by Sherwin B. Nuland, M.D.

We should disabuse ourselves of the notion that there are definite physical or emotional symptoms which can predict with certainty that further hope of recovery is in vain. But in spite of the absence of such fool-proof substantiation of futility, there nevertheless are certain kinds of strongly suggestive evidence that almost always appear, as we are approaching the point where good sense urges that the struggle be discontinued. By careful observation of the prognostic factor in disease which is most familiar to us -- the behavior and response of one's own body -- it is often possible to reach a reasonable decision based neither on the forcefulness of the doctors nor the misguided optimism of those who love us.

As time and treatment evolve in the late stages of a disease, there will come a point when our bodies begin to tell us that the benefit of the therapeutic method being used is proving itself to be less than has been predicted by the doctors. A variant of this situation is the recognition that the added suffering caused by the treatment is not justified by its meagre results. When a change in therapy does not improve the response, these kinds of awarenesses increase in magnitude, and our bodies are excellent interpreters of them. After a while, we know without being told that the time has come to to be realistic about what is at stake in continuing to harbor unjustifiable expectations. It is then that we should take counsel with ourselves, and cease to heed the urgings of well-meaning others that we have yet another go at squeezing out a few more months of agonized life.

It must be understood that the body's wisdom in such matters is not perfect. By heeding it we do run the risk of so misinterpreting the signals that we either quit too soon or persist too long. But such errors are much less likely than is the far greater mistake to be made when the messages from within are ignored. For all therapies undertaken when cure is ultimately impossible, there will finally be a phase of markedly diminishing value. We must watch for its appearance, and make use of it if we are to bring all possible peace to the last chapter of our lives.