Dr. Jeff Spiess

          Suicide is a disaster. I’m not talking about people with terminal illness who make the conscious choice to take control of the time of their ending by voluntarily stopping eating and drinking or who utilize Medical Aid-In-Dying. The disastrous suicides I am thinking of are those performed alone, in secret, are the antithesis of good dying, and leave the bereaved with profound pain.

           Gary was a middle-aged man who became my patient when I was a wet-behind-the-ears oncology trainee in Cleveland. Gary had advanced testicular cancer; at that time, the mid-1980s, having a patient with testicular cancer was gratifying, even fun, for an oncology fellow, as this was one of the very few diseases we could cure. Gary’s disease had spread extensively to the back part of his abdomen, next to the large blood vessels and kidneys, and had produced large, bulky tumor masses. The surgery to biopsy one of those tumors, combined with the bulk of the cancer, produced his complaint of persistent pain in the left flank.

         I arranged for Gary to be admitted to the hospital for the start of his treatment, a week of chemotherapy using drugs with frightening but magic names: cisplatin, vinblastine, and bleomycin. This was before modern antiemetic drugs, and this chemotherapy regimen produced severe nausea and vomiting, weakness, low blood counts, and hair loss. The rules of treatment, though, were pretty clear: give the drugs in full doses, on time, coach and encourage the patient as he goes through it, expect that he will be wiped out by the end of the 9-12 weeks, but most likely then he will be cured. Most patients with testicular cancer are young men and have the physical resilience to manage therapy. Gary wasn’t as young, though he was a robust man, so I had every hope of a positive outcome.

         But Gary didn’t play by the rules. He had a great response from the first treatment; the tumors melted, and, after he recovered from the side effects of this first cycle, he felt great. He said he had a personal crisis so he had to delay the next series, but later, his multiplying excuses and skipped appointments made it clear that he would not comply with my treatment recommendations. When his tumors grew back and he felt worse, he would at least talk about getting more chemotherapy. Of course, when tumors grew back, he also had more pain. I suspected that the Dilaudid I prescribed for his pain was more of an incentive for him to show up than his cancer was. He required higher and higher doses of drugs to manage his pain. At this time, didn’t have much understanding about the best ways to treat pain, but we knew that people develop tolerance to opioids, so if he said he needed more, I prescribed more. Gary had cancer, after all, so he probably did have pain. And when things would get too bad for him, he would agree to another hospitalization and get another go-around of treatment.

         The problem with on-again, off-again use of effective chemotherapy is that over time cancer cells become resistant to the treatment, so the cancer gets harder and harder to treat. Each time Gary would finally agree to get more treatment, his disease had not only grown back, but it had spread more widely than before. I saw that we were fighting a losing battle, but Gary tied my hands; I couldn’t force him to try to save his life.

         Eventually, Gary developed weakness on one side; the scans shows very widespread cancer, including now in his brain. He seemed to get the idea that he was in trouble now; we would give brain radiation, and try to get some ifosfamide, then a promising experimental drug. He agreed to the plan, but not to start that day. I arranged for admission a couple days later, and he headed home, with his new Dilaudid prescription in hand, enough pills to just last until his admission.

         This time he actually took the pills. All of them. There weren’t that many, and, given the doses he said he had been using, even this whole new bottle of pills should only have caused him to go to sleep for several hours and awake feeling groggy and sick to his stomach. But Gary died, not from the cancer, but at his own hand. The Dilaudid had been supporting Gary’s lifestyle, as he must have been selling at least most of the drugs he was getting, so he did not have the tolerance to survive this overdose. 

         Gary’s suicide taught me another lesson, though. A common euphemism when talking about someone who has died is to say that they “lost their battle with cancer (or whatever disease).” That phrase angers me, because most of the patients I have known have not lost at all, they continued to live, continued to be themselves, continued to find joy and love and fulfillment. Cancer may have taken their life, but they did not lose anything. Gary, though, lost his battle because he was fighting the wrong war. I’m not sure who he thought he was fooling as he was gaming the system, but when the truth finally became inescapable, he saw that he had only been fooling himself, and that he had lost.
Casket photo by Rhodi Lopez on UNSPLASH