A Dec. 26 article about the apparent ability of some people to delay death until a significant event arrives incorrectly stated that James Monroe, who died on July 4, 1831, was a signer of the Declaration of Independence. (Published 01/07/2000)
Richard Bram has a metaphor for what his life has been like in the last few months.
"You know how they send a space craft up, and they use the gravity of one planet to swing it to the next?" He pauses to cough. "That's what I'm doing."
Bram is dying. His rare form of cancer is long past cure, or even control. He is 68 years old and his life is almost over. He will tell you this without tears.
He is here, in the clinic of the Dana-Farber Cancer Institute, being transfused--two units of blood, one of platelets. The transfusions are keeping him alive. But they're not the only thing doing so.
Last month, Bram's son was married. The wedding was hastily moved to Thanksgiving weekend when it became clear Bram was unlikely to live until spring. The event pulled him through November like gravity.
Now, Richard Bram has another goal. He wants to see the new millennium. Jan. 1, 2000: It's the next celestial body on his calendar.
A real estate developer in Lexington, Mass., Bram is not a millennialist, not a numerologist. He has no burning desire to see how much--if anything--breaks because of the Y2K computer bug. But he would like to live a little longer, and New Year's Day seems like a good target.
The power of the mind to alter the course of illness is no longer in dispute, if it ever was.
Among women with early stage breast cancer, those who score high on a measure of depression and anxiety have a three-fold greater risk of death. Divorced and depressed men have poorer survival after a heart attack. On the other hand, a recent study showed that the mere act of writing about stressful experiences in one's life lessened the symptoms of asthma and rheumatoid arthritis.
Nevertheless, the ability of the mortally ill to delay death would seem to test the limits of this phenomenon. Yet, it's something that everyone who works with the dying says they've seen.
"It's not as rare as you would think," said Susan Walker, a social worker and the director of the Visiting Nurse Association Hospice Services in the District. "We certainly see patients waiting. What we see more often is patients waiting for a certain person to arrive."
She remembers a dramatic example of a few years ago. An old man was severely ill--"actively dying" is the term she uses. He had expressed a desire to stay alive until his daughter arrived. It took her two days to get to him, and nobody thought he would make it.
"I saw him greet her," Walker recalls. "And then he died. It was within a few minutes of when she came. He really didn't have enough left to have a conversation with her. But knowing that she had arrived was enough for him."
People hold on for births. They hold on to see a daughter going off to the prom, knowing they will not survive to see her graduate. They survive for more public events, too.
Marianne Matzo, a gerontologist and nurse in Manchester, N.H., said that in 1984, her great aunt, then in her upper eighties and quite ill, expressed a desire to live to see the Detroit Tigers win one more pennant. She survived the summer; the Tigers won (and went on to win the World Series, too); and the woman died that fall.
"Of course, I don't know if losing would have kept her alive for another year," Matzo says, a trace of a laugh in her voice. "But it was a goal."
There's evidence, beyond such anecdotes, that human beings have the ability to postpone death briefly. Not everyone and not always, but often enough for the phenomenon to be measurable. Much of this research has been done by David P. Phillips, a sociologist at the University of California at San Diego.
In a study called "Death Takes a Holiday," published in the Lancet in 1988, Phillips and a colleague looked at the relationship between Passover and the mortality of Jews in California from 1966 through 1988. Passover is the most frequently observed Jewish holiday in the United States. Men play an especially important ceremonial role in it, with a family's oldest male member leading the recital of the Exodus story at the Passover dinner.
The researchers found that in white men with unambiguously Jewish surnames, there were 25 percent more deaths in the week after Passover than in the week before. When the first day of the holiday fell on a weekend--increasing the likelihood of family gatherings--the effect was especially pronounced, with 61 percent more deaths. In each case, there was a compensatory shortage of deaths before the holiday. This pattern was not seen in Jewish infants, or among blacks and Asians, who presumably were not Jewish.
In 1990, Phillips and another colleague published a study of Chinese Americans in California and the Harvest Moon Festival--a holiday in which the central ceremonial role is played by the oldest woman of the house. Among elderly Chinese women (but not men or younger women) there was a 35 percent dip in mortality the week before Harvest Moon, and a similar rise the week after.
Phillips has also shown that non-religious symbolic occasions can also drive this phenomenon. Mortality dips before presidential elections and rises after them. For women (but not men), the single most common week for dying is the week after one's birthday. And then there are the striking examples from history.
Both Thomas Jefferson and John Adams died on July 4, 1826--50 years to the day after each signed the Declaration of Independence. (Curiously, James Monroe, also a signer, died on July 4--five years later.) Adams's last words, "Jefferson still lives," are famous, although incorrect, as his great rival had died several hours earlier. In one of his papers, Phillips gives Jefferson's less well-known final conversation, as recounted by a physician in attendance.
"[He] awoke, and seeing my staying at his bedside exclaimed, 'Oh Doctor, are you still there?' in a voice however that was husky and indistinct. He then asked, 'Is it the Fourth?' to which I replied, 'It soon will be.' These are the last words I heard him utter."
The great rollover of zeros six days from now has a variety of meanings, and for many people, little meaning. For a small number of people, it is a clear target for survival--truly a day to live for.
How many people with terminal illness want to live into the year 2000? Of course, there is no way of knowing. For some, it may be a secret and silent wish. For others, only a half-conscious one. For Richard Bram, it's a wish he's given words.
Only time will tell whether there are fewer deaths than expected this week, and more next. But Phillips won't be surprised if that turns out to be the case. One would expect the millennial boundary would be a particularly symbolic occasion, he said last week.
Richard Bram has liposarcoma, a cancer of fat cells that strikes about 2,000 Americans a year. He was diagnosed with it in 1993 and got all the standard treatment--surgery, radiation, chemotherapy. At different times, he has been on four experimental drugs, some of which helped, some of which did not.
Although a CAT scan in the spring showed the tumor was regrowing, he took the summer off, spending six weeks in Maine with his wife, Vicki. It was a good time for both of them. In the fall, he tried a new form of chemotherapy, which he says was devastating.
That is when he decided to stop treating the cancer. He didn't have pain, although he was weak from slow bleeding into his intestinal tract. He would get transfusions when he needed them, but that was it.
Bram and his wife have a son and a daughter, both of whom are psychologists. Soon after he made his decision, he told his son, who was engaged to be married, that he was happy the young man had found a woman to spend his life with.
It sparked a lot of thoughts--doing this wedding sometime next year without him there, Tony Bram said last week, sitting in the clinic waiting room as his father was transfused, "it was about the saddest thing I could imagine."
So they set the wedding for late November. The day after Thanksgiving, his father was the weakest Tony had ever seen him. But he got blood and rallied, attending the entire event.
Throughout the fall, many people have helped him keep up his courage and his spirits. In this, he says, his family has been most important, but also a rabbi, a counselor at Dana-Farber who has taught him visualization therapy, his physicians, many nurses. Of course, he isn't the only one coming to terms with death.
In October, when the last experimental drug was abandoned, Vicki Bram says she became very angry. At her husband, at the doctors, at many things. For herself, as well as for him, she's glad there's been a little more time. "I know how I want Dick to remember me, and how I want to remember him. A certain peace has come over us since then," she says, sitting in a chair at the foot of his bed.
But it hasn't been easy, and it hasn't been complete.
"Friends drop over, and I can't say I'm not resentful of their full lives," Bram says. "They're all at the stage of their lives where their children are grown, they have money and time. I wish them well. I wish I could partake of it." He allows as how his small goals, including the desire to live into the new millennium, are in some ways surrogates for all he'll never get a chance to do.
Bram almost died last week. The tumor is starting to invade his stomach. He began vomiting blood. But then it stopped. He got a transfusion, felt better, went home, read a book. He has his eye on Jan. 1.
How long can this go on? It's a reasonable question, says his physician, George D. Demetri, the head of Dana-Farber's sarcoma service.
"I realize blood is a limited resource, and has a cost. But it is very difficult to set limits and look the patient in the eye and say: 'We have an effective treatment, and you can't have it,' " Demetri said. "I think in his case, it's been a relatively easy decision. He has a pretty decent quality of life. He's not in pain. He's going through a lot of psychological growth, and he wants to stick around in this world."
For his part, Bram thinks he will know when it's time to stop. And he knows he isn't there yet.
"You know," he says matter-of-factly, "I say I have a tiny life. But right now, it's enough."
Virtually no research has been done on the physiological mechanism that seems to allow some people to delay death, at least for a while. Nobody knows whether it's the autonomic nervous system, the immune system, the adrenal-pituitary axis or some combination of them.
Wherever the will to live may reside, it clearly has its limits. Too much can be made of it, says Jeanne Brenneis, director of bioethics for the organization Hospice and Palliative Care of Metropolitan Washington. She has her own metaphor for the mystery of the timing of death.
"As a chaplain, I see things as a spiritual journey," she said recently. "It's a combination of when you decide to take the ship, and when the tide goes out."
CAPTION: Richard Bram wanted to be around for son Tony's wedding.