Leonard Cohen’s Death

Nine months after the event, I continue to receive questions about the cause of Leonard Cohen’s death. I am posting about two pertinent medical issues in hopes of resolving some of the confusion. Please be aware that this post reveals no facts about Leonard’s death that haven’t been previously published. Instead, I offer a physician’s take on the available information.

1. Leukemia, Coagulation Defects, and Falls

Prior to Leonard’s death, it was well known that he suffered from cancer (a fact most famously reported by David Remnick in the New Yorker), and since then, reports have been published that specified the diagnosis as leukemia.¹

On Nov 16, 2017, Leonard’s manager, Robert Kory, issued a widely published statement² about the cause of death:

Leonard Cohen died during his sleep following a fall in the middle of the night on Nov. 7. The death was sudden, unexpected and peaceful.

Much of the uncertainty in the queries sent my way arises from the misperception that a fall and leukemia are mutually exclusive causes of death. This is the viewpoint implicit in the opening lines of Leonard Cohen’s Cause of Death Revealed by Dave Lifton (Diffuser: November 17, 2016):

Although Leonard Cohen had been suffering from cancer, it was not the cause of his death last week. According to his manager, Robert B. Kory, it was the result of a fall he had recently suffered.

In reality, however, the explanation of Leonard’s death may well involve the combined effects of the fall and leukemia.

First, treatment for leukemia, as well as for pain or other symptoms of leukemia, may increase the risk of a fall.

More significantly, a common symptom of certain types of leukemia is faulty blood clotting, typically due to low levels of platelets although other issues can also be involved. Consequently, a fall could cause an internal hemorrhage that would ordinarily be stopped by normal coagulation before reaching dangerous levels, but in an individual with impaired clotting, bleeding from the same closed wound could continue relentlessly, leading to death, especially in the case of head trauma. In fact, Intracranial hemorrhage is the second leading cause of mortality in patients with one type of leukemia (acute myeloid leukemia).³

In summary, the most likely clinical interpretation of the presented data is that Leonard’s death was the consequence of bleeding which was immediately triggered by his fall and which continued unabated because of a coagulation defect, which was itself caused by leukemia.

2. No Heroic Measures

Some writers have questioned why no medical intervention was mentioned in the announcements of Leonard’s death.

It is not unusual for patients diagnosed with a terminal illness, especially those suffering physical deterioration, to stipulate in living wills or similar documents that no heroic measures or extraordinary life-sustaining treatment be implemented to avoid the coming of death. A typical provision of this sort follows:

If at any time I should have a terminal condition and my attending physician has determined that there can be no recovery from such condition and my death is imminent, where the application of life-prolonging procedures and “heroic measures” would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally.⁴

Given Leonard’s well-publicized statement, “I am ready to die. I hope it’s not too uncomfortable. That’s about it for me,”⁵ he may well have made similar arrangements. If so, a no heroic measures provision might have precluded a call for medical assistance.

Conclusion

Again, I want to emphasize that this post is a medical perspective on rather than an investigation of the events surrounding Leonard’s death. The key conclusion is simply that, while I have no definitive proof that the scenarios I’ve outlined are indeed what took place, they do represent reasonable, unstrained clinical explanations of the available information. If this seems anticlimactic, it’s because my personal belief is that the loss of Leonard Cohen was a tragedy, not a mystery.
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1. For example, in  I already knew Leonard Cohen was dead on Election Day (Slate: Nov 19, 2016), Bill Curry notes “The cause of his [Leonard Cohen’s] death was leukemia.” [↩]
2. E.g., in The New York Times [↩]
3. Prediction of fatal intracranial hemorrhage in patients with acute myeloid leukemia by C.-Y. Chen C.-H. Tai W. Tsay P.-Y. Chen H.-F. Tien (Annals of Oncology, Volume 20, Issue 6, 1 June 2009) [↩]
4. Source: Living Will [↩]
5. Leonard Cohen Makes It Darker, by David Remnick (New Yorker: Oct 17, 2016) [↩]