"Nothing in this world can take the place of persistence. Talent will not; nothing is more common than unsuccessful people with talent. Genius will not; unrewarded genius is almost a proverb. Education will not; the world is full of educated derelicts. Persistence and determination alone are omnipotent. The slogan ‘press on' has solved and always will solve the problems of the human race."
-- Calvin Coolidge
The notion that persistence is essential for success and happiness is deeply embedded in our culture. America's founding philosophy is with steadfast determination and unrelenting pursuit, people can overcome all obstacles. We're constantly reminded by Nike commercials, Wall Street, Michael Phelps and Warren Buffett that "perseverance pays off" and "quitters never win, and winners never quit." So profound is the notion of "pressing on" that people would rather endure failing careers, loveless marriages, and hostile work environments than quit. To quit is to give up, to throw in the towel, to give in to failure. After all, no one wants to be perceived as a quitter -- a loser who couldn't hack it when the "going got tough."
To be sure, studies show that persistence in pursuing a life goal can bring about positive long-term effects. Pressing on in times of difficulty can increase motivation, and lead to greater self-confidence, less stress, and overall well-being. On the other hand, "giving up" on attainable goals can lead to depression and low self-worth. But what about situations in which goals are clearly unattainable? Could "pressing on" actually lead to poorer health? What if, by shifting goals, quitters could actually win, and in the process, secure peace of mind?
Research suggests that when people are faced with situations in which they cannot realize a key life goal, the most adaptive response may be to disengage from that goal. In fact, a recent study by Gregory Miller shows that those who could not renounce unattainable goals showed increase levels of the inflammatory molecule C-reactive protein, which is linked to heart disease, diabetes, and early aging. Those who could disengage or shift from unattainable goals towards more manageable goals were able to create a different sense of accomplishment and well-being, and reported better health. Shifting goals to more manageable ones is easier if one already has other alternatives available.
Understanding cultural, physiological and psychological effects of quitting is useful when considering the psychological aspects that underlie the decision to pursue cancer treatment. The NYT's article "In Cancer Therapy, There is a time to Treat and a Time to Let Go" described a study on ovarian cancer where "patients with a shorter survival time...had a trend toward increased chemotherapy during their last three months of life and had increased overall aggressiveness of care [but] did not have improvement in survival." Their findings suggested that "in the presence of rapidly progressive disease, aggressive care measures like new chemotherapy regimens within the last month of life and the administration of chemotherapy within the last two weeks of life [were] not associated with a survival benefit." Further, though it's been shown that patients who choose hospice over aggressive treatment often live longer and with less discomfort, "with aggressive therapy, the majority of the women in the study who died did so without the benefit of hospice."
The decision to terminate anti-cancer treatments is perhaps one of the hardest and most personal decisions a person with cancer has to make. There is no 'right' answer; each person's situation is different, as is each person's will to live. Ultimately, the best decision is whatever feels right at the time. But when the cancer is advancing despite all efforts, there are confounding psychological and cultural pressures that can make the decision to disengage from treatment more difficult.
Strong is the belief that we have to "do something" when faced with cancer. Internally, we believe that we must seek treatment until the end, to press on in the face of adversity. To relinquish treatment is to "give up" and for some, to hasten death. Treatment is seen as a lifeline, as something tangible to hold on to. To end treatment is to be cut off from care, from the doctors and social networks that were an integral part of fighting cancer. Craig said that discontinuing treatment was like flying solo, or jumping out of an airplane without a chute. Craig would rather continue seeking treatment even if only for the peace of mind that he wouldn't be abandoned by his doctors, or by science. For some, staying the course is also perceived as "staying strong." Many want to be remembered for having tried every treatment possible, and for not giving up hope for a cure. To press on is to prove their commitment to not only themselves but to those that have supported them.
It's not always the patient who is reluctant to disengage from anti-cancer treatment. Staying the course is often reinforced by doctors, medical staff, family and friends. Subtle reminders to "keep fighting," "stay strong" and "never give up" urge cancer patients to keep pursuing every available treatment, even when the treatment may do more harm than good. People may just as soon stop treatment in order to have peace and relief at the end of life. Indeed, there can be a great sense of relief from not having to fight. The decision to stop can be overwhelmed by a deep sense of cowardice, failure, or guilt for "giving up" when others were "believing" and "staying strong."
Given our culture's pension for winning, saying "no" to cancer treatment can be emotionally painful. The social pressure to "never give up" can muddy personal decisions in the face of cancer. The problem lies not only in the social pressure to keep trying, but in the way alternative goals are framed. There is plenty of literature supporting people's fight against cancer, and even information on when to terminate treatment (i.e. when the costs of treatment outweigh the benefits). But there isn't much available with regards to helping people through the decision of letting go, of deciding to shift from one goal to another.
Decisions can be much harder when alternatives seem so bleak. But there are alternatives. Rather than couching termination of treatment as being an end to one's cancer process, perhaps the verbiage should describe the change as shifting ones goals to more attainable outcomes, like improving quality of life. As studies show, withdrawal from an unattainable goal (e.g. curing terminal cancer) may enable people to recoup personal resources that can be used to reengage in new goals. Focusing on improving ones quality of life during the end stages of cancer is a legitimate goal. Indeed, living a quality life is an alternative. And in this sense, hospice could be couched as an attainable treatment, offering peace of mind during the end stages of lie, where the focus is not on winning, but on comfort, and honoring a patient's wishes, respecting the process, and valuing life as it happens.
This isn't to say that Mom and Craig were somehow forced into the decisions they made. Rather, this post seeks to address both the internal struggle, as well as the social pressures of "never giving up," which can make deciding difficult. Ultimately, I will never know what was really in play for Mom and Craig, nor will I know their struggles. But, I hope that rephrasing alternatives could somehow help to reduce the emotional difficulties of choosing end of life options. --J
Watch for the next installment on Decisions: Treatment as a Personal Choice
This is very well stated Jill, and a pertinent, practical consideration of quality versus quantity to include the fragility of human life. Truly there is more to explore when it comes to quality of life than what we already or will ever know, and surely more than what science offers in terms of lengthening life at all cost. Heartfelt or conscious alignment and resonance with real circumstances are less measurable yields, yet no less significant in value, no less brilliant in realization. Hugs for ya'll.
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