The Good Death

The Doctor has to be comfortable with accepting that death is not their own failure, but that death is a natural event, and that medical care can help people die with dignity and comfort.

Christine Cassel
What should the leading cause of death be? We’re all going to die. Someday. (Barring some incredible advances in medicine that confer virtual immortality on everyone.) How should that happen?

We frequently hear about how such-and-such — heart disease, cancer, obesity, accidents, AIDS — is the leading cause of death among a subgroup of the population, or the population as a whole. And that inspires us to donate money to searching for a cure for whatever that thing is, and it inspires us to change our behavior to reduce our risk for whatever that cause is.

And those are good things. Deaths from most of these things still come too early. And I doubt anyone really wants to die from painful cancers or AIDS or Alzheimer’s.

But if we’re all going to die, all things being equal, what should the leading cause of death be? Heart disease in old age? Cancer? Suicide, especially of the death-with-dignity variety? In short, what’s the ultimate goal of modern medicine, short of immortality?

Scarequotes, from Suggest a Show June, 2006

There are only two certainties in life: taxes, and we all know the other one. Advances in medical sciences are staving off the inevitable but once it comes the toll on the individual and on society can be huge. In this program we’ll discuss how to die. Does the most comfortable and painless death coincide with what is least costly to society? What toll will the ageing boomer population take on the US? How do you think about your own death? In this hour we’ll address the ethical, economic and philisophical components of what it means to die.

Arthur Caplan

Director of University of Pennsylvania’s Center for Bioethics

Christine K. Cassel, MD

President and CEO of the American Board of Internal Medicine. Leading expert in geriatric medicine and end of life care.

Charlie Wheelan

Author, The Naked Economist, and he teaches public policy at The Harris School at the University of Chicago

 

Curt Tucker

Curt Tucker is a therapist, blogger and gallery owner. You heard his story at the end of this show.
Extra Credit Reading
Marilyn J. Field and Christine K. Cassel, ed., Approaching Death: Improving Care at the End of Life, The National Academies Press, 1997.

Hospice Guy, The Wharton School Weighs in on Hospice Care, Hospice Blog, June 6, 2006.

Christine K. Cassel and Katherine M. Foley, Principles for Care of Patients at the End of Life, December 1999.

Joao Pedro de Magalhaes, Should We Cure Aging? A Rebuttal of Myths About Immortality, Senescence, 2004.

Joao Pedro de Magalhaes, The Grandparents of Tomorrow: Winning the War Against Aging, Senescence, 2004.

Nurse Mia, Death Maiden.

Muriel R. Glick, The Denial of Aging: Perpetual Youth, Eternal Life, and Other Dangerous Fantasies, Harvard University Press, March 2006.

Related Content


  • Pingback: Dirty French Novel » What should the leading cause of death be?()

  • avecfrites

    We should all die during sex, at age 140.

  • avecfrites

    In addition to the medical and personal fulfullment angles to this question, there are undoubtedly religious ones for many people. Would anyone say we should all die of crucifixion, in perfect emulation? Or perhaps death is made obsolete by rapture. Or maybe death is redeemed by reincarnation.

    Throughout history lots of people have preferred to die in battle. Or with their boots on. Or with the most toys.

    I guess a good time to die would be at the same moment as your last remaining good friend.

  • chilton1

    Live by the ……….. Die by the …………….

    Die doing

  • chilton1

    Nature published an interesting April 1st spoof in the very early 90s sometime. The researchers supposedly took a mouse (with a altered p53 gene promoter), which meant that without daily morphine the mouse’s cells would all commit suicide (apoptosis). They crossed this mouse with a transgenic mouse that had a tortoise gene (“longevin” or something similar) which conferred a longer life on the mouse. The progeny lived longer lives but had a handy off-switch.

    i.e. long life no old age (and no burden on society)

  • An article I wrote last fall for the Earth First! Journal Natural Death, Green Burial: Reclaiming Our Last Rites is posted at:

    http://www.frappr.com/phpBB2/viewtopic.php?t=462857

    “As an environmental movement there are compelling reasons why it is in our interest to examine how the process of our dying is impacted by the corporate culture that surrounds us and how we can reclaim death as the natural and deeply meaningful process that it is meant to be. “

  • zeke317

    In his latest book Andrew Weil articulates the ideal as an active mental, physical and spritual life for as long as possible followed by a swift decline to death. It seems that both consumer culture and medical science offer competing images.

  • Resources to accompany the article posted above…

    On the Web

    Natural Death Care – Information on home or family run funerals

    http://www.naturaldeathcare.org/

    Funeral Consumers Alliance – protecting consumer rights.

    For what permits are required in your state, where to get them, where to file them, and when, call the FCA office: 802-482-3437

    http://www.funerals.org/

    A Family Undertaking – film documentary

    This PBS website about the film has a wealth of resource information

    http://www.pbs.org/pov/pov2004/afamilyundertaking/index.html

    Funeral Planning – Includes state laws for funeral service providers

    http://www.funeralplan.com/

    A Salon Special Issue

    http://www.salon.com/weekly/intro960805.html

    Books

    Caring For the Dead by Lisa Carlson.

    State by state comprehensive manual on funeral law for handling death without the use of an undertaker.

    The American Way of Death Revisited by Jessica Mitford,

    Revised edition of Mitford’s scathing expose of the American Funeral Industry

    Tibetan Book of Living and Dying by Sogyal Rinpoche

    Practical Tibetan wisdom for the western reader

  • Does it not seem rather ironic that when the nation is at war, inflicting unnecessary deaths on Iraqi civilians and billions are being spent on the military rather than on medicines that could reduce the number of victims of AIDs, diarrheal diseases, malaria and any number of other inflictions, that there can be a discussion of “The Good Death.”

  • Ron Rosenbaum wrote a compelling, anti-five-stages-of-grief article in Slate shortly after Elisabeth Kübler-Ross died in 2004. A choice paragraph:

    Whether or not Kübler-Ross is dead, her alleged “science” of Death ‘n’ Dying lives on in all its meretriciousness, rarely challenged any more. According to Kübler-Ross, there’s a right way and a wrong way to die, a sober responsible Five Stage Way. Forget “Do not go gentle into that good night” by that alcoholic Welshman Dylan Thomas. You better go gentle, buster, you better die the New Age Way or you’ll never appreciate how beautiful death can be. It’s the only way to go, you might say.

    It’s a great read, and perhaps Rosenbaum would make an interesting guest.

  • Linda Porelle

    Since coming across Andy Weil’s concept, compression of morbidity, I’ve been attempting to send the message to my body at the cellular level. His formulation is elegant…it acknowledges death as the end result up front and still advocates forcefully for a healthy life-style. I hope you give him a call.

  • chilton1

    sidewalker “Does it not seem rather ironic ….. that there can be a discussion of “The Good Death.â€?

    the original post frames this as an American death…conversation

    This kind of -centrality is reminescent of slavery…there are two types of people

    Americans and Non-Americans / free and not free

    one rule for one and another for the other

    as a result, there are some in the world might argue that an American death is a good death

  • Ben

    After thinking about this, I find it much easier to list what the leading causes of death shouldn’t be (name a disease, something curable or treatable somewhere in the world).

  • To Tibetan Buddhists a good death is critically important because it can set the tone for your entire next life. They practice Phowa in preparation for the inevitable time. Because they’ve practiced; if death captures them suddenly they can automatically go into the Phowa meditation. Phowa means, transferring consciousness into Truth, which could (but doesn’t have to be) embodied by the Buddha.

    Instructions are here….

    http://www.spcare.org/practices/phowa.html

  • And then… was it Crazy Horse? or is it a Native American warrior of my imagination, who would say before going into battle, “It is a good day to die.”

  • At age 17 I trained to become a hospital orderly. I was a serious kid and took my job seriously. Like so many people I had never seen death up close. After about two weeks of work I was given specific patients to work with on a regular basis. One of those patients was an elderly man who I came to like and appreciate. I knew he was terminally ill and expected his death to come soon and felt sad about it. Arriving to work one day the head nurse told me I would be spending time in his room to care for his needs more closely. I knew what that meant. He and his family had indicated that no resuscitation should be performed if he should die. He was in his eighties and had made the clear decision that he was not well enough to continue. At this point he was breathing with difficulty and not responsive. I performed the basic duties I was there to do but had some anxiety about his condition.

    As I finished my duties and stood at the head of his bed he opened his eyes, looked at me with great clarity, and stopped breathing. His eyes partially closed. I was shocked and slightly confused not knowing if he had really died. I called for the nurse and she confirmed it. She asked me stay in the room until the family arrived. I sat down in the chair and waited. As I sat there I watched him. It seemed like his chest was still rising and sinking with breath. I checked for breath sounds. I checked for a pulse. There was nothing. Each time I sat down again I would see the same movement. But there was nothing. No life. How could this be?

    What I saw was what I expected to see when watching a person closely. People never really stop moving even when they are asleep. The concept of a motionless body is alien. My mind and mind’s eye refused to let life go. Death was not really known to me. I had gotten to know this man and he was alive.

    Eventually, the rising and sinking of his chest stopped for me. The family arrived and I made an exit. His death was on my mind for days. Now, I think mostly about his life.

  • zeke

    I’m not sure how this might fit in to the show, but Peter Pouncey, former President of Amherst, has written a remarkable little novel called Rules for Old Men Waiting. The first sentence sets the tone: “The house and the old man were well matched, both large framed and failing fast. The house had a better excuse,…”

    House and old man are located on Cape Cod in winter where the man, McIver, has just buried his wife and is determined to confront his own demise in solitude. He devises his set of rules (how characteristically American to be practicing self-improvement on death’s doorstep) and sets out to live by them. One of them is to “work” in the morning; and nap in the afternoon if he needs to.

    “Now he had the answer to the question of what work he would do….The rage seems to be threefold–at the incompleteness of things, that however hard you take stock, nothing tallies to a total; and at the fact that you are no longer your own person, thinking your own thoughts, but increasingly the prey of random images that assault you; and at the fact, most important, that you were robbed long before the end of people you loved, of powers you had, and always pointlessly. The work you do should respond to all these furies: tell a story to its end.”

    In his heroic struggle to conceive and create a complete short story (about soldiers in WWI) he ranges back through own life and the events that combined to leave him “clenched tight as a fist” on the eve of his death. It is a remarkable juxtaposition of narrative, imagination and memory.

    From an interview in the back of the book, Pouncey seems accessible, erudite and succinct and might make an interesting guest. In any event, ROS listeners and blog readers for whom this topic resonates might find this book very worthwhile.

  • My wife is a nurse practitioner who works in the Johns Hopkins health system in palliative care. She advises patients and kin on withdrawal of life support, withholding care, entering hospice, etc.

    I bring this up because in hospitals, palliative care–helping people die comfortably and with dignity–is of growing importance. More hospitals are providing it, and more patients and kin are requesting it. This represents a paradigm shift for hospitals, which have always focused on intervention and preventing death.

    My wife has a theory that makes a lot of sense to me. She believes that the baby boomers will be drivers of this shift. We are the generation that insisted health care providers change their attitudes and procedures in childbirth. As we insisted on dictating the terms of birth, we are beginning to insist on dictating the terms of our deaths.

  • Though it sounds discordant, it seems to me that, as the full impacts of our budget deficits and out-of-control health costs become clearer, I expect that letting people die on pain medication, without heroic efforts to keep them alive, will become a lot more common. People who oppose euthanasia, e.g., will have to go along with others choosing it for financial reasons.

  • chilton1

    avecfrites “without heroic efforts to keep them alive, will become a lot more common”….

    how herioc would it be to prevent the very common death from…

    dysentery, Malaria, starvation?

  • Mellybee

    Bravo, Bravo – Chilton1 –

    Yes indeed, how simply ironic that in America we can be discussing the “good death” – it seems to be the ultimate in decadence to be able to think of the best way to go, and in fact possibly make it happen. I wonder if the innocent Iraqi’s are thinking “what way should I die today?” and then choose to be slaughtered – or the thousands that die daily from dysentery, malaria, starvation or even a basic flu/cold. What a luxury to contemplate the easiest way to die. I think it is a great topic, don’t get me wrong – but only in America, only in America. Like all great nations – this to shall pass.

  • manning120

    The medical profession would reject the notion that medicine should devote less attention to one cause of death to make that cause the “leading� cause. I spoke to a doctor about this. He said doctors want to cure whatever ails the patient, and avoid lawsuits. So I think the profession would probably assert that they have a duty to focus their talent and energy on fighting the most common causes of death. They would surely be sued if someone died a “preferred� death because of perceived neglect by doctors.

    Assuming we decide what way of dying we would prefer, we must consider whether, if we indeed had a choice, countervailing moral principles might turn us away from it. For example, it would be commendable to sacrifice one’s life to save or defend others, provided the act is motivated by correct ideals and informed by factual understanding. In that situation, it seems that at least some of us would choose to die in whatever manner the circumstances call for, regardless of how we would have preferred to die.

    Leaving aside that unusual scenario, most of us will be overtaken involuntarily by death. What manner of death would be preferable? In addition to delaying death as long as possible, it would allow the possibility of experiencing meaningful life as close as possible to the end. My personal opinion is that life’s meaning involves positive emotions evoked by events like winning something, loving (all kinds), graduating, having a child, learning or discovering profound truth, etc. The evocation of such emotions is also the chief mission of art and reminiscence. So the preferred death wouldn’t involve lingering in pain or discomfort beyond the point when one no longer has the capacity to experience those positive emotions. I don’t think we can say what exactly this means for each individual. Some may relish cheating death one more day, even if the quality of life leaves that as the only positive emotion. For others, intractable pain and disability may render further extension of life meaningless, even if they retain the residual ability to make rational decisions.

    Putting an end to brief or extended suffering is sometimes justified. One can appreciate the act of those who jumped from the World Trade Center towers rather than be burned alive. People with no hope of recovery from certain terminal conditions may act on their own if they still have rational faculties, or may be assisted if they have previously authorized such assistance. Either way, at the point when life can no longer have meaning, a quick end seems preferable. Determining that moment cannot be left to someone lacking the ability to reason because of such problems as depression, mental illness, or retardation. When the moment comes, I believe we have the moral option, for ourselves or for others, to pull the plug, or have it pulled for us, bearing in mind as mentioned above that there may be countervailing moral imperatives related to the effects on survivors of the choice to die, and the manner chosen.

    As a practical matter, I don’t think we’ll ever pinpoint a particular cause of death as preferable. But with the foregoing principles in mind, we can decide, on a case by case basis, whether and when to put an end to a hopeless situation. I think that’s what “death with dignity� is about.

  • In reference to the above comment: “…doctors want to cure whatever ails the patient…” :

    I agree. Of course, doctors want to cure people. After all, life:good, death:bad. No argument here.

    But increasingly questions of life and death aren’t being determined by doctors. They are being determined by politics and economics. Doctors don’t determine which drugs are paid for by health plans. Doctors don’t determine which public health education and outreach programs society undertakes. Doctors don’t determine staffing levels in ERs in public hospitals. Doctors don’t drive civil defense planning, whether for hurricanes or flu pandemics. Increasingly, doctors are just there to scoop up the mess that strains through our health policy sieve.

    This is not a good thing. But it’s sobering to consider that the manner in which you die will be influenced by some back room deal in Washington.

  • chilton1

    I am sorry avecfites

    I think (even taking into account that you are speaking from an American-centric point of view)…it is a little naive to say…

    “increasingly questions of life and death aren’t being determined by doctors. They are being determined by politics and economics.”

    -It has always been about politics and economics.

  • I agree about politics and economics. Only those with money can gain control over their healthcare dying. Only those of us in the nation that wields power can think about this on a larger scale.

    As I ponder the idea of being drugged to relieve pain while I die, i find that this is not attractive to me. I’d prefer a proactive euthanasia than a final stage of delirium. Lack of pain does not equal peace. I cannot prepare for death if I’m inebriated.

    As for me, I would prefer to be attended by an acupuncturist and an herbalist. Insurance doesn’t pay for that. I have paid for my own healthcare, plus health insurance, for the last 12 or 14 years. Medical professionals don’t support my approach to health care. i’m going through some serious health issues now. My acupuncturist has insisted that i get Western testing done. As soon as I stepped foot in that world, I was faced with enormous tension. I only want diagnosis by these doctors, I want to determine my treatment path. The docs want to control the process. They are in turn patronizing and skeptical. They either try to scare me into their way or they dismiss me.

    Financially, I may be forced down a path I don’t want or face a loss of the health insurace. I’m not at all looking forward to being told how I must die if I can’t afford my preferred choice and I don’t want to financially burden my family.

    And then there’s the question of disposal of my remains. I’m appalled that we allow chemically treated boxes to be put into the ground. Cremate me please! I want to remain in the life cycle. Allow my body to regenerate the planet. Oh, that’s another topic. Sorry. ;D

  • chilton1

    not all doctors are as you describe Allison

    and of course you should make your own decisions…but how can you do that if you are not informed?

    Trust your acupuncturist please….

    I think many people get modern western medicine mixed up with evils (corruptions) of capitalism.

    science and medicine result from the enlightenment (it really was an enlightenment) -an aspect of western culture of which we should be proud – not afraid.

  • This thread is giving me a flashback to college – I did my senior year project (a documentary I produced with my wife) on the rhetoric of the euthanasia debate. My academic advisor, Michael J. Hyde, later wrote a great book on the subject. Kinda heavy on the Heidegger and Levinas, but still a great read for anyone interested in a philosphical perspective on death with dignity…

  • A great, appropriate cartoon from Hugh MacLeod.

  • nother

    I heard it said recently that anxiety is the fear of death. I dismissed the idea initially but it keeps hovering around poking me in the back of the head. I Googled a little and found a similar thought by Tolstoy, “if a man has learned to think, no matter what he may be thinking about he is always thinking of his own death.â€? As far as my existence goes, there is a blatant Paradox of my very chill countenance and my anxiety ridden inner-self. Could the reason I chew my fingernails like corn on the cob be from fear of impending death? How often during the day do I think about death? I guess I do stare at that mirror a lot, keeping a scorecard of my bodies deterioration – but it must be more. I know I fear the death of my mother immensely. Something vital will die inside of me when she dies. My mom has smoked all her life and my heart skips every time I hear her cough; was that a deep cough I ask myself?

    To think about a good death, about how I want to die or my mom to die, well, it just seems redundant. All I think about is death, even when I’m not thinking about it, and all I ever come up with is – it sucks! It really really sucks! Asking what is a good death is like asking if you’d rather have a sledgehammer slam down on your fingers or your toes!

    I could do worse then defer to Socrates in this matter. “The fact is, those who apply themselves correctly to philosophy are simply and solely practicing dying and preparing for death.�

    A good death? I’ll be reading a good book on the day I die, a good book to wind down from a long day laughing with my friends and family, making love to the one I love, and breathing fresh air in between sips of vintage port. Ideally, after I pass those same friends will prop me up with a pint at the pub and drink to my memory, then they will merrily form a second line from the church to my grave, celebrating a life – I cherished so much.

  • When I tell people about my efforts to avoid junk food and excercise, some of them become defensive and say, “well, we’re all going to die.”

    And they’re absolutely right!

    What I see — and want to avoid — is increasing numbers of people spending 10 or even 20 years in increasingly miserable health and disability before death due to cardiovascular disease, diabetes, emphysema/COPD, and loss of mobility due to lack of excercise or excess weight. Add to that the rising cost of healthcare and you get misery AND poverty and the attendant anxiety, isolation, and loss of independence. Yet, cardiovascular disease, adult-onset diabetes, emphysema, and many aspects of non-traumatic mobility loss are largely preventable.

    The things that nother talks about enjoying on his last day of life — sex, having a long enjoyable day with family, reading, taking a deep breath, drinking an alcoholic beverage that’s sugary and doesn’t mix with many medicines — many are impossible in the context of what we might call the diseases of a toxic culture.

    I would like to live to be 85. And I don’t want to start dying at 65. Plan accordingly just to get a chance at it!, I say, to myself. Which reminds me, I really need to floss more.

  • Old Nick

    Re nother and Lisa Williams:

    We all have heard the phrase “aging gracefully�.

    Why not “aging youthfully�?

    It’s not the oxymoron it might seem: Lisa Williams is obviously doing it.

    I’ve been toiling at it myself for a couple of decades now. I don’t at all expect to ‘leave a beautiful corpse’, but I hope my choice to exercise and eat decently keeps my body a decade or so younger than the norm for my chronological age.

    I can live with that. And die, inevitably, with fewer regrets, too.

  • nother

    Good points Lisa and Old Nick, many people spend too much time worrying about extending life and not enough about enriching it. Now that I’m over 30 and not invincible, I take vitamins every day, eat fruits and vegetables, and exercise when I can. I guess I do it all so I can make love and drink port on my 80th birthday (would 90 be pushing it?)

    I just want to say that I know many people that are obsessive about the health food and exercise (esp. here in Cambridge, MA) and I feel that they are missing out something in the present with too much thought about their future – robbing Peter to pay Paul.

    A wise man once told me “everything in moderation, even moderation!â€? I work out and eat healthy – so I can indulge without guilt.

    The exercise that is most important though is the exercise of the mind. If we follow the advice of Socrates and apply ourselves to philosophy by continuing to read, think, and acquire knowledge as we get older, we will be more prepared to pass with contentment.

  • chilton1

    live as long as you pay taxes

  • rcain

    The preceeding threads perfectly deny the subject at hand- death…our cultural and medical mind set is that death is optional.

    Well, I do death- I see people who have chemotherapy on the day they die.

    I hear clinicians tell patients, “Well, statistics are for populations, your case may be different.

    I spent time last evening, on the 4th of July, in a nursing home, with a 75 year old lady with “end stage” lung disease- I did not know her- , who had come in for “one last try” at therapy. She was wild eyed, sobbing, “I just want to go home”, despite the extra morphine and ativan, she was inconsolable. Providentially, because the right hospice nurse was covering and we could get the drugs she needed to avoid suffering, and her son was right there, and we could cut throught the paperwork, we got her home within an hour. Later that night, her son relayed she was so happy, she didnt need hardly any medication….

    A good death must be “direct to consumer” marketed, not hidden in the myriads of complexity. You can’t buy a good death now, even with millions

    We set up the nursery room, lets give the same exquisite attention to detail to the other end of life..but that takes budgeting (not depending on Medicare funding), designers (palliative care clinicians who know how to anticipate and treat symptoms) and cutting through all the barriers and denial. If we embrace death as we do birth, there will be no need to “hasten” death (we don’t “hasten birth!)

    When I finally buy my own hospice, it’s going to be named “Way to Go!

  • Robert Buxbaum

    I care for dying patients and their families. The degree of denial that exists in our society is beyond comprehension. Since the absolute death rate is one hundred percent, why don’t we manage deaths as we do births: with support, understanding, dignity, and management of pain and other symptoms? Why do my medical colleagues fail to inform their patients and help them prepare?

    The resources should be there, but aren’t. Every family (unless they’ve learned how to prepare from an earlier death and perhaps experience with hospice), approaches this event as if they were they only ones and as if it’s a complete mystery.

    This is a public health issue and a challenge for an entire population. Consider how grief and loss have transformed some people and some policies: the Lockerbie bombing and how the families, in their grief, banded together and changed US policy toward Libya; the 911 families and the Congessional initiative; Mothers against Drunk Driving (MADD) and state policies about driving, for example.

    Well, now it’s time, in my view, for those who care about the quality of care at the end of life to speak up and take action. The hospitals won’t, the professions won’t, the medical schools won’t, legislatures won’t, until and unless this happens.

    Bob Buxbaum, M.D., F.A.C.S.

  • nother! so nice to see you.

    your post about your last day reminded me of my own vision. In business school I was asked to write my own obituary. The idea was to try and think about what you’d like to accomplish in this life. It was hard for me to write in the way they wanted. I kept thinking that all I wanted was to be old, sitting in a rocking chair on a porch, looking out at a beautiful countryside, with a long-time companion next to me and to be saying to each other, “Its been exquisite, hasn’t it?”

    I’ve thought about death since early childhood. I was obsessed with Vincent Price movies in my pre-teens. I don’t think I was simply being morbid or simply playing out my troubled mind at the time. It was the beginning of a process of asking myself what this life was about. Knowing that it could end at any time, in any way. That it could be torturous. What did I hope to experience? And, though I thought about death quite a bit, I never stopped imagining a full life. I always pictured myself growing contentedly old and then passing on. Is this denial? Of course, I could be hit by a car tomorrow. But that possibility doesn’t have staying power in my vision. Perhaps we need to delude ourselves? I don’t know. I do know that this vision acts like a guidepost. In challenging times, when I don’t feel emotionally peaceful, I ask myself, “Am I on the path to that porch?”

  • The question can be asked: A “good death” for whom? For example, we live and die enmeshed in a world of institutions, where concerns about blame, fault, risk minimization and profit maximization frame many decisions. For some hospital administrators and big pharma, I suppose, a “good death” is one that has led to profit maximization and risk minimization, concurrently.

    Institutionally, a “bad death” is one that creates liability.

    Then there’s the daily reality of dying for a cause, as in Iraq. Is the death of a young soldier or civilian ever “a good death?” What constitutes this definition, for various audiences? (Consider the shifting narrative frames around the death of the ex-Arizona Cardinal football player, Tillman, and “revisions” of the initial fable around his death, by the DoD).

    The symbolic interactionist ideas of the 1960s still have some value. A “good death,” for an external audience, is what the majority of the audience believes is “good.” Becker and Goffman are still useful on this point.

    In terms of our own intrapsychic realities, there’s a relationship, I think, between a good life and a good death: Did we live the kind of life where we had the opportunity and the courage to develop our talents and skills? To follow our productive passions and interests? Did we live (and for how long) under what Neruda once called “Plenos Poderes?” (Full Powers). And, of course, what (and or who) will we leave behind, as a echo of the better part of our natures?

    A “bad death” comes in many ways, then, often stained by the promise left

    unfulfilled or the damage done . . . there’s too many types of failure and pain to catalog for this post. At the end of a life, maybe we view Art Buchwald’s recent decision to turn to hospice, rather than to be subjected to fruitless medical interventions, as a current model for a “good death,” one that accepts the lessons of that particular life, and peacefully releases into . . . whatever.

  • nother

    Allison, nice to see you as well, I missed you! Your rocking chair on a porch vision is beautiful. Is it possible that you/all of us should be spending more time on that porch, not waiting to the end. It boils down to an everyday philosophical question I debate with myself; how much time of this precious life should I spend trying to be productive and wonder why we are here, and how much should I be trying to slow down and sit on a porch and smell the fresh air and appreciate basic existence. I’m probably getting too far out their because I’m off to work and only had a minute to write, but thank you Allison for always being generous with your exquisite view from that peaceful porch of yours.

  • Potter

    Oy! This is personal.

    My mother is not what is called “actively dying� in hospice language but she is dying. She is showing me how to do it too. At 92 and she has a mass on her lungs which is most assuredly cancer. Yet she is refusing a lung biopsy, taking a strong stand against doctors’ advice which would put her through all the procedures and treatments they would put anyone through regardless of age,futility, effects. .

    Angry with the care she had been getting, the system in general, she switched to another doctor, one trained in the Soviet Union. We are very impressed with her. She is willing to give her time generously, to focus, to listen, to agree to palliative care, and she has a terrific bedside manner, offering my mother ( and me) a hand to hold. Prior to this switch, my mother had argued with all of us, dug her heels in– and now we see her incredible wisdom and courage. Each day that she gets up is good and she is thankful. What an example and what courage from one who loves and is so interested in life still.

    To be sure, my mother is somewhat in denial too. Either that or she is the bravest person I have ever met. She says �everybody get’s cancer. So what?�

    But she was brought up with death in the house. She lost tiny siblings to diseases including the 1918 Flu. She tended her mother at her death, giving her morphine injections until the end. She washed her sister’s dying body years later. She held her brother’s hand as his life was ebbing away.

    She knows there is nothing she can do about the inevitable and what is happening to her other than guide it , challenge it, and maybe ignore it. She cannot change it. So the focus is on first being thankful, getting up in the morning and looking at the world another day, grateful for a good memory, a good article, a good passage in a book, a good phonecall.

    I tell you, I am for denial. Denial works. Whatever keeps one in the moment, less anxious and fearful, I’m for. When active dying begins, we will focus on that. When she dies, I know part of me will die as well. I can’t bear to think of that now. No, now is a time to live.

    Until my time comes I want full force life and amnesia about it. That there is death cannot be avoided; it’s everywhere and it comes through like a train. When my moment comes I want to accept it, be thankful that I lived, not be greedy but be gracious enough to let go.

    I do not know how mine will occur. I’d like to think I will die with a poem on my lips and a sip of wine no matter what. But that is an expression of defiance. Chances are it will not be so grand. My father died so very afraid. How sad for me to think of that.

  • loki

    Two great books: Ernest Becker’s “Denial of Death”(written before he died) and Robert Langs MD” Death Anxiety and Clincial Practice”. We cannot forget the Woody Allen adage”I don’t mind death-I just do not want to be there when it happens” On a somber note, howe can we forget the more than 2500 US troups who have died in Iraq,the more than 18,000 wounded. An how many Iraqi deaths and children maimened.

  • Potter, thanks for sharing your story. My father is also now fighting Time as his body breaks down and he too is thankful for every extra day he’s given, which he learned from his battle with bottled spirits.

    Thought you might like these lyrics written for a dying parent, by none other than the Grateful Dead.

    Box Of Rain

    Look out of any window

    any morning, any evening, any day

    Maybe the sun is shining

    birds are winging or

    rain is falling from a heavy sky –

    What do you want me to do,

    to do for you to see you through?

    this is all a dream we dreamed

    one afternoon long ago

    Walk out of any doorway

    feel your way, feel your way

    like the day before

    Maybe you’ll find direction

    around some corner

    where it’s been waiting to meet you –

    What do you want me to do,

    to watch for you while you’re sleeping?

    Well please don’t be surprised

    when you find me dreaming too

    Look into any eyes

    you find by you, you can see

    clear through to another day

    I know it’s been seen before

    through other eyes on other days

    while going home —

    What do you want me to do,

    to do for you to see you through?

    It’s all a dream we dreamed

    one afternoon long ago

    Walk into splintered sunlight

    Inch your way through dead dreams

    to another land

    Maybe you’re tired and broken

    Your tongue is twisted

    with words half spoken

    and thoughts unclear

    What do you want me to do

    to do for you to see you through

    A box of rain will ease the pain

    and love will see you through

    Just a box of rain –

    wind and water –

    Believe it if you need it,

    if you don’t just pass it on

    Sun and shower –

    Wind and rain –

    in and out the window

    like a moth before a flame

    It’s just a box of rain

    I don’t know who put it there

    Believe it if you need it

    or leave it if you dare

    But it’s just a box of rain

    or a ribbon for your hair

    Such a long long time to be gone

    and a short time to be there

  • Rose Cain

    a little bit late?? the median length of stay in hospice in Massachusetts is 15 days…..we often refer to these precipitous situations as “admit and pronounce”…

  • diogenes

    Farewell

    If you miss me when I go

    Then miss me good and hard.

    But do not mourn my passing

    As a thing unfortunate

    Or worse, untoward.

    It is my nature to come and to go.

    It is who I am.

    My coming and my going

    Are equal in goodness.

  • BJ

    Here’s a modest proposal: At our 65th birthdays we’re given the opportunity to direct palliative care only for any potentially terminal condition and divert the dollars that would have been spent on heroic measures toward health insurance for a young person who doesn’t have coverage.

  • joel

    I want to die when I feel about my life as sometimes one does about a really good day at the end of which the only thing one wants is to have a really good sleep.

  • kristeva5000

    what about euthenasia? the question of being able to choose it at certain point

  • Karen5

    After 54 years of marriage, my Mom died suddenly and unexpectedly last year of a heart attack.

    Her only symptom was chills. She was working in the kitchen and walked into the living room to tell my Dad that she was having chills. He put his arms around her, but it didn’t help. Mom decided to go to bed and Dad followed to bring her a warm blanket. He put it over her, lay down beside her (I imagine them spooning, though Dad has never been specific), rubbed her arms and back. After a few minutes she made “a gutteral sound in her throat.” Dad called her name, but she didn’t answer. He leapt out of bed and called 911 immediately.

    Paramedics arrived within a few minutes and performed CPR, but it didn’t work. One of the responders told Dad there was nothing they could do, and if they were able to bring her back she would be brain damaged or brain dead. The whole episode took 30 minutes at the most.

    Like so many other things, Mom did it right.

    I wish she’d lived a little longer (she was 76). I miss her terribly and still sometimes have the urge to call her and tell her something I know would interest her. Dad misses her more.

    But I remember the Law of Unintended Consequences (also know as “Be careful what you ask for….”) Had she survived, might she be incapacitated in a way that would no longer make her the Mother I remember? Might she be in pain? I would not want to be responsible for wishing that on her. The only thing I can wish is that, when my time comes, it is as quick and easy as hers.

  • harriet

    I’m 84, healthy, active, thinking, but ready to go any time my body or mind fails—with the adage Loki attributed to Woody Allen but which I heard Steve Allen say on TV some years ago, although I do not know whether his wish prevailed at his death. If nature doesn’t provide it I hope euthanasia can just put me to sleep, as quickly as MDs do in pre-op. My husband, suffering with cancer at age 76, repeatedly asked to be put to sleep and not awake but we failed him by doctors offering only palliative morphine which took weeks, along with self-inflicted starvation, to finally cut off his breath. I hope my sons do not have to witness that again. At this age I can think of no reason to carry on beyond being able to care for myself and take pleasure in the day’s activity.

  • chilton1

    thinking again about the idea of a good death…(problem is no one comes back to tell you …good, bad, or otherwise).

    We must all have our own good death

    like for a bull and a death in the afternoon

  • juniper68

    I’m a pastor who works mostly with older folks. As I sit with these lovely people, who are dying or getting ready to die, I’m struck by this: it’s not necessarily the money spent or not that makes a good death. It’s not even the health that the person came into old age with (although I’m with all you good eaters and exercisers in practice). Instead, it seems to me that people who can die well have two things going for them. First, they have the ability to love — love themselves, other people and God, however God is named for them.)

    Second, they have perfected in their whole life the ability to let go. There has been a lot of talk here about control — controlling your death by what and how you eat, staying healthy, talking to your family, exercising, etc, but ultimately death is really about really letting go, about surrender.

  • nother

    A very moving post, Potter.

  • Potter

    How could I forget my dear sister who was murdered? Death comes in so many ways, Not only illness. Car accidents, war…

    Thank you and for so many good posts here. I really did not want to listen to this show but it did not hurt. The post above that put a lump in my throat was Karen5’s. Regarding, The line in Sidewalker’s ” love will see you through” It’s the love ( and acceptance) that makes the letting go easy. Diogenes, “my coming and my going are in equal goodness”.

    It occurred to me last night while listening that the doctors described who want to do everything they can, who were trained to do so, are also not necessarily thinking of or listening to the patient. They are thinking about themselves, what they need to do for themselves. Not all, of course not all.

  • bft

    “Unless a person comes to the place where he wants to die, he has been licked by life.” Vernon Johns, quoted in “At Canaan’s Edge: America in the King Years 1965-68” by Taylor Branch (Simon & Schuster, 1996).

  • colin

    I couldn’t help but be reminded during this conversation of the closing lines of Sleeper, spoken between Woody Allen (Miles) and Diane Keaton (Luna) in a bubble car, after toppling the tyrannical nose of a futuristic distopia.

    Luna Schlosser: Oh, I see. You don’t believe in science, and you also don’t believe that political systems work, and you don’t believe in God, huh?

    Miles Monroe: Right.

    Luna Schlosser: So then, what do you believe in?

    Miles Monroe: Sex and death – two things that come once in a lifetime… but at least after death, you’re not nauseous.

  • bft

    I’m sorry; the Taylor Branch book At Canaan’s Edge is new, Simon & Schuster 2006. I was looking right at the copyright page, too! The quote is from Johns’s last sermon, “The Romance of Death.” Earlier books in the Branch series do go back that far: Parting the Waters (1988), Pillar of Fire (1998). There is quite a bit on Vernon Johns in the first of these. Here’s a web page that says Branch got Johns wrong: http://www.vernonjohns.org/tcal001/vjfinal.html

  • manning120

    In my June 23, 2006 post, I failed to say that the positive emotions art and reminiscence aim at evoking give meaning not just to life, but to existence itself, which includes suffering and death. The positive emotions related to suffering and death aren’t as easy to describe as the others I mentioned. I think they involve a sense of being part of a universe that somehow transcends the self, into which the self merges upon death. Publicly, nothing can provide access to this emotion better than art, and especially music (which may or may not be associated with religion). Most people know particular music that evokes for them the emotions of which I speak. The greatness of music may be measured by how well it does that. In contrast to public art is private reminiscence. One form of reminiscence occurs when people believe they’re about to die. Survivors of this experience report consolation from memories of an entire lifetime flashing through the mind.

    I believe last days with retention of the capacity to experience the emotions that make existence meaningful are preferable to last days without that capacity, as when one dies from Alzheimer’s Disease or in a drug-induced stupor. I believe Karen5 and harriet would agree.

    By the way, thinking about preferred ways of dying may have a lot to due with risky behavior such as driving race cars, climbing Mount Everest, etc.

  • FilkeeVT

    Have to add in a quote from my friend Michelle Shocked who said in her song from the album (we still called them albums at the time) Kind Hearted Woman, “Fever Breaks”:

    A slow and painful death comes faster than the eye can see

    Taking your last breath seems like eternity

  • I’m late to the party as usual. . .but my father-in-law always felt a good death, “would be at the hands of a jealous husband”. At nearly 80, married to the same woman for more than 40 years I think his chances of having a “good” death are next to none. Let’s hope he has a peaceful one instead.

  • Pingback: » The New Age of Old Age()

  • Pingback: Penns Ultimate Professions Guide. | 7Wins.eu()

  • Pingback: this is a good death()