How We Die: Reflections on Life’s Final Chapter

Hi Friends. I’ve been bouncing around between Jacksonville and Atlanta these past several weeks looking at condos, attending Michelle’s graduation, and shopping for a cello. So big news: Michelle graduated from law school and is now a lawyer! She has to take and pass the bar exam before she can be called an attorney. Other big news: we bought a condo in the Virginia Highland neighborhood of Atlanta. It’s a little over 3 miles from Emory. Importantly, it’s close to Piedmont Park and the Beltline thereby fulfilling my one essential requirement of nearby running trails. I’m really looking forward to only having to move once for the next 4 years.

I just finished reading How We Die by Sherwin Nuland. There were heaps of nuggets of gold in the book. Biggest take home: ars moriendi, the art of dying aka the “Good Death” or death with dignity, is not always possible. Often, biomedical science and medicine hinders one from it. But “Ars moriendi is ars vivendi: The art of dying is the art of living. The honesty and grace of the years of life that are ending is the real measure of how we die. It is not in the last weeks or days that we compose the message that will be remembered, but in all the decades that preceded them. Who has lived in dignity, dies in dignity” (268). These were some other passages that struck a chord.

…Dr. Leo Cooney, who later summarized his viewpoint in two pithy paragraphs of a letter:

“Most geriatricians are at the forefront of those who believe in withholding vigorous interventions designed simply to prolong life. It is geriatricians who are constantly challenging nephrologists who dialyze very old people, pulmonologists who intubate people with no quality of life, and even surgeons who seem unable to withhold their scalpels from patients for whom peritonitis would be a merciful mode of death.

We wish to improve the quality of life for older individuals, not to prolong its duration. Thus we would like to see that older people are independent and lead a dignified life for as long as possible. We work to decrease incontinence, manage confusion, and help families deal with devastating illnesses like Alzheimer’s.” (71)

Our bodies have a finite lifespan, just like mechanical parts have lifespans. It’s just the way it is. Pursuing invasive, taxing treatments to prolong a dying person’s life (regardless of the quality of life) rather than acknowledging that death is near avoids the real issue at hand. And it prohibits people from making connections and finding closure.

Such self-generated opiates do, in fact, exist, and they are called endorphins. They were given that name shortly after their discovery about twenty years ago–by contracting the two words the describe them: They are endogenous morphine-like compounds…Morphine, of course, recalls Morpheus, the Roman god of sleep and dreams. (131)

So I had no idea that Morpheus is the Roman god of sleep and dreams. Definitely want to read Edith Hamilton’s Mythology soon.

Too often, patients and their families cherish expectations that cannot be met, with the result that death is made all the more difficult by frustration and disappointment with the performance of a medical community that may be able to do no better–or, worse yet, does no better because it continues to fight long after defeat has become inevitable. In the anticipation that the great majority of people die peacefully in any event, treatment decisions are sometimes made near the end of life that propel a dying person willy-nilly into a series of worsening miseries from which there is no extrication–surgery of questionable benefit and high complication rate, chemotherapy with severe side effects and uncertain response, and prolonged periods of intensive care beyond the point of futility. (142-143)

Since the time of this writing (1994), I think hospice has become more widely accepted. We can’t fix everything, but we can comfort what we can’t fix.

I would argue that of the many kinds of hope a doctor can help his patient find at the very end of life, the one that encompasses all the rest is the belief that one final success may yet be achieved whose promise vanquishes the immediacy of suffering and sorrow. Too often, physicians misunderstand the ingredients of hope, thinking it refers only to cure or remission. They feel it necessary to transmit to a cancer-ridden patient, by inference if not by actual statement, the erroneous message that it is still possible to attain months or years of symptom-free life. When an otherwise totally honest and beneficent physician is asked why he does this, his answer is likely to be some variation of, “Because I didn’t want to take away his only hope.” This is done with the best of intentions, but the hell whose access road is paved with those good intentions becomes too often the hell of suffering through which a misled person must pass before he succumbs to inevitable death. 223

Hope is an astronomically interesting thing. After reading this, I think that to die a good death in today’s medically advanced society (I hesitate to say this because what’s advanced today is archaic tomorrow) means having a full grasp on your own values and dreams and making sure health care providers hear and understand YOUR values, not theirs. Dr. Nuland describes how “the quest of every doctor” is to solve The Riddle, which is “to make the diagnosis and design and carry out the specific cure” (248). But solving The Riddle may induce a course of action diametrically opposed to one that would uphold the patient’s values. I guess put simply, you just gotta (sometimes forcefully) be you.

So enough with the heavy stuff. I’m giving myself a break and kicking back with some Mythology, LOTR and Harry Potter.

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