How to Die..A Role Model

Brian Cahill, on a recent visit to a friend’s house upstate. Around three years ago, he was told he had three to five years to live.Credit...Sarah Blesener for The New York Times

By John Leland

New York Times

On the day that Brian Cahill’s life zagged, he spoke by phone with his brother in Cincinnati, worked out with his personal trainer and shopped for groceries. He assembled a new bed in his apartment and hauled the old one to the basement. He was ready for an afternoon nap.

He was 58 years old, in excellent physical shape, able to leg press 500 pounds. He had a rent-stabilized apartment, a good job as a media consultant and an exuberant interest in sex.

“I was feeling very good about my life,” he recalled.

When he rose from his nap 20 minutes later, he felt a searing pain in his back and collapsed to the floor, immobilized. “On one to 10,” he said, “it was a 20.” He prided himself on being a strategic thinker, able to anticipate circumstances before they arose. Now he crawled to the door to unlock it in case he had to call an ambulance.

Finally, around 3 a.m., he called 911. At the emergency room, doctors gave him a couple of Valium and a prescription for physical therapy and sent him home. 

That was March 5, 2023. Seventeen excruciating days later, after another ambulance trip, he finally learned where the pain came from. He had a collapsed vertebra and needed surgery right away. But more serious was the underlying cause: He had prostate cancer that had metastasized to his spine, hips and ribs.

Prostate cancer is typically a slow-moving disease that people outlive. Brian’s cancer was the exception.

A man in a plaid sports coat smiles.

On New Year’s Eve, Brian was in New York and headed for Times Square.Credit...Sarah Blesener for The New York Times

The orthopedic surgeon broke the news: At his stage of cancer there was no cure. With the best available treatments, he could expect to survive for three to five years.

In March he will reach the end of Year 3. There are promising new drugs in development that may extend his prospects, if he can stay alive long enough for them to become available. But he has watched as the Trump administration upended funding for research, interrupting trials that were already underway. 

“You asked me what scares me,” he said the other day. “That’s what scares me.”

I have known and liked Brian for more than a decade, during which we have become oddly matched friends. He likes show tunes and dropping his pants among friends, and he strikes up personal conversations with strangers; his laugh could wake the dead.

In the months following Brian’s diagnosis, as I watched the effect he had on me and others, he became something unexpected: a role model for how to die.

‘Tell Me What to Do’

If you learned suddenly that you had only a few years to live, what would you change? Would you shut down — or would you rage, rage against the dying of the light?

Brian faced cancer as if he were running for class president.

“It was never, ‘Why did this happen to me,’” said Che-Kai Tsao, Brian’s first oncologist, who is now chief of solid tumor oncology at the Northwell Cancer Institute. “It was always about, ‘OK, I have this cancer, Doc. I want to do everything in my own power to make myself better. You tell me what to do.’”

After his diagnosis, Brian went into what he called “project mode.” Living with cancer, he figured, was an unsolved problem, and he hated unsolved problems. 

He had been a bullied child, a singing actor, a soap opera executive, a gay activist, a lawyer and a media consultant. He once took a few calls as a phone sex operator. Now he was a person with a terminal diagnosis.

Newspaper clippings of photos of performers in a scrapbook.

A scrapbook features memories of Brian’s life in the theater.Credit...Sarah Blesener for The New York Times

He made spreadsheets of his medical appointments and pills and various doctors, and methodically recruited friends and relatives to help with his care. The eldest of six siblings, he had always been the one helping others — with tech support, financial advice, a shoulder to lean on. Now he needed help. His cancer, he determined, would be a collective endeavor.

He brought several people to doctor visits, either in person or via cellphone, in case he missed any details. “I would always be talking to a crowd of three or four people, which was great,” Dr. Tsao said. “Sometimes they asked questions that he didn’t ask, and that were important to his care.”

He asked two friends to remove him from Facebook, telling them, “I don’t want some person who bullied me in grade school getting word of this and starting a prayer chain on Facebook for me.” 

Brian had been in his early 20s when AIDS hit, and the crisis had instilled in him that his time was finite, not to be taken for granted. “I’ve often thought, I should already be dead, but I’m not, and I’ve gotten this gift of all this time,” he said. “And I think of my friends who didn’t get the gift of that time. So I’ve always been in a little bit of hurry because of death.”

What Brian didn’t have time for: the consulting job. He went on disability and then fully retired. “I’m facing my own mortality right now, and making a PowerPoint presentation is the least important thing I could possibly be doing,” he said.

His doctors hit the cancer with chemotherapy and radiation, then focused on medications to deprive it of male hormones, or androgens, which fuel its growth.

The drugs work only for a limited time, typically two and a half to three years, before the cancer becomes resistant and starts to grow. At that point, options are less promising.

Brian, sitting in a chair, talks to a doctor who sits at her desk.

Brian’s treatment took away his libido and left him sometimes with brain fog.Credit...Sarah Blesener for The New York Times

Without testosterone in his system, Brian lost sexual function and libido, which had been a core of his identity. 

“That has been the hardest part of this,” he said, with typical directness. “Because I love being a man. I love being in a man’s body.” His libido, he said, had been the furnace that gave him energy. “Not having that,” he said, “you have to rethink.”

He also tired easily and felt intermittent brain fog, and had to cut back on activities. He bought a medical reclining chair for his back and leg pain. He bought a cane, then a rolling walker.

He did not feel that he was dying, he said. But his world was getting smaller, piece by piece. “My daily life,” he said, “is a series of incremental losses.”

A Drug ‘Holiday’

Last spring, two years into his treatment, the cancer was still not advancing. Brian asked his doctors about taking a three month “holiday” from the drugs — allowing his testosterone levels to rise for a short spell so he could feel like himself again, without the fatigue and brain fog and sexual dysfunction. This was “not the standard of care” for someone in Brian’s condition, Dr. Tsao said. But some research — itself controversial — suggested that improving a patient’s quality of life, even temporarily, could offset the risks of pausing the treatment. 

After deliberation, they slated it for the summer of 2025, when he planned to spend several weeks on Fire Island, long a mecca for gay men and women.

Friends had misgivings. He was doing so well on the drugs. Why risk letting the cancer resurge? But he had lost so much to the disease. Here was a chance to briefly reinhabit his old energetic, sexual self. “Just to make up for it having been so abruptly taken from me,” he said. “Even if I know it’s my last one.”

Brian raises a glass at a dinner table with friends, who raise their glasses.

Brian toasted with his favorite cocktail, a Cosmopolitan, at dinner with friends.Credit...Sarah Blesener for The New York Times

Then in June, as he was starting his drug holiday, his father, Tom, who was 86 at the time, received his own diagnosis. He had Stage 4B prostate cancer that had metastasized to his bones, the same as Brian.

It was absurd, Brian thought — “that we have the same thing, and that I got it first. Then I thought, Well, now we all got to get through this.” 

On Fire Island, without the testosterone blockers, some of his old energy returned. Light whiskers sprouted on his cheeks. One day he set out for the beach, eager for an outing not shaped by his cancer.

But when he came to a slight incline in the footpath, he realized he could not make it. It was another incremental loss, but it was devastating. He broke down in tears.

By midsummer, it was becoming clear that his drug holiday was not going to deliver as he’d hoped. He still had no libido, let alone sexual function. “That was, I think, the only time where I’ve seen him really depressed,” said Tom Kenaston, one of his housemates on Fire Island. Sitting by the pool, Tom’s husband, James Adolf, asked Brian if he could raise a “really dark” question. “I said, ‘Do you think things have taken a turn,’ meaning, ‘Do you think you’re dying?’

“And he said, ‘Yeah, I do,’” James said. “That was probably the darkest of his spirit that I’ve witnessed.”

A Wrenching Decision

His life in New York was getting harder. Just opening the front door of his building while using a walker was a battle. If he wanted to stay alive, he realized, he would need more support. He began looking for a care facility that would provide services as his cancer progressed, from independent living to hospice. 

He quickly discovered that any facilities near New York City were way more than he could afford.

On a visit to his parents, he came across a solution that would have been unthinkable before his cancer: leave New York. A new facility in Cincinnati cost a fraction of its equivalent in New York, and he would be able to help his parents.

Until that point, many of his choices had been made for him, by the cancer or the treatments available. But now the choice was his.

A man in a bathrobe looks out an apartment window in Manhattan.

Brian knew that staying in New York City would shorten his life.Credit...Sarah Blesener for The New York Times

To stay in New York would surely shorten his life. But to leave would be to part with the life he had made here, the friends, the theater. To people who knew him, he was still that irrepressible guy at the restaurant, gleefully re-enacting his calls as a phone sex operator. How could he leave, and for a facility filled with people much older than him?

He made the decision as he had made so many others, with a firmness that few of us, I think, could have summoned. 

“I sat in my medical recliner and cried and cried and cried for hours,” he said. “And then I got up and started working on it.”

He fixed a date at the end of January to move, and began filling up his remaining days — with friends, plays, final visits with his New York doctors, trips to Cincinnati to engage and begin treatment from his new team. His new apartment, in an independent living building, would be twice the size of the one he was leaving. By mid-December, when he had 40 days to go, he announced that he had filled every time slot.

On a visit upstate he made snow angels in his pajamas; in New York he pushed his walker through Times Square on New Year’s Eve.

What Is a Good Life?

More than 300,000 American men will receive diagnoses of prostate cancer this year, and more than 30,000 American men will die from it, more than from any cancer except lung cancer. Some will die surrounded by friends or loved ones; others alone.

If there is such a thing as a good death, perhaps it is this: one that comes at the end of a life spent preparing for it, by forming close relationships and living as if time is limited. And if there is a model for a good life, I realized watching Brian, perhaps it begins with these preparations. 

On the day before the move to Ohio, he spent the afternoon in his apartment of 30 years, savoring a last look out the windows. “It’s what I looked at all through the pandemic,” he said. “It’s what I’ve looked at through relationships, dinner parties, hip replacements, chemo.”

The next morning, it took movers less than three hours to remove all traces of him from the apartment. In his car, Brian carried his meds in a container the size of a small aquarium.

Several times over the preceding months, I had asked Brian how he imagined his end. Though raised in an observant Catholic home, he did not believe in an afterlife. The end, he said, will be the end.

“I do know that at some point I will be a guy in a bed with people coming to say goodbye,” he said one day. It pained him that he would cause them sadness, he said, but that was the nature of love. “And I just hope they have the good sense to bring me a Maker’s Mark Manhattan and a bottle of Amarone.”

There was a dash of theater in the remark, and maybe nostalgia — by then, Brian’s body had made it unpleasant to drink alcohol. But it was also pure Brian: to conjure a last hang with friends or relatives, envisioning the moment as a shared pleasure. 

He mentioned the funeral for his grandmother, who lived all her life in her childhood home and ventured out mainly to the parish across the street.

“But when I went to Cincinnati for her funeral, the church, a big church, was standing room only,” Brian said. “And I thought, this quiet woman who rarely traveled outside a one-mile radius touched all of these people. And I thought how nice that was — that you can be a simple person, living a simple life, and affect all these people. So when I die, if there’s a big room full of people crying and laughing and grieving, in a weird way, it’s kind of a nice achievement.”

As he packed his last things for the 600-mile drive to his new home, that day seemed far off. “I want to be here on earth as long as I can possibly be here,” he said. “But I’m not afraid of death. Honestly, death is what gives value to this life. You know, being here. This is it.”

It was the kind of truism that took on sinew coming from a person with a terminal illness. Brian delivered it with relish.

“So enjoy it, suckers,” he said, and he laughed to wake the dead.