.Thankfully it had not spread.
I did a lot of research on it, and started taking action for myself while considering possible treatment. This was like a shotgun effect with different actions taken on my part. I scheduled a removal of that bad ol prostate in Sept of 2023 and the biopsy on that showed a Gleason of 7. I was going in the correct direction.
You have time my PC brother. I tell folks that they are the most influential person in their own health. We all are different and you can probably find what you can do personally to help your situation, and I don’t know if it’s legal to include an email contact here.
But, I’d like to encourage you to … learn, and act.
Your situation reminded me of a family friend, the late Dr. George Sheehan of Rumson, NJ. Dr. Sheehan was a heart doctor who took pains to remain in good condition as he aged, and became a quite famous long distance runner on the East Coast, collecting many trophies for his age groups as he got older. He also has written many thoughtful books on making life meaningful, on the value of competition, and most of all, on aging. His most famous book is probably “Running and Being”. But his last book, “Going the Distance (One Man’s Journey to the End of His Life)” is what reminded me of you. Sheehan was diagnosed with inoperable prostate cancer in his late 70s, and the book documents his fear, anger, resistance, internal conversations and ultimate peace, through his passing in 1993, seven years later. He was a much loved figure in the community and I recommend his book to you.
Thanks for that memory. Dr. Sheehan died when I was at my running (local road races) peak. Running and Being, plus several books by Jim Fixx, were on my bookshelf and I referred to them often.
Robert, I agree with your choice, you say you are worried about your wife passing first & you being sick & alone in a foreign country while being profoundly deaf now, this would be a worry for anyone. May I suggest joining facebook ex-pat groups in Mexico, if you haven’t already, you may find someone who can communicate on your behalf with local people to acquire in-home care when you need it. Often people become bed-ridden in the last few weeks/months with chronic illness & you may need help. All the best in your treatment journey, let us know how it’s going, you never know what HD readers suggest that maybe beneficial.
There may also be an app to translate voice to text if you point your phone to whoever is speaking.
Thank you for this sobering piece of writing. When my husband had a PSA of 347 at his Medicare-age exam, a friend told us to look at every step of the voyage to this new land through a quality of life lens. That advice served us well. He was diagnosed with Stage 4 with bone mets on his spine. He said no to surgery, radiation and chemo, sticking to a course of hormonal treatments. That was over 10 years ago. We have been full-time travelers for 4 years now. And recognize each day how lucky we are that his body has responded so well to the medication route.
Another doctor friend and his literary wife wrote an extraordinarily compelling book with chapters written by each about their marriage and end-of-life decisions. Thoughts on Death and Life by Marilyn and Irv Yalom. I highly recommend it.
Live your life. Live your life.
Wishing you the best
Your article is about death and dying and was much appreciated. Since I have changed my approach to health over the past few years, I feel the need to plan how I would address cancer. I will eschew chemo, radiation. I will instead focus on healthy eating, supplements, exercise, water quality, and meditation that will address the root cause. My body/mind knows how to heal itself. I just need to give it an optimum environment to do so. Check out sites like collmed.org. The current model of care often does more harm than good. We need an upgrade.
It was very nice of you to share your personal story. Only wishing you the best…..in your ongoing voyage.
Robert, thanks for your commentary. I’m turning 81 in a couple of weeks and am facing a similar situation. I went through 44 radiation treatments two years ago with what appeared to be a successful treatment of a fairly aggressive PC contained in the prostate. Upon followup PSA checks I went from 0 to 3.7 in 6 months and my urologist scheduled a PET scan which revealed it had moved to the bone in 9 areas the brightest spot being on my lower spine.
That lead to an excellent radiation oncologist deciding to treat all with a much higher intensity radiation in eight sessions. I’m currently on shots of Eligard every 6 months and Xgeva every 3 months until the end I assume.
A fairly new drug Abiraterone daily(1000mg) for a year. Minimal side effects so far.
I’ve always been athletically active and still play tennis, hike and mountain bike desert trails and am hoping to experience minimal fatigue side effects.
It now appears to be an aggresive stage 4 with an optimistic 4-5 years of a functional life as I’m currently living.
I view life and death very much the same and am lucky to still feel comfortable physically and will pursue a similar ending when the time comes. My favorite saying has always been..’damn the torpedoes…’ and am in that mode currently being aware in each moment with acceptance of life
as it presents itself.
Memento Mori and Amor Fati.
Ron Stark..this is my wife’s addy.
Thank you, Dr. Dailey, for your openness and courage in facing this challenge. My journey into Vedanta philosophy began with a friend, and it inspires me to share this poem with you, in honor of the profound spirit and purpose that define your life:
Your essence, timeless soul, in this cosmic play,
is not the cancer, nor the weary frame.
You are the sky where storms are born and die,
the witness to the cosmic dance, eternal and high.
lovely 4 line poem. You get me.
Robert, that is a remarkable piece of writing. Thank you for sharing it and condolences on the situation that caused you to produce it.
You are nonspecific about what the words “changing course” might represent, but I would guess that such an analytical mind has compiled some clear specifics. So I ask the intrusive question: Does one of them include actively avoiding the uncomfortable death you anticipate?
The availability of assisted suicide in my state was a significant comfort to me when diagnosed in my late 50s with a stage 4 cancer that offered the certainty of rapid, painful progression and no hope of long-term survival. (The average at that time was eight months.) I told every doctor I worked with that I had no intention of dying of cancer, of being a drugged-up skeletal figure in a metal-railed bed, and that at the point where such an existence beckoned, I would require from them the prescription enabling me to choose my own exit. And if they weren’t comfortable with that, they should let me know and I would change physicians. All were supportive.
Having that control, knowing that I wouldn’t die in agony as a shell of myself, gave me a comforting modicum of control in a situation where much was beyond my control. My decision was reinforced regularly by the many hours I spent in infusion centers sitting next to tragically younger and sicker people, sometimes accompanied by family members in various stages of grief, painfully fighting for more time.
As it happened, my diagnosis coincided with the FDA approval of a combination immunotherapy that would not only save my life but eventually prove a breakthrough for thousands of people with various cancers. So I never had to take that anticipated action. But even today, in my eighth year of remission, the thoughts that went into my decision remain sharp and clear.
I wonder, embarking on your own odyssey now, what your thoughts are on this subject. Will you share?
Thank you for raising this issue. I like the middle road Robert has chosen, but that may only take him so far. I am with you on end of life choices – in fact I wrote an article for Humble Dollar on the topic. Unlike other commenters I have no intention of raging against the dark. Instead I do hope to “go gentle” and have written advance directives accordingly. Now I have moved to a CCRC I wear a DNR pendant and have the relevant paperwork on file.
Another MD has written what is now a widely read book pondering such themes, https://atulgawande.com/book/being-mortal/ . The gist, like yours, might be summed up in saying that it is reasonable to weigh quality of life versus quantity of life, especially as the end approaches. Thanks for sharing.
Being Mortal has a prominent place on my bookshelf.
Dr Dailey. Thanks for an honest and thought article. I’m a 13 year prostate cancer survivor. I wish you the best in whatever choices you make.
It’s been 15 years for me. At age 50, my situation seemed so straightforward: Surgery was the most logical, thorough choice. I cannot imagine anyone better suited than you, Dr. Dailey, to make such difficult decisions. I admire your fluid approach and your willingness to share it with us.
Robert, thanks for a terrific, insightful article. So many different life experiences here on HD but you illuminate the one journey we will all share.
I hope you keep us updated on your experience and thoughts. I suspect there will be much to learn from them.
Dr. Dailey, thank you for the very well written article.
At 78 I accept that I am much closer to the end than beginning and I face the end without fear or regrets. I have been privileged with a life of adventure and feel confident that the three generations after me are thriving and contributing to those around them. I have been surrounded by love my entire life and hope my last days are not a burden on others. The circle of life continues in spite of the mysteries of death.
Thanks again for the insights in your article and I hope you write more.
I’ve read many physicians will throw the kitchen sink at a patient’s illness to save or extend life but routinely choose to go quietly in their own. They know what’s happening, know the odds, and often pick the road less traveled.
Perhaps the greatest improvement to medicine over the last 50 years was the shift to treat the patient — not the malady — so care is centered around patient choices (if they’re lucky enough to afford them). I personally might make the same choice as Bob for my journey from this vale of tears.
Best wishes for plenty more good, happy years of birding, travel, and investing, Dr. Dailey.
We have a guy in our bible study who had a similar experience 4 years ago. His PSA score was off the charts and has metastic PC. He is taking an expensive drug. Not sure what it is but it has brought his PSA down to zero. He takes it every 2 or 3 months, and he claims there are no side effects. He is doing well and enjoying life.
As a doctor, you probably know what that is. I can find out if you are interested.
I pray the Lord will bless you with good health for many years to come.
Dr. Dailey – I read your post several times to make sure I gathered all the wisdom you impart. I doubt I could write as dispassionately if I were you, but your logic is tough to ignore. I wish you well on your journey and hope you are able to provide updates to your journey.
Robert, you have to be one of the most analytical writers on this site. Thanks for sharing your thought process as it may be helpful when others face these decisions. Best wishes going forward.
All the best. Your article was one of wisdom.
First of all, I enjoy a good article that includes a word I’m not familiar with. In this case it was “Manichean.” So, I’m a little bit smarter and a lot more appreciative today. I try very hard to stop and count my blessings every day, but your good article made me stop sooner and longer. I worked in a funeral home when I was 22. I would turn the lights off every night and take a quick glance at the open caskets. I wondered what advice they would give me and came to the conclusion it would be, “Live your life.” As the keeper of my graduating classes’ obituaries, I’m reminded of this quite often. Thank you for an interesting and observant article.
We can say memento mori. But it doesn’t get real until it gets real. Thank you for your observations and inspiration.
Robert, Our thoughts and prayers are with you and your loved ones. I am confident you will approach your decisions with grace. Thank you for placing us in your shoes, and allowing us to ponder how we would handle similar circumstances.
My friend, the undertaker who is my age (68) says: “No one gets out alive”. Thank you for sharing your odyssey with us, Robert. If you have time to read: “The Gift of Peace” by Joseph Cardinal Bernadin https://www.penguinrandomhouse.com/books/12702/the-gift-of-peace-by-joseph-cardinal-besnardin/ I hope it helps you. Best wishes.
Dear Dr. Dailey, while we all feel differently when our time is nigh, I say “Do Not Go Gently Into that Good Night”. We can face death with dignity and ferocity.
You have been given so much… a purposeful life and a full one. I love all the expression and meaning in your writing. Your last article remains my favorite humble dollar article of all time.. I think you are incredible.
Whatever comes to you and whatever decisions you make…I wish you love.
I’m with Marjorie: Thanks so much, Dr Dailey. And now I’m going to read the article Marjorie references, as I’ve missed some lately.
I have been dealing with the same mortality issues as you for over a year now with similar robust support, for which I am very grateful, If I may add to your well written thoughts, I have chosen to work with hospice to find my way . I’ve had several excellent physicians (and a couple of clueless docs) as well as select family members help with my decisions. I’m still learning to be flexible. I’ve learned to not plan too far ahead since my health and my feelings keep evolving. What works today may not work tomorrow. There are good days and bad days. Don’t read too much into either; but savor the good ones. I was predicted to be dead “in two to four months” several times now. Nobody knows nothing. You cannot be objective about your own health.Seek out those you trust for counsel and ignore the others with good intentions and bad suggestions. Dying is like most jobs, it takes longer and cost more than expected, can often be boring, and has to be done. Sooner or later.
Extraordinary contribution, Max.
The Gaynes family wishes the Gainey family the very best.