“Life like this is just not worth it. I feel sick all the time. I can’t even get off the couch most days. My family has to take care of me, almost like I am an invalid. I have always been an independent person, now I need someone to do everything for me. I am sick of being so weak! My plan is to stop chemotherapy, but does that mean I am suicidal?”
This is the question I heard recently from a patient with metastatic colon cancer. Tom was referred to see me, a psychiatrist in the cancer center, because his oncology team was concerned that he might be clinically depressed. Over the past months he had been dealing with abdominal pain from his cancer, a complicated surgery, and a round of chemotherapy – the first of six. Now, at the start of his second round, he asked the nurse about stopping chemotherapy. Though the oncologist had told Tom before surgery that chemotherapy could slow down the growth of the cancer and give him a longer life, Tom wasn’t sure it was worth it. After surgery, and during first chemotherapy, he had developed such terrible nausea and fatigue that he could not work in his yard or take walks in the park with his dog.
The first thing Tom and I did was review the symptoms of clinical depression – a loss of energy, poor appetite, low self-esteem, guilt, lack of pleasure, sense of hopelessness and, sometimes, suicidal thinking. While his energy and appetite were low from the chemotherapy, he did still have pleasures day to day. He liked listening to jazz music, organizing photo albums and writing campaign letters for a local politician. Given his contributions to his community, and his involvement in the life of his 10 year-old grandson, he thought he was a worthwhile person. Tom denied any heavy feelings of guilt. And he was looking forward to some activities over the coming weeks – a concert downtown and art festival that would feature wood carvings that his neighbor was doing.
At the time of his colon cancer diagnosis, Tom had hoped he would be completely cured of cancer with treatment. But as he learned more about metastatic colon cancer and met with expert physicians, he realized that his disease could only be managed, not cured. His sense of hope evolved from thinking about living another 20 years, to thinking about what he might enjoy in the “here and now.” He hoped to have the energy to watch a baseball game with his grandson and the appetite to enjoy Thanksgiving dinner. “I realized that hope does not have to be wishing for more time, but hope could be about having a good time now.”
When asked to describe his thoughts and feelings about dying, Tom was clear, “I want to live, there are things I still want to do like fishing in the Gulf of Mexico, but I can’t do anything if I keep feeling this bad. No, I am not going to do anything now to end my life or hurt myself, but I want to focus on the quality of my days, not the number of days.” Tom was not suicidal, but he was not ready to continue with chemotherapy, even if it might extend his life.
Every person diagnosed with cancer will have a unique medical journey. There will certainly be times in your journey when you don’t feel like carrying on with treatment. What is most important is to have a detailed conversation with your oncologist about how chemotherapy may help you. Questions may include: Doctor, what would you do if you were me? Are there high quality medical studies that show this chemotherapy will help me live longer? Will I be able to work after this treatment? What might I do day to day to stay as healthy and functional as possible during chemotherapy?
Tom was able to meet with his oncologist and come up with a plan to manage his nausea. His fatigue improved with one week off of chemo and a dose reduction. With these changes he decided to continue with chemotherapy for his colon cancer. Fortunately, he also managed to make his grandson’s baseball game and fish at a local pond, although he is holding out hope for a spring trip to the Gulf of Mexico.
Any person with thoughts of giving up on life should talk to their doctor immediately. Suicidal thinking is very closely related to clinical depression, and depression is treatable. Depression should be treated not only to prevent suicide but also to alleviate suffering. Organizations such as the American Foundation for Suicide Prevention, as well as crisis phone lines 800 273 TALK are available to help patients and families.
Dr. Baer is paid by WebMD to provide/present this information. The opinions expressed are those of Dr. Baer and do not necessarily reflect the views of Emory University or Emory Healthcare.