Heroic Measures

The online writings of a woman who has been fighting cancer for seven years invite us to think about the different approaches people take.

Comments: 159

  1. Can those clinical trials looking to enroll patients offer an incentive like help with case management? I'll bet that would improve participation. I have no idea whether it is allowed.

    I personally feel much more affinity with the father-in-law's approach, but, to be fair, he didn't have young children -- I do think that makes it harder to let go. So I applaud the idea of making it more culturally acceptable to manage a disease process without assuming the patient will "win," and maybe that will also allow younger individuals to find new approaches to doing what they can for their children besides trying to extend their (the parents') physical lives.

  2. No one has the right to tell others how to confront the issues related to the end of their life. We will all have that opportunity for ourselves when it is our time. Having lost the woman I loved to cancer which was terminal on diagnosis I must tell you that I find the battlefield euphemisms about cancer to be a bit absurd. Particularly when it is pretty clear that cancer in advanced stages that has traveled to multiple organs and sites will not be stopped and that aggressive efforts to fight it (including trials that are unlikely to help the patient undergoing them) often provide nothing more than the illusion of resistance accompanied by senseless pain, discomfort and continual hospitalization which can obliterate the potential for good, luminous and bittersweet (often happy) time hat a relationship unhindered by all of this drama can provide. When death is inevitable (as it is eventually for us all- including every single doctor nurse and patient at Sloan-Kettering) great palliative care is often of far greater value than spending one more invaluable shrinking minute hospitalized and feeling wretched once more in an illusive quest to win a nonexistent "fight". I know with certainty that it was for my sweet wife and I.

  3. Mr. Keller, my uncle Jack died from bone cancer after 21 months of treatment, age 68. To us, he received a good, reasonable level of care, and that was enough.

    That is as opposed to past news stories, whereupon some uninformed person demands others fund unlimited "heroic" care for another patient. And consider the cases of Mr. Sharon (eight years in an unresponsive coma from stroke) and Mr. Mandela (advanced elderly, end-of-life).

    Now -- does this mean that The Times and other news media finally realizes there is not an unlimited amount of time, resources, and funds for medical care?

    Others and I hope so -- and prepared to be disappointed, again.

  4. I am a hospice nurse. This patient is only 37. I say keep fighting.
    Like Mother Teresa purportedly said, "pray for the dead, but fight like hell for the living."

  5. She must be about 44 by now (she was 37 when diagnosed; has been fighting cancer for 7 years).

  6. Lisa is now 44; she was 37 when the cancer was first detected 7 years ago.

    Whether this affects your argument is a different question.

  7. 44 is too young as well.

  8. Honestly, from reading your and your wife's columns, it is as if you've never read Lisa Adams's blog. She shares her experience in all its pain, ugliness, and rawness, and she's hardly delusional about what's going on (metastatic breast cancer), as she reminds her readers very frequently. I think it is at best misleading to imply that she'd never reach a point of "acceptance" - as a reader of her blog and her tweets, I would say it is very easy to imagine that that point might come, and she's certainly always supportive of others when they choose to, say, enter hospice care. The author of this column seems to have a specific "best" way of handling cancer in mind and is reading things into Lisa Adams's blog that are simply not there. (I began reading her blog last year when a friend was diagnosed with stage 4 breast cancer at 40, and I found it to be very helpful for many reasons, including AVOIDING spouting the pablum about fighting on, etc.)

  9. I think the column is also pointing out that a patient can't take this patient's approach without the resources she has.

  10. I go for my first follow up PET scan since my cancer treatment 4 years ago to see whether my symptoms are progression. Science indicates that once recurrent disease takes hold there is very little to be gained by pursuing outrageously expensive, toxic treatment. Typically young mothers with children are the breast cancer patients most motivated to pursue aggressive treatments, which add greater toxicity and often reduce their quality of life while actually shortening it. They want to live for their children; honorable choices, but medicine has little to offer them that works.

    I draw distinction between Adam's heroic struggle and the uneasy trajectory of patient care at MSK, where Medicaid patients like myself cannot obtain care (I was told I would have to wait 3 to 6 months for an initial consult, while privately insured patients are given immediate appointments). NYU Hospital simply refuses Medicaid patients, saying none of their doctors will offer care. Both hospitals have indicated they will restrict offering care to the newly insured through the health care exchanges, on the grounds that they may not be able to afford the copays, deductibles, and other cost sharing fees, thereby defeating the efforts of national health care reform to provide access to care to all Americans. When cancer care is delayed, or denied it may be a death sentence. When care is given, the financial toxicity can be destructive to patients and families. There is little heroic to be applauded there.

  11. How horrible that money dictates your choice of medical treatment. A shameful indicator of greed in an increasingly uncompassionate society.

  12. I don't feel like Ms. Adams' writings make your father-in-law's choice to go peacefully and quietly seem like failure. And I believe no matter the choice a patient makes, they all deserve to be "unduly" praised. Cancer is an intensely personal journey faced by different people in different ways. Who knows how we will face a diagnosis until we receive it?

    I find the stories of those who struggle to live, and those that accept death, equally compelling in hopes that should I be the recipient of such a diagnosis I will have the lessons of some one else's journey to help me navigate my own.

  13. As one who survived Stage IV throat cancer almost 3 years ago, I spent a lot of time thinking how I would die. My treatment was terrible but I got through it with the help of my dear husband, children and many friends. In those long hours of chemo and radiation fatigue with a feeding tube providing all my nourishment, I decided that if the treatment didn't work and the cancer came back, I would not take the warrior route. There is one place in the world where you do not have to be a resident to get assisted suicide: Switzerland. So should that or another cancer take me to the point where I can no longer function as a whole person, I will be on the next plane to Switzerland.

  14. Lisa ... we're all dying. Not much comfort when the medical people say your ultimate trial may be imminent but, one hopes, some comfort: it's one of the very few things that absolutely every one of us who has ever lived has in common. But here's the difference: you're less alone than almost every human being has been during this time.

    It's a wonderful thing, given the alternatives, to die among family that loves you -- but you have thousands who follow you and are concerned about you. That's given to very few of us: you made a dent. And as others are forced to face similar trials, your counsel will be remembered, and it may ease their passing, as well.

    And it's inspiring to see someone refuse to give up in such straits -- could inspire others to buck up when they're merely facing the difficulties of life, rather than of death.

    But Goodman's right. Just as we shouldn't be second-guessing a woman considering an abortion, we shouldn't second-guess people who have concluded that the slimmest hope of a better life is worth the risk of what almost certainly lies before them.

  15. There are those who will fight their condition to the very bitter end and others who decide to quietly slip away. I see no reason to disparage one or the other type of person.
    We need the Lisa Adams in this world to help advance research and help better understand cancer. We also need those, like your FIL, to show us the sanctity of life and how to end it with dignity.
    It is not a matter of praising one approach or another, making a hero of one and a villain of the other, as far as I am concerned.

  16. A young mom is going to do whatever she can for her kids. In this case it is to fight for her own life. As with most medical decisions each life is unique and the end is a mystery. I am glad she has found so many reasons to live.

  17. First, she has young children.
    And, second, many women with her type of breast cancer live for quite a long time on therapies that do not seem to have worked for her, so I think that it make sense for her to try some of the new and specific treatment approaches that are becoming available.

  18. It's interesting that yesterday Maureen Dowd wrote about Paul Tsongas who, when running for President in 1992, said he was cancer free and this was confirmed by his doctors at Dana-Farber, a cancer center every bit as respected as Memorial Sloan Kettering. As it turned out it wasn't true. What was troubling was the willingness of the doctors to participate in a lie. This raises a very major issue commonly encountered in care of patients with terminal illness: the unwillingness of physicians to be honest with patients and their families about the true prognosis.
    As a physician involved in palliative care,
    I have often observed situations where terminally ill patients and families have a clearly false view of prognosis. Sometimes the treating physicians have purposely misled them to encourage them to continue treatments, sometimes, sadly, because it generates income to them; sometimes it's a result of physicians trying to put as good a face possible on a very bad situation.

  19. I am also in hospice and resonate so much with a young mother's desire to be there for her children. Young breast cancer patients do often respond to new therapies temporarily but any metastatic solid tumor will be fatal eventually-at some point, a realistic assessment of the risks and benefits, and the opportunity to spend some quality time at home free from the horrific side effects of chemo, might be the better option.

  20. It is perplexing that you write about Ms. Adams' legion of online followers without mentioning that many of us found her blog because it was listed in the Motherlode section of the NYT. And while many have been reading her clean, direct prose for some time, you obviously did not read enough to know that she has written extensively about why battle and warrior metaphors are unsuitable for describing cancer patients. I see Lisa Adams as a talented memoirist. It's not relevant to me whether her output comes in book form or on 140 character blasts.

  21. Lisa is not someone who employs battle metaphors (read her writing). Like myself, she hates the tropes of war when it comes to her disease. Also, it is far different to face cancer as someone at the tail end of their life than as someone in their prime. To compare your father-in-law's experience with that of a woman in her 40s is ridiculous. And to question what a person shares about their experience with cancer -- my god, do we take to task the person who spouts platitudes about how "beating" cancer made them a better person? Why is it that when someone shares the realities of living with an incurable cancer diagnosis, it is suddenly too much?

    Maybe you are confused because you don't know what it looks like for someone to live with advanced cancer. Guess what, it looks like this. It is spending time in hospital, it is coping with pain and experimenting with drugs. It is giving your body over to medical teams and research, not just for yourself, but for others who come after who will benefit from what is learned from your body.

    I was diagnosed with ovarian cancer in 2003 at 22. It came back in 2010. I have written about the mental, emotional, and physical trials I have been through, and I will continue to write and advocate for those with advanced cancer. I am not battling cancer, I am living with it. I'm sorry if that makes you uncomfortable.


  22. Please see other practitioners to use other approaches. There are so many alternative approaches that the Science Press Council does NOT allow to be printed, only negative stories about alternative approaches can be published, hence the skepticism over alternative treatments. Yet, we are not skeptical when we read a story like today's of treatment that also does not walk all the time

  23. It's a choice for how you go, but not when. Lisa is happy with her choices. This reminds me of Jane Pauley on CBS's Sunday Morning today before I left the house: " "I send my family pictures sometimes, a view out of my window on the Mississippi River in St. Paul. The moon rising over Monterey Bay in California. I sent these pictures and Garry sent his response, it was a text: 'You really are seeing the world.' And I thought, I not only seeing the world, I notice it." " Thanks for "noticing" life, Lisa, and sharing it.

  24. If you feel that Ms. Adams' decision to live her cancer onstage invites your readers to "debate it" then your readers should know the facts. Some facts and my thoughts:

    1) Ms. Adams has THREE young children, not two as noted in your column. As a cancer survivor and mother of young children, I know first-hand the sense of purpose having kids would give any cancer patient. I would fight tooth and nail to see my children live for as long as possible.

    2) Ms. Adams has not "spent the last seven years in a fierce and and very public cage fight with death." According to Ms. Adams, she first was diagnosed in 2006 and it was not until 2012 that she learned the breast cancer was back and had metastasized in her bones.

    3) Describing Ms. Adams as the "standard-bearer for an approach to cancer that honors the warrior" is such a misrepresentation of her digital presence. It was Ms. Adams' blog that made me appreciate the negative connotations of the "battle" metaphor. As she explained, if someone "fights" cancer and dies, does this mean she did not try hard enough or fail? Of course not.

    4) You juxtapose Ms. Adams' choices to your father-in-law's, but fail to explain that she may be at a very different stage in her cancer progression than he was when he decided to accept "inevitable fate with grace." Ms. Adams stated that she is not on her deathbed yet and is in the hospital getting treatment. She still has life ahead of her and in my opinion, we should just let her be.

  25. You know who else cringes at the combat metaphor? Lisa Adams, as she has strongly and repeatedly stated on her blog and elsewhere. God only knows why you chose to characterize her this way -- cruelly, judgmentally, and incorrectly -- given that fact.

  26. Lisa Adams is a very valuable teacher, not just in terms of all the medicine involved, but in the humanity she portrays. The Doctors will learn from her, and she will teach them empathy.

    This was a great story, thanks.

  27. Your comments reveal an incredible lack of knowledge of Lisa Bonchek Adams and the value her blog posts have for those of us who are facing a devastating diagnosis and illness, or have family and close friends who are.Your comments are careless and heartless, and seem to deliberately misunderstand her posts. You even question whether her posts been a public service - revealing remarkable arrogance. Her posts are informative, educational,written in easy to understand language that readers can comprehend and apply sometimes in their own medical decisions, and sometimes to understand a loved one's decision-making. What personal feelings or experiences could possibly prevent you from understanding this?

  28. Breast cancer is in reality a series of diseases, some that will not affect survival (such as intraductal cancer) and others that, by the time they are found, have become invasive, at times relentless, resulting in our premature death. A number of these malignancies cannot even be seen by mammograms or ultrasound before they spread, metastasizing to bones, lungs, liver, brain. There used to be a current of magical thought advocating a warrior attitude to 'beat' this cancer, or the need to have a positive attitude...or else, almost suggesting that a lack of will or concentration on our part was somehow responsible; or even submit to incantations of a religious nature, to hopefully conquer evil spirits, and reverse the process. Clinical trials are most important to find effective combinations of ?medication, ?radiation, ?surgery, ?immunotherapy, and eventual personalized therapy to at least acquire symbiosis ( a truce of sorts... as it may be difficult to eradicate our own cells that have become malignant). I feel empathy for Lisa Adams, a courageous woman in a desperate situation. Tomorrow is another day, and we must trust that we are gathering the best minds and resources efficiently... and the sooner the better.

  29. Readers unfamiliar with Lisa's writings should be aware that this article displays a number of factual errors. Lisa has not, as the author writes, "spent the last seven years in a fierce and public cage fight with death." To the contrary, she was in remission for five of those years. She has not treated her terminal disease "as a military campaign." In fact, each year on Memorial Day she writes an inspiring post honoring the members of our Armed Forces for their true bravery and heroism. (http://lisabadams.com/tag/bravery/) She is not, as the author suggests, the "standard-bearer for an approach that honors the warrior." Rather, her writings are about the power of connection, caring, and appreciation. Each morning she encourages people to "Find a bit of beauty in the world today. ... Some days this may be hard to do. Persevere." Finally, she does not "raise false hopes," but goes out of her way to counter such thinking. (http://lisabadams.com/2012/06/28/the-hidden-danger-of-hope-the-stockdale... The author suggests we honor those who accept their fate with "grace and courage." Lisa has written of her desire to use "the time I have now while I am able to be functional ... to teach, to enlighten, to share, to support, to fundraise for research… and to always honor those who have died." It is unfortunate the author and his wife couldn't find this also worthy of "equal praise."

  30. Help me out--I thought I was reading the paper of record? This seems like a great post for a gossip blog. Not for nothing, Mr. Keller, but Ms. Adams has three children, not two (the quickest glance at her site would indicate this?) and has openly rejected militarization and war metaphors when it comes to her diagnosis and treatment. I'm not sure why you chose to use that sort of language, but it seems like it is largely your interpretation?

  31. Sensitivity training? Perhaps we need to go back to basic human empathy.

  32. I checked, and the website of Caring Canines (http://www.mskcc.org/cancer-care/counseling-support/canine-therapy) specifically mentions that its team is made up of volunteers. I don't think it's accurate to present this as a mysterious, expensive, or exclusive perk - the other amenities mentioned in that sentence may be unusual, but it doesn't sound like the pet therapy is. I thought it was important to note that this could be available to anyone in a facility with such a volunteer program, because my family member was in an Alive Hospice facility and was very happy to have visits from the pet therapy team, who were also part of a volunteer program.

  33. The best advice I ever received, shortly after being diagnosed with breast cancer at age 42, was "never trust anyone who tells you what they would do if they were in your situation." Everyone's cancer is unique, and no one else can know what it's like to be in Lisa's shoes. This writer has no right comparing Lisa to his father, nor advising her on what she should do.

  34. As a physician I try to provide patients the same advice regarding care that I would give to my family members and I expect physicians who care for me and my family to do the same for us.
    If you don't believe your physicians are treating you this way, I would strongly suggest you seek care from others.

  35. This should be a matter of choice totally left to patients. Doctors, hospitals and government should have no voice in this decision.

  36. There are many issues about cancer patients and social media. This op-ed, though, is a mean spirited ad hominem attack on the choices that a woman and her family made for her treatment. The real heroic measure here is that someone who is sick became a strong online advocate for herself and others like her. That should not be second guessed by anyone, much less a journalist.

  37. I always wonder about people in the "control group". I am not a research scientist, but this might explain the reluctance of some people to participate in studies.

  38. Your characterization of "palliative care" and the related lung cancer study does a great disservice to cancer patients. Palliative care is a specialty that provides comfort care to patients and family members from the day of diagnosis -- before, during, and after treatment. Cancer patients can be receiving aggressive treatment and still receive palliative care.

    In the lung cancer study you mentioned, patients were assigned "to receive either early palliative care integrated with standard oncologic care or standard oncologic care alone." This means the patients were receiving active cancer treatment. They were not "going gently." They were trying to stay alive.

    An article recently published in the Journal of the American Medical Association indicates others suffer from the same lack of understanding as you. It states, "Seventy percent of Americans describe themselves as ‘not at all knowledgeable’ about palliative care, and most health care professionals believe it is synonymous with end-of-life care.” http://www.nejm.org/doi/pdf/10.1056/NEJMsb1305469

    Palliative care may be offered during hospice, but palliative care is NOT the same thing as hospice. Cancer patients in treatment need comfort care too. Misrepresentations such as yours will keep many of them from getting it -- they'll think palliative care means the doctor has given up.

  39. Sounds like you work for the medical industry where the standard "cut, poison and burn" is the only option. The war on cancer is a complete failure ! After all ,why would you want to cure something that puts you out of business and makes you billions of dollars.

  40. Mr. Keller didn't indicate whether or not cancer patients who agree to participate in research programs have all their medical expenses not covered by the patient's medical insurance picked up by the research organization. Knowing that their family won't be bankrupted by fighting the cancer would encourage many patients to participate in research programs.
    As for me, I recently quit after 40%2B yrs of smoking. After watching one family member and a couple of friends go through the fruitless pain and trauma of "battling" cancer, if my four plus decades of vice does catch up with me in the form of a lung cancer diagnosis, I'll go for the morphine drip.

  41. The Twitterverse is agog at the callous, insensitive tone Keller takes in his column, and the numerous and important factual errors about Lisa Marks. That storm is about to hit.

    So I'll just focus on one essential point. It hardly seems fair or logical to compare the cancer treatment decisions of a 37 yr old mother of 3 young children who was diagnosed fairly recently (not seven years ago as stated) against that of an 80 yr old man with numerous other chronic health issues (pacemaker, diabetes, incontinence, depression.)

    Keller's father-in-law opted for entirely reasonable (and fairly standard) palliative care appropriate to a person of his age, medical issues and prognosis. It was only unusual in that he remained in a hospital, rather than dying at home or in a hospice.

  42. Thank you. Having watched a friend die at 42 and leave behind her children, but fight until the bitter end, the choices that my friend fought to make to giver herself the time for her daughter to grow from 3 to 5 years, and start kindergarten, can in NO WAY be compared to the choices a much older adult, whose family has grown and is at a much different stage of life, would make. While I despaired for my friend and wish that some of the time she had with her children had been less impaired by pain and surgery, there is no way that I wouldn't fight to see my children grow up with every weapon in the arsenal if I was put in that position. Cancer is not one size fits all. Keller's false equivalence muddies the issue.

  43. Exactly!

  44. One of my greatest friends waged a similar battle. Diagnosed with breast cancer when she was 28 she endured treatment after treatment with one merciful multi year remission. Her wonderful oncologist came to know her personally and understood her every need. She saw children grow and graduate. We traveled to Europe, saw great theater, debated world politics and worked for charities. She rarely missed work. She wanted every medical option available and took the time it gave her and made the world a better place. She died peacefully at 46.
    This is a discussion about choice, not right or wrong. Rock on Lisa .

  45. Age may have a lot to do with it. I have known older adults with a new cancer diagnosis. Some of them generally in good health with good mental capacity who have chosen not to do chemo or any other treatment. Often they feel fairly well when diagnosed. The decision is to live well. One, who had pancreatic cancer, had one of the best cancer deaths I have seen. She was really only "sick," i.e., in pain & nausea, for about a week before she died after having had some uncomfortable, but not painful, foot swelling for a week or two before that.

    I have known others to begin chemo, but quit when it made them sick and landed them in the hospital for things like dehydration (diarrhea/vomiting). One lady in this group went on to live a pretty good life for about 18 months before she became 'sick.' She was 82.

    An important question has to do with whether the treatment will truly prolong life - or whether it will simply make what life is left miserable. That will vary from person to person and from cancer to cancer. Treatment choices are highly personal and should be respected whatever they are.

  46. Many of the people I know have had chemo, radiation etc and were send home to DIE, but decided to have intravenous Vitamin C and recovered. Two personal riends -one 45 had breast camera return and the other 88- had lung cancer after radiation had "cured"them, only to have it retun in one and produce lung cancer in the other. .Both are now cancer free after intravenous Vitamin C and a diet of No sugar, wheat meat. They had been through the
    "regular" treatments and know now that one has to HEAL, more than fight. I have met others of all ages who have had colon, pancreatic and many other kinds of cancer. why is it so difficult to believe that There are more humane ways to deal with cancer, and they are effective? Could it be that it is because they treatments cost less than 10% of the big Pharma drug!!!!

  47. Insanity is doing the same thing over and over and expecting a different result. Forget the poison treatments and try huge does of intravenous Vitamin C or ozone. Many others and I have lived a healthy painless life with cancer for years. There are alternatives the DO work.

  48. The "choice" to employ aggressive cancer treatment is only available to a small number of people in wealthy developed countries.

    In the US countless poor and working class people have not been able to avail ourselves of cancer treatments, and as the cost of cancer care shoots astronomically high even the middle class has been priced out of life saving care. Even the staid American Cancer Society took the controversial position years ago that research efforts no longer were the determining factor most important to saving lives, it was lack of ability to pay that killed more people, unable to access any treatment at all.

    Cancer bankrupts patients, their families, and remains the most expensive disease of all. Once patients are sick and disabled by the cancer or by the treatments, paying for further care becomes an insurmountable obstacle. The topnotch hospitals like MSK, where Ms Adams is being treated, severely limit access to the poor, Medicaid patients, and now even the newly insured by Obamacare, believing that such newly insured patients will not be able to pay the deductibles and copays they will be subject to. Alternative and complementary care, not covered by insurance, are completely out of reach.

    I wish every cancer patient had the choice of whether to pursue aggressive care or not, but that is only so for a small sliver of humanity. For the rest of us such choice is an unreachable luxury.

    We need single payer.

  49. The choice to receive palliative care is also available only in a limited number of countries. A global survey by the European Society for Medical Oncology found “a ‘pandemic of untreated cancer pain’ caused by too strict regulation of pain medication.” You can read about the survey results here:

  50. The Brian Stauffer graphic that accompanies this piece is stunningly moving. I was reminded of Omar Khyyam's famous quote:

    “The Moving Finger writes; and, having writ,
    Moves on: nor all thy Piety nor Wit
    Shall lure it back to cancel half a Line,
    Nor all thy Tears wash out a Word of it.”

  51. I wish I could have blogged about my mother's fight with uterine cancer how Henry Ford Hospital in Detroit shunned her because of her age & while Karmanos Cancer Center treated her it was already too late how my sisters & I witnessed this alive active woman reduced to pain, chemo and supportive living the excruciating pain she felt during the last month of her life not to mention the hospice staff who allowed her to die at peace & dignity. There is nothing wrong with Lisa Adams talking about her cancer her fight her hopes & her pain. Shame on you Kellers for saying otherwise

  52. right on

  53. An oncologist is trained to do whatever it takes to keep his patient alive (and is really good at it) while a living organism has a strong will to survive no matter what. Put the two of them together and you will often have the situation of a terminal patient's life is going to be extended a few months beyond its expiration date by the marvels of modern science. But I can't see the wisdom of staying alive a few months longer and prolonging my suffering through "heroic" and very expensive measures unless I had some very important mission to complete. And what does all this money spent on patients during the last few months of their lives mean for a society trying to move to affordable universal health care? The thought of having install government "death panels" to keeps costs down is enough to kill the idea of universal health care. So for improved quality of life at end of life and for the benefit of society, doctors need to present to their sickest patients realistic alternative choices where they currently are not.

  54. Perhaps there is a better quality of life, when one places ones energy in loving others, rather than clinging to self.
    Both combat with cancer and acceptance of advanced cancer offer the possibility of caring for others.
    I myself, think it will choose the path of non violence, as I attempt to in my better days living in this conflict ridden world. Leaving loved ones with kind words seems more important than being in a state of pain sedation with loss of mental clarity.
    A personal choice for me, but I wish well for all who take up combat against cancer for themselves and others.

  55. A tale well told.

    A fiercely determined struggle for life can, in the long run, end only in defeat. If modern medicine is full of its wonders, we should retain the realistic modesty to grasp that what we can do is small in comparison with what we can't.

    We will help each other understand what twilight is like only by sharing our experiences of it, as here. Then it won't be a tragedy or surprise when the sun sets.

  56. I too have been concern with the language around cancer and other diseases - warrior, war, victim, fighting 'xxx'. As a parent of a child with a severe disease- this language then suggests the opposite when we choose alternative treatments and that somehow our plans are less. The strength it takes to take the path of death is much more difficult than the strength to 'fight.'
    In addition, where does the separation between the person and the disease begin? I refuse to let my son be defined by his disease. Instead we choose his last days to be words of love.

  57. It's really disappointing to see this outlook in the NYT, which until now I've appreciated for bringing new information about cancer research and treatment, wellness, and healthy living to light. Does Mr. Keller feel the same ambivalence toward Suleika Jaouad, who has brought young readers to the NYT through her equally stirring and powerful writings about her own struggle with cancer?

    It's also very unfortunate that Mr. and Mrs. Keller felt it necessary to write these hurtful editorial pieces within days of each other. For individuals who have both had personal encounters with cancer, your lack of empathy is astonishing.

  58. Beware the power of the written word, my friends. This piece raises some important questions about end-of-life care decisions, about the effectiveness of clinical trials, about the way cost may limit some patients' access to medical care - but it does so in what, after Emma Keller's Guardian piece, feels like another round of playground bullying. I'm certain that Ms. Adams knew that she would leave herself open to criticism by making her experience public, but the Kellers' bilateral assault on her decisions seems strangely petty. Both pieces also reflect a fundamental misunderstanding of her message, because Ms. Adams has repeatedly made it clear that yes, she is dying, that Stage IV breast cancer is not curable, that a resolve to fight or acceptance of prayers, positive vibes and good wishes will not make her cancer go away. She has, many times, reminded her readers that there are thousands of cancer patients who are neither interested in nor able to maintain the "warrior" role.

    Lisa's writing is not perfect. Her choices may not be those we're all inclined or able to make. But she has long honored those who make different choices, and has asked her readers to do the same. I'm sorry Mr. Keller missed that point.

  59. I should point out that Ms. Keller @emmagkeller has refused to engage on Twitter as it relates to her Guardian op-ed, except to thank those who have "tweeted" in support of her article.

  60. The premise here is that every "fate" is inevitable. If we accept that premise, why should we use medicine at all? Why fight the totalitarian plutocracy? Why bother to attempt to create lives of our own? I prefer Dylan Thomas's view:
    "Do not go gentle into that good night,
    Rage, rage against the dying of the light."

  61. As is usually the case, each person has a different experience when it comes to dealing with cancer.

    My wife, at the age of 45, chose and survived surgery, chemo, and radiation treatments for her breast cancer. There were plenty of tough days but she got through it and is still alive and enjoying life 20%2B years later.

    My Dad accepted chemo when diagnosed with lung cancer at age 88 because he was told it would prolong his life and reduce the pain he would probably otherwise experience. The treatments made him so ill he had to take a 2 month respite from them. He had about 2 months of feeling relatively better before he rather quickly passed away. All told, he lived less than one year after his initial diagnosis.

    My Mom's lung cancer, at age 89, was so advanced that surgery, radiation, and/or chemo were not really viable options. She chose instead to receive palliative care with a great Hospice nurse who got and remained incredibly and supportively engaged. My Mom lived 13 months after the diagnosis when the docs predicted she might live about 4. There were moments of pain and despair. But overall she lived 12 of her remaining 13 months to a very full degree with us middle aged%2B kids and our spouses, her young adult grandchildren, and some very dear and close friends. It was a blessing overall to have been able to spend so many good moments with her in those last months.

  62. I find this to be a harsh, bitter and ultimately unfair comparison between two very different approaches and situations to a similar disease. A more nuanced and balanced approach could have generated a more useful conversation starter.

  63. Patients in the United States, no less than those in Great Brittan, ALWAYS have the option of being , as you say,'unplugged' from extraordinary measures.
    The dilemma here is what you describe later in the piece, the mindset that has developed, and much advertised in the media, that certain people 'beat' cancer. 'Beating cancer' is now part of our accepted lexicon. Treatment is far too often oversold to those who really aren't likely to 'beat' cancer.

  64. In Great Britain, you can get a prescribed cocktail that will put you out of your pain while here in this country it is illegal.

    For decades, researchers have known that there are better solutions to cancer prevention and its treatment than taking a toxin to see if it kills the cancer before it kills you. If the cancer does not kill you, and it usually does, your body is in a weakened state open to all kinds of illnesses where quality of life is poor.

    Recently a few are starting to speak out knowing that the body has the ability to fight off cancer if only the science allowed research to develop the triggers the body needs to defend itself. The question that needs answered is; why after billions of dollars and promises of a cure around the corner; we have nothing but empty promises and less money that make for richer cancer fundraisers. The lies told and led to believe is criminal and the deaths of millions is a crime against humanity. It is time we hold all profit making entities at our expense accountable for their transgressions against life

  65. I would not stare death in its dark, hollow eyes with any effort at grace. A measure of courage is inevitable and more of it, not for display but for the moments of inner peace it might bring, would be welcomed.

    We torture people to death in the name of keeping them alive. The elderly are the targets of this torture and they deserve something better in those last, few days. Then, quietly when even the slimmest hopes are shattered, they are given morphine to help them with the "transition".

    We have gone off the deep end and cannot find our way back to land. We are living a bad joke of victory over death so that pain can be prolonged as a barely beating heart receives the message. No one is laughing.

  66. As Mr. Keller points out in this column, it was his wife, Emma G. Keller, who wrote the Guardian op-ed.

  67. One point overlooked (unless I am the one who overlooked it) is that circumstances play a role in treatment options. What a person is willing and able to do at seventy and beyond may be very different from the treatment one chooses at fifty or younger. Death is certainly inevitable, and I watched my mother face it "with grace and courage," refusing treatment options that might have bought a bit more time, but not much quality of life. I have one sister who had difficulty with her anger at my mother for not fighting harder; I understood how tired she was. But she left with a sense of a full life and she was ready to go. On the other hand, i have a friend who is a cancer patient who, like Ms. Adams, is far from ready to let go because he has so much more he wants to accomplish. If death is inevitable, it will come, but the decision of Mr. Keller's father and of Ms. Adams are two entirely different stories and it isn't necessary that one must be silenced in order to tell the other.

  68. Age makes an enormous difference. Awareness of the imprecision of medical science is another factor: doctors do not always know what will turn out to be fatal. They also do not know which treatment will work on which patient. On the other hand, sometimes the treatments are truly far worse than the disease. Buying time in the the hope of new treatments is also a rational strategy. One thing is clear - when there is a reasonable chance for a meaningful recovery, and a patient opts to fight on, he or she should be "allowed" by the world at large to do so.

  69. Treatment choices should always be made with the PATIENT'S values in mind. Not the doctor's, and certainly not the op-ed pages of the NY Times.

    I find it both laughable and enraging that someone sees fit to pass judgement on a young-ish mom's choices on cancer treatment, using an elderly man (his father-in-law) as the paradigm for graceful death.

    Lisa Adams has chosen to fight, so she can see her children grow for as long as she can. I don't fault her for that decision, nor do I fault Bill Keller's f-i-l's decision to go gently into that last good night.

    It's only when the medical machine turns off the "shared" part of shared decision making that we wind up on the crazy train. Witness the case of Marlise Munoz in Fort Worth, where a brain-dead woman is kept on life support at the order of the state, against the wishes she expressed in an advance directive. I'd suggest Mr. Keller take up that topic, and leave Lisa Adams to soldier on.

  70. I am perplexed that The New York Times found it appropriate for Keller to essentially rewrite the column that his wife wrote for The Guardian last week.

    Clearly, Lisa Adams is a person about whom the Kellers have strong feelings--such strong feelings that they seem to have obscured Bill Keller's grasp of a number of facts, among them the number of children Adams has, the length of time she has been dealing with her diagnosis of metastasis, and the value that Adams places on palliative care.

    Keller seems determined to draw a distinction between palliative care and cancer care (a short-hand term I use to include chemotherapy, radiation, or any other treatment designed to reduce the number or size of tumors), but even the most cursory read of Adams's Twitter feed and/or blog makes it clear that she is pursuing both.

    Clearly this is a personal issue for Keller as he points to his wife's own brush with cancer (something she, like Adams, wrote about in a public forum) and his father-in-law's death. Being so close to the topic, Keller seems determined to insert himself into it. It is Keller's opinion that Adams treats "her terminal disease as a military campaign"--but that "combat metaphor" that made Steven Goodman at Stamford cringe is one that Adams has also plainly rejected.

    It is unfortunate that Keller took so little time to get to the know the subject of this column. With the barest of efforts, he could have seen the "'grace and courage'" right under his cursor.

  71. Remarkable person. May God be with her.

  72. My 40 year career as an RN (including hospice care) has informed my decision to decline treatment should I be diagnosed with cancer. I am 71 now, healthy and very active. My objection to treating cancer is that if it can be cured, then what of another illness, and another? Do I want to lie in a hospital at age 98 dying of------absolutely nothing? No. I refuse to watch myself become debilitated and decrepit. I want to end my life when I still have a good life, on my terms.

  73. Keller's piece is bombastic and judgmental, and not worthy of his journalistic talents. Though I have not followed Adams' blog, I did follow the trajectory of a friend's struggle with metastatic breast cancer for the 15 years between her initial diagnosis and her ultimate death. In the interim, she watched her three children grow up, managed a busy psychotherapy practice, danced at a daughter's wedding, and held her first grandchild. Who is to judge her? Thank God she was willing to be a human guinea pig for the women who have yet to be diagnosed with this disease. There is a world of difference between a young mother able to make her own decisions and an older man at the end of his life. Each made choices in light of their own circumstances. I'm a great advocate of humane, end-of-life care, but to deny treatment to one who seeks it is as cruel as denying hospice to those who wish to die in their own way.

  74. The beauty of this moment in time is that we have options. We have the bounty of solace and palliative care through hospice, we have the advantage of research and trial drugs, and we also have the online realm, which offers measures of both comfort and research.

    The other thing that I hope that we get to is acceptance—the compassion to allow and understand that one approach does not negate or diminish another. How is one path any less grace-filled than another?

    I think what Lisa is doing, and what women like Susuan Neibur and Dawn Gentz before her did, is pulling back a curtain to reveal a side of living with cancer—fighting, resting, accepting, combatting, and ultimately having a very human, very real experience with a disease that is more than a pink ribbon and the month of October.

  75. I am a Hugh fan of Bill Keller's columns. I think the tone of this one is all off.. A total miss for me.
    I agree with his Father in Laws' choices, but I think his comment about the young woman lacked any empathy and was unhelpful in the debate he wished to inspire.

  76. Why is there a perception, particularly in the case of Mr. Keller, whose wife's tactless and brutal "analysis" of Lisa Adams' blog and tweets caused a horrified reaction among her followers last week, that her method of dealing with her illness somehow diminishes the path his father chose? Is there not enough room for patients facing death to choose any number of end games? Are age and family status not factors? (Mrs. Adams is the mother of three children, by the way. A look at her blog features a picture of her family. What a careless error for Mr. Keller to make.) If I faced metatastic breast cancer when my children were young, I would have fought tooth and nail to buy time, which is what Lisa Adams is doing. I am 70 now and would fight as well to spend time with my husband and watch my grandchildren grow. At 80 or 90 I might choose to bow out peacefully and quietly.

    I appreciate Mr. Keller's use of his reputation and access to powerful media to try to redeem his wife's egregious and demeaning piece in The Guardian. How knightly of you, Sir. However, should you or your wife choose again to tread all over another's life, I would hope you would rather choose one of your own lives and leave others alone.

  77. We are all on our death beds, inexorably, every day. The challenge is to accept it and face every moment with integrity and authenticity, making your life meaningful to yourself and those around you, whether you live to 30 or 85.

  78. Reading LIsa's twitter feed and blog has taught me a great deal about living and appreciating the cards you have been dealt each day. One technical thing I've learned is that palliative care includes what I had previously thought of only as cancer treatment. That MBC patients need to fight their tumors with chemo and radiation in order to get pain relief was eye-opening to me and Lisa's struggle. Thank you, Lisa for your generous spirit and grace.

  79. Long ago, when I was in grad school, my adviser had a recurrence of cancer. We grad students rallied around. It was clear to me he was losing his "battle" - at barely 40 years old. What also became very clear was that he was really unable to deal with his own death. Nor were the doctors, many of whom were his friends.

    I concluded, at the time, that how he dealt with his illness and his dying was his choice alone. And it was not up to me to judge, but to "be there".

    I am reminded too of a fellow college classmate, whose battle with Pancreatic cancer lasted for over 5 years - during which our class (a group of about 125 women) organized a weekly email and "prayer circle" - which was not only helpful to our classmate but has endured, even though she died nearly 3 years ago now.

    Though she reached out to us and kept us informed, I never thought she was looking for attention. Only for sustenance. She was courageous in disclosing her illness and at one point, when the cancer recurred, she wrote us that she didn't know any other way to cope - but to fight.

    Fight she did! And formed a support group for others facing the same cancer. She had 5 more years with her dear husband, her daughters and their children.

    When it came her time to die, she was an inspiration. She went into hospice. She met with two of our classmates just a few days before the end. She told them of how she could already sense the afterlife - as a nearby place. She gave us that final gift!

  80. Did your father-in-law have 3 young children? Have you read Lisa'a blog? I could go on, but I'll stop with this: I only hope my writing stays obscure, because I'd hate to think that I might have to withstand not just dying of an untreatable disease while my child is still at home but also this kind of thinly veiled attack on my treatment choices and self-expression. For shame.

  81. The palliative care decision could only be the last choice once all the treatment options are exhausted, and informed medical opinion supports such preference for calm and peaceful death.

  82. During the Obamacare debates, Rep. Alan Grayson (FLA) made a poignant argument criticizing the Republican alternative. He summarized their "plan" as 1. don't get sick, and 2. if you do get sick, die quickly. However, holding this plan up to the light, it actually makes sense.

    First, we don't really have health care. We have sick care. We should put more resources into getting and keeping people healthy. So much money is spent on treating preventable disease. And so many economic forces have a vested interest in those preventable diseases. This cycle should be halted.

    Second, we spend an awful lot of money on keeping people alive in hospital beds for an extra month or two. Without minimizing the value that this may have for patients and their families and also for research, we should be more realistic that helping people transition into the afterlife will often more beneficial to the patient.

  83. Excellent. Thank you for inserting palliative care as equal to the big fight to survive cancer. We in America are culturally biased toward competition. When this extends into end of life decisions, what results is pain, medical expense, anxiety of loved ones and a fruitless effort to delay the end. And I would add, if children see this struggle and think it is for their sake, are we not leaving them with guilt, if not trauma, as their legacy?

  84. Patients' reluctance to enroll in clinical trials may be because they are not covered by insurance.

  85. Also because they don't know whether they're getting real medicine or placebos and don't want to take a chance. Can't say that I blame them.

  86. If one is in a clinical trial, it should be paid for by the people conducting the trial.

  87. How is it acceptable to use the NY Times Opinion page to criticize one woman's personal choices? She is one woman sharing her life with an audience who chooses to listen to her. And learn from her. And laugh with her.

  88. The choice is the thing.
    My choice at 65%2B will be a lot different than my choice would have been at 25 or 35 or 45. Type of cancer and stage of disease will make a difference too as will whether one has a supportive family and friends and how old the children are. It's very personal and at my age and situation my plans are made, written and understood by the people who love me: as much peace and comfort in my efforts to shuffle off as can be managed.
    Plan for a good life and plan for a good death.
    Expect surprises.

    P.S. There are many more ills that end our lives than cancer. Cancer gets all the press while cardio-respiratory conditions, diabetes and all the neurological syndromes are just as painful, harrowing and final.

  89. A dear friend of my sister's fought breast cancer for a decade. I think her youngest (of four) was around 10 at the time of diagnosis. After the first couple of years, it was pretty much taken for granted that she was going to die. But after recently receiving treatment with something called the cyberknife, at a hospital in northern Virginia, she has no signs of the disease, and a new lease on life.

    I think part of the bad reaction to Mr. Keller's piece has to do with the fact that in our country, doctors often don't know when to stop treatment and let people go, and a lot of patients and their families seek immortality through medical care, and such a high percentage of the US' medical bill is spent in the last half year of life. I have been highly critical of Mr. Keller's stance on other issues, but in this case, I don't feel as if Mr. Keller was criticizing Ms. Adams' choice.

    My parents both checked out via in-home hospice care. My two siblings and I were in complete accord about that. Both lives could have been prolonged, but to no particularly good end. (And I strongly believe my father chose his time, as nothing was obviously killing him, but he was tired of being dependent on others for all of his activities of daily life.)

  90. "I think part of the bad reaction to Mr. Keller's piece has to do with the fact that in our country, doctors often don't know when to stop treatment and let people go, and a lot of patients and their families seek immortality through medical care, and such a high percentage of the US' medical bill is spent in the last half year of life."

    I agree. I don't think Mr. Keller is being "condescending" about the choice Ms. Adams is making (as some have suggested), but rather looking at the issues surrounding it. Of course Adams wants to be alive as long as possible for her children. But how much are these treatments extending her life, and what kind of quality of life are they giving her? Many people support the choices Ms. Adams is making to keep pursuing treatment, but I would guess many of these people would also be against patients pursuing continuing high-cost treatments that may not yield much in terms of quantity and quality of life, regardless of how old they are or whether they have young children.

    The one thing about this column that I do find offensive is the quote by the Stanford dean, who says, "Equal praise is due to those who accept an inevitable fate with grace and courage." Maybe it's just taken out of context, but this statement seems to imply that Ms. Adams is *not* showing grace and courage in her struggle. She definitely is.

  91. Tone-deaf. Insensitive. Disgraceful. Where is his empathy? Why does he decide how Lisa Adams should die? Turn off her feed, don't read her blog if you don't like it. It's not required reading. Why make it your business, unless it was simply to defend your wife, who is also tone-deaf, insensitive and completely lacking in empathy?

  92. Did you actually READ (and understand) the column. How does: "The first thing I would say is that her decision to treat her terminal disease as a military campaign has worked for her." jibe with Mr. K. making a judgement about how she should die? My reading says that he does believe it is up to the individual to choose, and the choice of going with palliative care is not dishonorable or lacking in courage.

  93. I have admired Bill Keller's work in the past, but there is something really dreadful about his thinking here. His scorn for Lisa Adams seems cruel and very personal and makes me wonder what drives it. How did this get into print, and especially why are the Kellers teaming up in this way to explain to everyone precisely how and why they disapprove of the way Lisa Adams is behaving around her advanced cancer?

  94. I read the NYT daily, and comment on your articles occasionally. I read Lisa Bonchek Adams site occasionally, as I lost my mother to breast cancer and my mother in law has survived breast cancer for almost 29 years. My mother in law had young children and her attitude helped her a great deal. She was a registered nurse and found that patients with good attitudes were more likely to survive than those who gave up. My mother, however, was almost 70, had already lost my father, and gave up. Mr. Keller seems to be shaming Ms. Adams for her will to live. His condescending tone is one I've heard from fertility doctors (who told me I'd probably never have kids) autism specialists (my son has improved in ways I was told would never happen, including spontaneous speech and ability to travel) and my high school English teacher who told me that I wrote 'crap' poetry (I'm published in four countries, and studied under one of the greatest poets of the 20th century.)

    Mr. Keller, if you don't care for her blog, please don't read it. She is writing about her personal experience. She has children that need to know she fought to see them grow up, she experiences terrible pain yet wants doctors and scientists to know what treatment does to a person, and at no point does she tell her followers that she knows more than the medical community, but instead says what she feels is working for her. You will never be in her shoes. This is her choice, not yours.

  95. A very nice story. My dear wife passed away in October suffering from a very
    virulent cancer - (no survivors beyond 6-9 months). She battled this disease for more than 18 months. Finally, her body started to shut-down. Her will was iron. Her medical team used the slash/burn/poison treatment plan and she sloughed on. After, three clinical trials - all chemo, she said enough. We both knew that the disease had won. Her last scan showed the cancer progression
    was text book - lungs to spine to brain. My wife was a medical professional and dealt with the coming outcome. She helped our sons, their wives, and our grandkids come to the place that we were in. Her passing was quick and relatively peaceful. We were all at her bedside (she was at home in Hospice).
    My only other comment about the current state of cancer treatment is this,
    luck plays a major part in the outcome. This should not be the case. The current research should begin with the cause not the cure. We have spent billions of dollars on cancer research. Your story, my wife's story, the kids with cancer stories should not depend upon chance and the theories of researchers.

  96. Have we learned nothing from the feminist and disability rights movements? Bill Keller’s incorrect reading of Lisa Bonchek Adams shows his own fear of disability and sickness more than anything else. He interjects his own interpretation of “war” metaphor on her writings and criticizes her right to make her own communication and medical choices. As a person with a disability, I have read Ms Adams posts as comments from the part of life that we want to hide – that of pain and sickness. Her tweets are a woman speaking for herself. I wonder what Bill Keller’s father-in-law would have said if he had written for himself instead of Keller usurping that role? As a medical interpreter, Ms Adams’s tweets have been educational and have informed my work. As a feminist, I believe Ms Adams embodies the ability of a woman to choose. Bill Keller’s patronizing and public comments are definitely self-serving. His “journalism” should not be unduly praised since he seems to simply want to oppress women further by telling them not only how they should live, but how they should die.

  97. Mr. Keller invites us to compare the decisions of a middle aged woman, raising three children, to those of a (presumably) much older gentleman who, in addition to cancer, was fighting failing kidneys and diabetes.

    What exactly is the point of comparison? Well, they both have "terminal disease", a nonspecific category that includes heart failure as well as cancer. But look beyond that and you see very different pictures: an elderly man fighting several illnesses versus a woman first diagnosed at age 37. Is it really surprising that Lisa Bonchek chooses aggressive therapy where Mr. Keller's father in law did not?

    Please, Mr. Keller, in your next column that takes a stab at cancer patients who fail, in your opinion, to display the requisite "grace and courage" needed to forgo treatment, please at least make a more apt comparison. This one failed far short of what you needed to win your argument.

  98. I think it is important for Times major contributors (and Keller used to be more than that) to combine their personal stories with the events they observe.

    I am writing this because, almost eighty years old and apparently cancer free (a survivor of two cancers, mostly thanks to New York's Sloan Kettering) I am thinking about a tolerable way to go.

    It seems to me that UK and Europe in general have a better way of handling our last days than most places in this country.

    Cancer becomes, in many case, a truly terminal disease. There is no shame to 'slip peacefully from life'.

    This option was, apparently, used by my father in Prague (1974) and I hope to be offered similar option by hospice services here if (when) the time come.

    This, in my opinion, does not constitute rejection of Ms. Adams's approach, a lost heroic battle for survival is something we all admire.

  99. I have been reading Lisa Bonchek Adams' blogs and tweets with tremendous respect and gratitude. As a college educator, I know many people who are fighting back against cancer -- colleagues, students and mentees, the family members of students. Lisa's writing has educated me in countless ways and helped make me a better supporter and ally.  

    Just the other day, a young teacher friend who has served low-income families with extraordinary generosity for 15 years told me of her recent breast cancer diagnosis. She was, of course, worried about minimizing difficulties for her students, her colleagues, and her family.  

    Upon reflection, I called back my friend to suggest that she needed to shift her service mindset a bit and become her own best advocate, now, to fight back against this disease. 

    I think this was important advice for a former student to hear from a mentor. I surely wouldn't have known to offer it without Lisa's extraordinary teaching. It's a shame Bill Keller's piece doesn't capture this valuable dimension of her writing and life. 

    Painful and uncomfortable as it may be sometimes to contend with Lisa's account of her struggle against cancer, I consider her work essential reading and a great gift.

    Daniel R. Porterfield, Ph.D.
    President, Franklin & Marshall College

  100. It is a personal decision as to what path to take when diagnosed with cancer. There is no one way, no right or wrong. Mr Keller seems to take Lisa Adam's decisions for her own care taking as a personal insult to his father in law and himself. His disapproving judgement and harsh insensitivity for her decision to fight for her survival is inappropriate. Lisa Adams should be applauded for her strength and courage.

  101. Mr. and Mrs. Keller should butt out and mind their own business. One's response to any serious disease that seems likely to ends one's life is very much a matter of personal choice, and having those choices meanly criticized by strangers is offensive.

  102. And yet the cost of health care is not always a personal choice, as current debates over health spending remind us. Part of the debate is how much of healthcare spending goes to those who are in their final phase of life.

    It's legitimate to ask how much healthcare resources and money should go to patients with advanced conditions who have limited chance of meaningful quality or quantity of life.

    I don't always agree with the tone of this opinion piece, but I think Mr. Keller is certainly within his rights to bring up these issues.

    I have to wonder if some (many?) of Ms. Adams's friends/supporters are also in favor of limiting healthcare spending on people with advanced serious illnesses... except that they don't want that care limited for their friend.

  103. So 165,000 tweets over seven years comes out to 4 tweets every waking hour (assuming 8 hours sleep per day) since she started.

    "Her aim was to buy as much time as possible to watch her three children grow up".

    Doesn't seem as though it turned out that way, does it?

  104. Wow, what an observation. This gave me chills. Whatever time she has gained for her children has been used up by her social media adherence.

  105. And you know this how?

  106. How ignorant you are, sir. Caring Canines is an all volunteer organization, and they do not charge the hospital or patients for their visits. They do it out of the goodness of their hearts, which from your words I find you sadly lacking.

    I suggest you read Matthew 25:36. You might actually learn something, instead of attacking someone for making a choice you don't approve of...

  107. This makes my blood boil. Every person's battle is personal and you have no right to judge or even voice an opinion. My mother died of breast cancer when I was 12. I wish she had fought harder and longer. Her death had devastating consequences in my life. And then at the age of 38, I was diagnosed with breast cancer as well. I went through mastecomies on both sides, had my ovaries and Fallopian tubes removed and had chemo and radiation and am here today. Funny you talk of the UK... I was living there when I was diagnosed. I went to the top cancer hospital in the country - The Royal Marsden - and they missed the cancer for 2 years, which allowed it to spread to my lymph nodes and meant I had more than 10 tumours on one breast. I was lucky enough to come to the US to be treated by Memorial Sloan Kettering which saved my life. Why don't you mind your own business and instead spend your time on helping raise funds for research, etc.

  108. Bill, I have always considered you to be humane man, but you have really done something terribly cruel here. There are legitimate points to be made, points that have importance for our health care system. But to do so in a way that calls out a dying woman, and to do so in such harsh terms, wrong. And to posit that a young woman with children should face a terminal diagnosis with the resignation and acceptance of an older man misreads the values of the culture we live in. I don't know Lisa, I have never read her blog (and I don't feel a need to) but I applaud her for fighting for her life. And though I appreciate some of the points you have tried to raise, I think by doing so in this harsh way you have actually hindered the discussion.

  109. I don't see anywhere where Mr. Keller is judging any individual - he points out that there is a cancer-battler's fan club that rallies with one motto - and that not everyone can or should be enlisted in that rally.
    My mother and my wife both died of cancer and both went to their early graves with grace and dignity. But as I mentioned above, my mother was diagnosed with stage IV cancer and then driven to "fight" by my father - and suffered terribly for it even though she explicitly said that she had no wish to prolong the suffering. My mother had no issues with death.
    I am not judging her anymore than Mr. Keller is judging Ms. Adams - but there is no one way in which we should forced into facing our passing.
    And we should never be misled by groups shouting hosannas for the latest treatments - the answer to how to proceed is in every heart and I don't believe Mr. Keller has anything less than respect for Ms. Adams.

  110. I don't think Keller was saying what Lisa Adams is doing is bad at all. I think he is saying different choices are right for different people, especially when they are at varying points in their life trajectory.

  111. A survey among doctors familiar with end of life care found that most of them would refuse all treatment on themselves except for pain killers. These physicians know better than most the extensive suffering and poor outcomes when a patient is near death. This says volumes about misguided hope, related policies, and the harm it causes.

  112. I appreciate Mr. Keller's willingness to tackle a sensitive subject and his ability to do so in a considerate and humane way. As the spouse of a cancer survivor, I can't say enough good things about MSK.

  113. Thank you for this piece. It takes a different kind of courage (a journalistic sort) to question the combat metaphors and also to question how Sloan-Kettering and Adams are shaping public perceptions. Thank you also for challenging the (wrong) idea that studies are meant to save subjects' lives.

  114. One antidote to this meta-discussion about ranking the usefulness of stories being blogged about is to simply find countervailing stories and link to them; put the issues in context. The blogs of other sufferers like Jay Lake fill out the picture. If you believe the narrative of heroism isn't sufficient, open up the discussion to these other sources and respond positively. The veil of privacy around social media is objectively permeable but there is some social responsibility to pierce that veil with sensitivity and spread your focus to the social context.

  115. Side note: as several people on Twitter have noted, Emma Keller's original piece at The Guardian has been removed. A statement there says, "This post has been deleted with the agreement of the subject because it is inconsistent with the Guardian editorial code."


  116. If only the Times editorial code were as humane.

  117. I find Mr. Keller's comparison of the decisions of an elderly man and a young mother inapt and reprehensible. For him to sit in judgment, as he implicitly does, of her decisions as being somehow inappropriate is wrong and demeaning to Ms. Adams. I think an apology to her is in order.

  118. Keller never said her decisions were inappropriate. He said it should be a personal choice between the patient and the doctors and no choice is better or worse. Looking at it that way, one person's life isn't more valuable than someone else's. Your comments imply otherwise.

  119. I
    Do not concur with those who say Mr Keller is being judgmental. Rather I detect a strong admiration for Mrs Ames and her decision and dedication to that decision. Each of us makes a personal choice around end of life issues and no one is awarding a white feather to those who would choose not to argue with the inevitable. Bravo, Bill Keller.

  120. I believe Mr. Keller conflates "palliative care" with end-of-life "comfort care."

    While similar etymologically, "comfort care" implies treating only uncomfortable side effects of a condition, rather than treat the condition directly. "Palliative care" on the other hand, does *not* carry the implication of discontinuing treatment of the primary diagnosis, though palliative care may also be employed at end-of-life. Perhaps your father's caregivers used the terms interchangeably for his particular circumstances, but they are not, in fact, interchangeable in most disease circumstances.

    You should issue a correction.

  121. As the wife of a stage four cancer patient, I take great exception to Mr. Keller's attitude and criticism (no matter how subtly clothed in sympathy and admiration it is). An active participant in cancer forums for my husband's disease, I frequently see divided opinions on proper treatment, the "right" way to approach handling the disease, but the truth is, even when sharing the same cancer, every person is different. Not just their body, but their beliefs, their personalities, their outlook on life. No one size fits all, and when dealing with something like cancer, it is not for outside observers like Mr. Keller, or even another person who shares the experience of fighting a possible losing battle against cancer, to comment on what one person chooses to do or not to do, especially when it comes to coping with the disease.

    I saw something similar to Mr. Keller's sentiments about "dignified acceptance" when my husband and I created our own blog to share with our loved ones and friends what we were going through. Most of our friends expressed support, told us they were so glad we were writing the blog so that they could, even for a little bit, understand what we were going through. But not everyone--we had friends who turned away from us because of this. I simply don't understand this. I may be biased here, but to me cancer patients deserve understanding and compassion, not judgment.

  122. My mother and my wife both died of cancer. Cancer is a disease with characteristics, progress, and outcomes as unique as each individual - no one suffers the same way and no one cancer can be predicted. I know you will stay by your husband's side through whatever may come and I wish him remission and recovery.

    But you might be viewing Mr. Keller's column through your anger over your husband's current condition. His column was not a critique of those who chose to fight - especially not those who have the fortitude to fight. My mother completely accepted her late diagnosis of stage IV and simply wanted to live out the rest of her life with some joy, dignity and as little pain as possible. But my father urged her, against her better judgment, to fight, to jump at every new treatment, to subject herself to constant pain and the gradual wasting away which she avowedly wanted to avoid. She "fought" for three years because she loved my father and I can't describe how utterly stoic and uncomplaining she was.
    My wife on the other hand went rapidly, did what she could without subjecting her daughter to the trauma of a long fading away and accepted her diagnosis sadly (her daughter was 12) and without complaint. Two different cancers, two different stories.
    Mr. Keller is suggesting that every person with cancer take the path that his heart points to - and not join a club that blindly rallies under one banner. Life concludes differently for each of us.

  123. I think it is very difficult to talk about the issue of "choice" in how hard to fight cancer. When I read Bill Keller's piece I did not hear so much insensitive criticism of Lisa Bonchek, which he is being accused of, I heard Bill Keller defending his father's way to depart life. He concludes the choices are equal; one is not better than the other.

    The public cheering of Lisa's heroic struggle can sound like an implicit criticism of we who choose not to employ all the most aggressive means. Keller seems sensitive to our feeling looked down on, for not choosing to heroically "fight".

    Many cancer patients feel defensive when someone else is hailed for being a "fighter", and dread the many people trying to impose on us the "be positive and fight" routine, which we often experience as what the other person needs us to do to make them feel better, not what we need to do for ourselves.

    Science proves the "Stay positive, fight, fight, fight" attitude does not appear to make people live any longer, or better.

    I agree with Bill that we need an ongoing conversation, because for many patients subjecting ourselves to aggressive treatments do not make sense, and are not good medicine. For many quality of life matters more than quantity; a deeply personal choice. Some of us spiritually prefer to make peace with death, and not prolong suffering. Death is natural, and part of life.

    We are not all "fighters", and we need you to be OK with that. It doesn't make us "failures".

  124. He had no need to defend his father-in-law's choice; no one questioned it. No one asked him to defend anything. He chose to attempt to defend his wife's choice to publish (a now deleted) an article about Adams.

    You're attempting to defend something that did not occur to Mr. Keller.

  125. Is it just me or has the Internet age coupled with anonymity resulted in more and more intemperate expressions of manufactured outrage about any opinion expressed about any conduct by any person which is less than totally positive? Mr Keller (and indeed Mrs Keller) wrote thoughtful and thought-provoking pieces expressing an opinion which was mildly critical (if at all) of a degree of over-sharing and misdirection of emotional wherewithal. I was brought up to believe that the views of others mattered not if the course I pursued was one I believed in. Now, it seems, others who don't share my belief are insensitive and unfeeling. Are we all really that fragile emotionally?

  126. It wasn't the opinion that ppl are outraged over, it's the person they chose to use as an example--a 47 year old mother of 3 who is dying of cancer. You don't think they could have found a more appropriate example of a person oversharing?

  127. I found Mrs. Keller's Guardian piece a bit snarky, but not overly so. But I was puzzled that she was framing Adams's tweets as an "ethical" issue. Ms. Adams has every right to post her tweets, and Mrs. Keller has every right to discuss the subject of people with illnesses tweeting.

    Interesting note: Mrs. Keller's article has been taken down; a note at the site says "This post has been removed pending investigation." (A previous note said the post was taken down for not meeting the Guardian's editorial polices.)

  128. Bill, I don't find your dad's decision to accept his inevitable fate with grace and courage to have implied that my grandfather was obstinate, stubborn, and wasteful of public resources for prolonging treatment. Seeing that this is how you think, I just didn't want you to feel bad.

  129. My mother died of breast cancer at age 84. She was first diagnosed with it in her 60s. She went through chemo, which at that time was brutal compared to today. She remained cancer-free for 20 years, and then it came back. She kept it at bay with a pill (tamoxifen) for a few years, and then had a few x-ray treatments, but when it came to going through chemo again, she said no.

    My lesson from this is that every person is different and so is every cancer case. We are put in the position of asking: what are the odds? How much more time will a particular treatment give us? If it's a few months in return for huge discomfort, forget it I'd say. If there's a real possibility of years ahead with good quality of life, then go ahead with the treatment. Of course, most cases fall somewhere in between these extremes. And nothing is certain. To say the least, we're talking about hard decisions.

    In the end, though, I agree with Mr. Keller. I admire people who can go gently and admirably.

  130. I suspect that the attitude of cancer patients is highly dependent on their age. Lisa at 37%2B has young children and a great incentive to stay alive. -
    My wife, when diagnosed with pancreatic cancer at 84 and given 6 months decided instantly against heroic measures. She enrolled in a hospice program and continued with lowered activity for 6 months of fairly normal life, but with much rest. The hospice provided all the palliative pain meds one could want. She never felt the need to resort to her little pouch that was an instant way out. Five days before the end, we went out for lunch with family. Three days before, the end signaled its coming. -The conclusion is that young people with children have an incentive to fight the disease and extend their lives. Oldsters, over 75 or so, should accept the inevitable and bid the world farewell, when the quality of life has decreased below an acceptable level. - I even hold that view for a healthy life at 90. I shall go when I choose to, not when the body gives out.

  131. A curious point of view. Age is the line is it?
    Maybe Mr. Keller is just presenting (as columnists are supposed to do) there are no absolute answers.
    Just dealing with life as it comes at us.
    Palliative care versus extrodiniary measures will be a continues argument.
    Odd, though, my Father tougher than nails said if he ended up like the disabled people I supported and looked after, he would rather be dead. Well. after years of dialysis treatment he has found out he has a cancer on his lung. Surprize, he is willingly going in for radiation treatment.
    Gunst, until you walk the road. Shhh.

  132. Everyone's cancer is different and everyone's experience with it is different. Some people want to share the details and some want to be quiet, and not talk about it unless they have to. All of these approaches are equally valid -- who is anyone else to judge them? Even those of us who have walked in their shoes have no right to judge them.

    If you don't want to read a blog detailing someone's cancer treatment, don't read it. If the rawness offends you, click the little x in the upper right hand corner of your screen.

  133. Thank you for publicizing a wonderful resource for cancer victims and the people who love them. Mainstream media seems to emphasize either fatalism or "why me" when it covers the human side of this disease. Now many more people will know to look for and read Lisa Adams' blog.

  134. Bill Keller isn't so much criticizing other patients for their military campaign on cancer as he is stating that he does not feel like his father-in-law was a failure for not doing so and appears concerned we have taken too much of a stance on this "battling cancer". I think his main point is simple- "fighting cancer" does not have to be a combat-driven active-process by the patient and sometimes accepting we, as people aren't always in "control" is a dialog worth having as well.

    Reading many of the comments I feel the criticism of Lisa here is a bit overstated, maybe a gut check response emotionally. As he acknowledges, viewing it as a fight can be empowering to patients, but in some instances, where there is a little chance of success, sometimes having the will to accept what will happen is also another important perspective to take into account. I personally hope that my death will not be one where I am fighting to my end for life, but that there are moments of serenity.

  135. There are times when a journalist needs to assiduously stand back and observe, and not editorialize.

    I would argue, trying to compare how different people confront death is one of those moments.

    I have known those who fought (and still fight) to live even through great suffering. I have known those who refused heroic treatment, and decided to seek peace and acceptance at the end rather than mortal combat to the end.

    I have also known one person who took her own life rather than face the coming of death at all.

    And what can I say?


  136. Had I been writing the piece I would have written about my aging father's decision and not compared his decision with hers. As a senior myself I am upset with many of my friends' decisions to pursue life extending procedures, often leading to more painful deaths, and certainly buying into an idea that life is infinite. A mother with young children should be allowed to buy time.

  137. There's a huge difference between the UK and US attitudes toward death and illness. But there is also surely a huge difference between a woman of 44 with young children--someone who is fighting to give those children, as well as herself, more life--and your father-in-law, who I presume would have been in his 70s or 80s. One of my best friends died several years ago from a rare, ultimately incurable cancer; when diagnosed, she was the single mother of a 16-year-old son. She tried everything available, and more, and eventually extended her life by about a year and a half beyond the original prediction. It was a bad decision in terms of cost-effectiveness, but maybe not so much for her son, who was 19 and finished with his first year of college by the time she died. That's what at least 75% of her battle was all about--getting him on the road to adulthood. It seems harsh to put a value judgment on that.

  138. Interesting perspective. As a contemporary of Lisa, who has been living with metastatic disease four years as well as sharing my treatment online, it has never occurred to me that anybody would critique my choice to continue treatment. Lisa and I both know how this ends. I don't want to speak for her, but on my blog I have said hundreds of times that I know I'm going to die of breast cancer. We all know this is an incurable disease. However, my child is still in high school and I am going to do what I can to see him through. I have had fearsome treatments: liver resection, cyber knife, 7 chemos, 3 targeted therapies - and I too, spent some time in and out of hospitals, the worst with c-diff sepsis. Now however, I am stable, with cancer stopped, at least for now, planning my stepdaughters baby shower, helping my son with college essays. There is no reason to think that Lisa will not be stable one day too. At my worst, my quality of life was still better than death.

    Yes, it will be temporary, she will die of cancer, as will I. But we try to delay it as long as we can for our children. We are not saying anybody is wrong for choosing palliative care. In fact, I think we both know that there will come a time when that will be our choice as well.

    But not yet.

    I believe one can accept the inevitable with grace and courage, while still trying to prolong life. The two are not mutually exclusive as Lisa -and I - understand.

  139. Mr. Keller, I admire you for speaking up on this controversial issue. You didn't have to; you could have written a piece on poverty, which would have been less controversial. It is curious, however, that there has been little information on who have been paying the enormous cost of the "battle." The "opportunity cost" of her battle may be many other lives saved.

  140. Bill, it's really not your business how another faces possible death.

  141. I went read the original article in The Guardian by Emma Keller but got this "This post has been removed pending investigation." Interesting.

  142. An excellent column. I would add that obituaries that stress a deceased's 'courageous battle' also imply that those who have chosen to limit or end the battle lack courage.

  143. When we made Saturday rounds on our cancer patients in the ICU, my older partner would would invariably ask, "what of the gentle art of knowing when to quit?" In that era of aggresive treatment of cancer, almost every patient was Lisa Adams. In the 70's and 80's there was a war on cancer and little consideration was given to the possibility that the patient might be Bill Keller's father. We wouldn't know if we didn't ask. Thirty years later a lot has changed, but I wonder if we've mastered that gentle art.

  144. Many variables have to be assessed by the cancer patient and their loved ones, their caregivers, and their doctors when deciding on a course of treatment. The age of the patient, physical health, type of cancer, etc. make this a highly individualized decision. I have been through chemotherapy and two highly invasive surgeries to treat my rare appendix cancer. Despite the pain and discomfort, I think for me, the course of my treatment was the right one. Cancer used to be a death sentence, but new treatments have saved many lives over the last few decades.

  145. I have been following @AdamsLisa for almost 4 and possibly 5 years. Taking her communications through Twitter and her blog as an entire work over those years, Lisa has been selfless in her presentation of her time post breast cancer when all seemed well and then her writing after her diagnosis with metastatic breast cancer.

    The Keller's have gotten this all wrong. She has presented her situation with the idea that she might help others care for, deal with, and simply live in the same world as someone suffering from an incurable disease. If she had written a memoir rather than a Twitter feed of her experiences, the Kellers would not be making these comments. In fact, Lisa is telling her story in real time and allowing people to engage and ask question and comment. If you do not want to here about it, you can easily opt out and not follow.

    The Kellers decided to attack her. THIS column smacks of "don't pick on my wife or else" by Mr. Keller since Ms. Keller's column appeared first in the Guardian. Well, Mr. Keller, your wife attacked first. I am sure that Lisa's husband is not happy that you attacked his wife nor are his children happy that you painted her out to be some sort of self serving cry baby which she most certainly is not.

    I am dismayed by the timing, tone, and the fact that BOTH you and your wife took this on.

    Shame on you both and the New York Times and Guardian for printing these columns.

  146. Why, oh why cannot we all pass away in a way that the Bill Keller family approves of? Who do we think we are?

  147. I really don't have the words to describe this piece of 'journalism'. I could barely read on from your comment "to her (so far tumor-free) brain". The tone of your writing is disgusting, cruel and terrible journalism. It reads as thinly veiled attack on a mother who dealing with her cancer in the way that she so chooses. Why a couple would decide to gang up on someone who is going through what must be the toughest time of their life is beyond me and how these pieces have ever been published is astounding. I hope one day you and your 'delightful' wife will realise that words do hurt and I hope your own family feel some disgust about you that I do now. I know nothing about either of you but if you are religious please pray for forgiveness as I'm not sure any God would understand what you have done. Lisa, if you happen to read this keep making your choices and know that there are so many people sickened by what these disgusting couple have written.

  148. Everyone is entitled to their own choice in how they fight. I fought at 42 - several surgeries, no chemo/radiation. My sons are now 15 and 20. If it comes back, I will most likely choose to go quietly. My life should be about quality, not the length. That said, no one has the right to judge anyone else for the very personal choices they make. No one has walked the exact path that Lisa has walked.

  149. I agree with P.Z. Myers. It's not Keller's place or anyone else's to tell a cancer patient how to react to their illness.

  150. It must be wonderful to be able to pass such insensitive judgments from your throne at the NYT. When your day passes there, perhaps you can be elevated to the thrill of stomping on baby birds.

  151. I believe you have provided a valuable look at life and death. I agree that it should be the person with the diagnosis who has the most control over how aggressive they want to be in treating their disorder. The use of heroic measures, in my opinion, is most justifiable as it can serve to increase our knowledge and perhaps lead to new , more effective treatment regimens. A person with young children,or any young person, have the most to lose when they are looking at catastrophic illness. A life cut short is a tragedy.
    Anyone who chooses to be a warrior against their disease, particularly if it is done both for knowledge to the world as well as to extend their own life, has made an honorable choice. But we will all die some day--and choosing to let life go without pain and chaos is an equally honorable choice.

  152. 4 years ago at 74 I was diagnosed with Hodgkins Lymphoma. I chose to deal with it without Chemo and have used diet vitamin supplements and Homeopathy while continuing to Produce Feature films which is stressful. Now at 70 having tried, Bee stings, Marijuana oils and continued recommended foods my lymphoma is as it was. I have developed a growth in my liver and when it is diagnosed I will treat it naturally as well. The major problem I have had is advisors who are not caught inside the AMA web of our way or none other. Choice is what I am missing and I suspect many who opt not to use Chemo suffer similarly from a lack of real cooperation between the paradimns of healing. The ctscans and biopsies have been invaluable in helping me understand my illness and dealing in a direct way with it. To even find a doctor who will order a ct scan is difficult. I am discouraged from trying other says. I am discriminated against and it is emotionally a challenge and time consuming to find real help that is affordable and willing. When will there be a fairer system so choice is honoured and supported by the Government and the AMA.

  153. Mr. Keller,

    Time to get off your pontificating soapbox and allow Ms. Adams live her life as she chooses. She did not write a blog about your father or your family and is only expressing her own experience which is helping many people. Who are you to judge? Shame on you and your wife!

  154. The bottom line on all of this is that you are free to read, or not, someone's Twitter feed.

  155. What a horrible and dismissive article, each choice of word dripping with condescension. Back off. Who are you to publicly chastise the choices of a desperately ill woman with three young children. You set up a false equivalence, when you praise your father in law for going quietly into the night. 44 years old with young children and 80%2B are not the same.

    To write a column about aggressive cancer care is one thing, to publicly call out a woman, by name and question her motives, her dignity and her choices, is completely in appropriate and an abuse of the power you hold as a member of the NY Times staff.

    You owe her an apology.

  156. When my son died at 3 and a half, after a life of illness, everything I read and heard seemed to be an implicit criticism of the way I cared for him. I had failed at the most important job I would ever have and everyone--even, like, the writers of comic strips--seemed to be blaming me. It was and is hard to live with the fact that you have failed to save someone you were supposed to save. Perhaps Mr. Keller is dealing with the same kinds of feelings, and finds release in pointing out the negatives of other people's approaches. I would understand that. It's still an unkind thing to do, though.