Why Some Patients Do Not Want to Ring the Bell

This page is for anyone near the end of a treatment phase who feels unsure about ringing the "end of treatment" bell. It explains where the custom came from, why many people decline, and other ways to mark the day.

The bell in the infusion suite or radiotherapy department is a recent invention. The practice is generally traced to a single US cancer center in 1996, and it spread from there to hospitals around the world. It was never designed as a clinical intervention. It has no evidence base behind it. It became standard largely because it looked good and felt right to the people who introduced it.

For plenty of people it does work. They ring it, their family cheers, and something that needed marking gets marked. For plenty of others it is the last thing they want, and they find there is no obvious way to say so.

The audience. This is the one people mention most. The bell is rung in a room where other people are mid-cycle. Some of them are not going to finish, because their treatment is continuous or because their disease will not stop. Oncology nursing literature describes patients with metastatic or progressive disease reporting anger, resentment and low mood when they hear the cheering. They know this particular milestone is not available to them. Some units in the UK have removed bells for exactly this reason. Being congratulated in front of people for whom the same ending does not exist is not a small thing to ask of someone.

The ending is not an ending. Chemotherapy finishes, but endocrine (hormone) therapy can run for five or ten years. Immunotherapy continues. Maintenance treatment has no completion date. Surveillance scanning goes on for years. Ringing a bell announces completion. When what has completed is one phase of something ongoing, that misrepresents your situation to everyone in the room, including yourself.

It stopped for the wrong reason. Treatment ends when it is not working. It ends when toxicity becomes unmanageable. It ends when someone decides they have had enough. There is nothing to celebrate in those endings, and a ceremony built around triumph has no shape that fits them.

The feeling is not there. People often reach the last session exhausted. They are frightened about losing the safety of regular monitoring, and grieving things treatment cost them. A public celebration in that state is a performance, and performing gratitude on demand is draining.

Superstition. Some people simply do not want to declare anything finished. That is not irrational. It is a reluctance to make a claim the scans have not yet confirmed.

Privacy. Some people do not want a public moment of any kind, on any subject.

This is not only a patient complaint. It is being discussed seriously in the professional literature and at nursing conferences. The core criticism is about the implicit message. A ritual celebrating completion, performed in a shared space, suggests that completion is the definition of success. That quietly places everyone on lifelong treatment on the wrong side of the line.

The responses have been practical. Few centers have simply gotten rid of the bell. Penn Medicine redefined its bell so it marks any milestone: a good scan, the end of a phase, a hard day survived. Signage explains the wider meaning, so that patients on continuous treatment can use it too. Duke Cancer Institute moved bells outdoors into garden spaces. Ringing there becomes a private choice, rather than a public event staged for an unwilling audience. Other centers offer certificates, a quiet word with the team, or nothing at all.

Saying no is easier in advance than on the day. "I would rather not ring it" is a complete sentence, and staff hear it often enough not to be surprised. You can also ask whether you can ring it at a quiet time, or somewhere else. That is reasonable, and frequently possible.

If you do want to mark the end, private markers may fit better anyway, such as:

• A meal with the two people who drove you to appointments.
• A walk you could not have managed six months ago.
• A note to the nurse who got your IV line in on the first try.
• A day off doing nothing at all.

And if you want the bell, the cheering and the photograph, take it. The point is that it is optional, and that neither choice says anything about you.

• Redefining the Bell: Recognizing Milestones in Cancer Care (PubMed)
• Penn Medicine: redefining the cancer bell
• NCI: Facing Forward — Life After Cancer Treatment
• NCI: Follow-Up Care After Cancer Treatment