Cancer is certainly not always a death sentence, and most people find it helpful to hold onto hope. But I have found that many cancer patients, especially those with a poor prognosis, think about their eventual death and whether they will be at peace with it when the time comes. They want to come to terms with it, as best they can, before they find themselves with only days or weeks to live. In this essay, I will discuss how patients I know have come to feel some sense of acceptance about their death, even though it may be several months away. Although it was a gut-wrenching process, it was not an impossible one. If you are struggling with this issue-wanting somehow to feel reconciled to dying, when the time comes, but not knowing how to get there-it may help to learn how other people with cancer have done it. If you have determined there is just no way, because dying feels so inherently unacceptable, it still may help to see how others have traversed this difficult path.
The phrase "coming to terms with death" means different things to different people, and often other phrases are used that convey the same general idea. These include "a sense of acceptance," "feeling reconciled" "being at peace with" "a feeling of equanimity about/' "feeling okay about," "being resigned to," "giving in to," and "letting go." As you can see, there are different nuances of meaning in each concept, and I cannot think of a single conceptualization that captures all of them. Perhaps it's best to say that patients who have come to terms with their death do not feel they must continue to fight or protest it. It can be a long, heart-wrenching struggle to reach that point.
Another aspect of coming to terms with death is becoming less frightened or horrified by it. It would be difficult to approach death with a sense of peace or acceptance if you dreaded the process of dying. It may help to know that in the large majority of cases, the pain and suffering involved in dying of cancer can be effectively managed and controlled by the judicious use of opioids and other strategies. When the time comes, whether from cancer or some other cause, a hospice team or other palliative care specialists can play an invaluable role in helping with a peaceful death. Don't be hesitant to turn to them.
This essay is based not only on what patients in therapy have voiced to me, but also on interviews I conducted as part of a study with patients who were under fifty years old and had a poor prognosis. They sought to come to terms with their death as their cancer progressed and found that perspective, more than anything else, helped them in this process.
When I was at the UCSF Comprehensive Cancer Center, I knew many young patients who had a poor prognosis and who had managed over time to come to terms with the fact that they were likely to die within a year or two. I wanted a better understanding of how they had reached this point, an understanding that would help our team (and others in the Held) to support these patients in the ways they needed. In a semistructured interview, twenty-five of these patients were asked to explain the kind of thoughts, emotions, beliefs, and experiences that had helped them in this process. The interviews were recorded and the transcripts were analyzed to identify common themes or factors (that is, certain thoughts, beliefs, or experiences) that helped these patients in facing an early death. Our research team identified six factors that were relevant to at least 50 percent of the patients interviewed. These were not the patients' initial feelings when first learning of their prognosis; these feelings evolved over time as they sought to come to terms with this prognosis.
This first factor was an astounding finding, attesting to the power of gratitude. It was discussed by 84 percent of the patients. They had looked back over the course of their lives and felt grateful for the number of years they had lived and for the positive experiences they had enjoyed. For most, feeling grateful helped to offset feelings of being cheated of additional life. It is common for older patients (in their seventies or eighties) to be grateful for a long life and for this to balance the negative feelings that death evokes. I learned from the interviews, however, that younger patients can feel grateful too, and to the extent they do, they feel less cheated. This was the most common factor mentioned by the patients I interviewed.
If you are a young person and have a poor prognosis, then you can look to the future and feel cheated of the life you will miss. But you can also look back at the life you have already had and feel grateful for that. Both perspectives are completely justified. One of the patients said that it was her choice-to look forward or to look back-and that she was choosing, and doing her best, to look back and take stock of what she could feel grateful for. Her gratitude provided comfort and helped ease the sting of an early death. She was only forty-two years old.
People who feel entitled to a good life, perhaps taking it for granted, seldom emphasize a sense of gratitude. Gratitude comes from seeing your good fortune in a world where no one's good fortune is guaranteed.
2. A Sense of Pride
This factor-a sense of pride in one's accomplishments or in the inner qualities the person had developed over the years was mentioned by 80 percent of the patients. To feel proud of oneself is a positive feeling that can come from asking: "What have I done with my life? What have I made of myself?" The patients were not boastful about this; in fact, many were reluctant to use the word proud. They were more inclined just to say they felt good about certain things-usually something they had accomplished in work or in their personal lives, such as a long marriage, or being a good parent. When asked, however, they would say yes, it was a nice feeling of pride.
The idea of "a life" unifies our number of years into a whole. This construct has given birth to the question, What have we done with this thing called our life? Have we just lived, day in and day out, without any sense of unifying purpose that spans the years? But if we feel instead that we have put our lives to a positive purpose, then we can approach death with a deserved sense of pride. As with gratitude, this feeling can help soothe the emotional pain of dying young.
3. Religious Faith or Spirituality
Seventy-two percent of the patients said their religious faith or spirituality helped them come to terms with their prognosis. For many, it was the belief in some sort of afterlife, such as heaven or reincarnation. Some mentioned their spirit, essence, or soul-an aspect of their inner being that would live on in some spiritual form. Some had a basic belief in God's will or plan-a plan in which something positive would come from their death or how they dealt with it-and sought to accept their illness in that context. One patient mentioned the idea of surrender to God's will-of letting go and accepting whatever might happen.
Some patients said Buddhist beliefs and principles were helpful to them when thinking about death. In essence, these are beliefs about letting go because of the transitory nature of all that is. The following analogy conveys this essential teaching. Think of the ocean with countless individual waves and ripples on its surface. Underneath, there is only a vast ocean, a whole with no distinct parts. The distinct parts are on the surface only. These waves and ripples come into existence from the ocean, but are not the same as the ocean. They linger awhile on the surface and eventually go back into the deeper sea, the deeper whole wherein everything is one. All of nature, including ourselves, participates in this grand process of coming into being for a short while and then resolving back to our source. This conceptualization helped many patients feel it was okay and safe to let go.