Death As A Process

We are all hurtling toward oblivion. And none of us want to talk about it, much less think about it.

Alex Proimos photo
Alex Proimos photo

The real problem, however, is that, although we are all careening toward our own personal extinction, modern medicine is doing a bang up job of forestalling the moment. Average life expectancy back in classical Greece was under 30 years; life expectancy in many countries today is over 80. Globally, over the last 200 years, life expectancy has essentially doubled, and the trend continues. A recent Lancet study tells us that life expectancy for men and women has increased by about six years in just the past two decades. It is said that the first person who will live to age 200 has now been born!

‘What’s the problem?’ you may ask. Longer life = a good thing. No?

Well, no and yes. A healthy, meaningful life, free of pain, sure. But, as many of us have seen, the final years, under a miraculous contemporary medical regime, can be contrary to all three of those descriptors.

We used to, more often than not, die at home. Not anymore, although almost all of us will say that we’d prefer to. And again, the trend continues; one study says that in the U.K., by 2030 fewer than one in ten will die at home (and that includes a ‘nursing home’). When the end comes, we are very likely to be within the walls of a cool, clinical institution.

But again, I don’t think that’s the worst of it. We used to die far more precipitously. We got old, we got sick, we died, like dropping off the earthly plane. Now, as stipulated in Being Mortal, Atul Gawande‘s excellent book on this untidy business, the pattern of our death is typically a prolonged series of much shorter drop-offs. We develop heart disease, there are effective drugs for that. Our legs go; here’s an electric wheelchair that can spin around inside an elevator. Cancer crops up, begin chemotherapy. Today’s medical model is an interventionist one; if the problem can be addressed it will be, or at least it should be. And so our lives are repeatedly extended, and each time, the quality is not quite what it was.

What’s more, the final expiry itself is no longer definitive. Our demarcation of death used to be based upon the heart and lungs stopping their involuntary movement. Then, back in the late 60s, given the interventionist aplomb of doctors, we switched to ‘brain dead.’ But now, even that definition isn’t working for us. In a recent National Geographic article, brain death is broken down into five separate stages. (The first is short-term memory loss, and if that’s true, I’m dying as I write this.)

Just above, I used the word “moment” in referring to death, but hang on. As quoted in the same article, Sam Parnia, in his book Erasing Death, refutes that notion explicitly: death is “a process, not a moment.” And doctors can now resuscitate our dying selves well along into that process, up to 30 minutes in with adults, much longer for children, long after we would have been ‘left for dead,’ just a few decades ago.

It’s all very disorderly and difficult, and something we all need to think about, vis a vis our own short lives. As my mother said several times in referring to particularly decrepit friends, “We can live too long.” And yet, as a friend of my own once said, with unsettling accuracy, “We cling to life.” (Well, not my mother. She wasn’t in pain, but, dying of cancer, she asked for, and would have taken, if it had been provided for her, a “euthanasia pill.”)

And a final point here. It is often the family members of the dying, not the dying themselves, who prompt the intervention. We cling not only to life, but to our connection to the dying. And if one thing is clear to me in all this messiness, it’s that the decision to intervene should rest with the dying, not the interventionists, whoever they may be.

Ask your aging loved ones what they want, what they fear, when the end comes. Make sure that you have a ‘Living Will’ in place, that a ‘Do Not Resuscitate’ sign will be hung on the end of the hospital bed where you will likely expire, if that is your desire. Make your wishes known to your family members before you’re incapacitated, and the decision has to go to them.

If nothing else, go out on your own terms.