The woods decay, the woods decay, and fall,
The vapours weep their burthen to the ground,
Man comes and tills the field and lies beneath,
And after many a summer dies the swan.
So begins Tennyson’s haunting poem “Tithonus,” a meditation on death as part of the natural order of things. Natural, that is, for everyone except Tithonus, to whom the gods granted immortality but not eternal youth. Thus he grows older and older, ever more feeble with each passing day, yet can never die.
Today, “Tithonus” seems an uncanny prevision of much contemporary medicine. Drugs and radiation, chemotherapy, ventilators, feeding tubes, medical drips and monitors — all these may be worth enduring when a reasonable hope exists for a return to the world outside the intensive care unit. But, suggests Katy Butler in “The Art of Dying Well,” for more dire cases, when there is no cure for the cancer or one is already old and frail, alternative courses of action may be preferable. Some noninvasive treatments and gentler medications may allow a life with dignity, even if a shorter one, and avert the suffering and purgatory of a living death.
Butler isn’t a doctor, but she is a professional science writer and author of the widely admired “Knocking on Heaven’s Door,” a critique of our broken medical system told through case histories and an account of her father’s traumatic last years. Not surprisingly, then, this “practical guide to a good end of life” delivers on its subtitle, offering detailed advice on dealing with — in poet Philip Larkin’s phrase — “age, and then the only end of age.” Butler’s factual, no-
nonsense tone is surprisingly comforting, as are her stories of how ordinary folks confronted difficult medical decisions. In short, if you’re coming up on three score and 10 or have already passed that biblical term limit for earthly existence, you will want to read “The Art of Dying Well” and keep it handy, if only for its lists of what to do as one’s physical condition changes.
Overall, Butler’s advice can be summed up in the Boy Scouts’ motto: Be prepared. If you’re merely approaching the end zone, do all you can to preserve your well-being. Exercise. Keep your weight down. Eat lots of vegetables. Control your blood pressure, cholesterol and sugar, ideally without medications or with the smallest dosages possible. Stay mobile, but watch out for falls. Be sure, too, that your financial and medical records are organized, comprehensible and digitally accessible to the appropriate people in case you are incapacitated.
After all, accidents and unexpected diagnoses happen, and no one knows when or from where the blow will fall. While you can, think through possible medical futures, however unpleasant. Do you wish to be kept alive no matter what, at any cost? Are there procedures you want nothing to do with? Whatever you decide, make sure that your family, friends and medical advisers are aware of your desires — and that you and they have the proper documentation to implement them. These start with a durable power of attorney for health care, so that someone you trust can make decisions if you can’t. You should also set up a living will or advance directive as a guide to what you want and don’t want if you land in the emergency room. Better still, consider the somewhat similar POLST or MOLST — physician or medical orders for life-sustaining treatment — which is more scrupulously honored by hospital personnel because it is signed by your doctor.
In general, Butler tends to be wary of the medical establishment. Pharmaceutical companies, hospitals, physicians and nursing homes make money on drugs and high-tech procedures, often overprescribing the former and automatically recommending the latter. Butler suggests that palliative care, milder, less invasive protocols and physical therapy are often underutilized, work well or well enough, and avert the ravages and often devastating aftereffects of expensive Hail Mary treatments.
Throughout “The Art of Dying Well,” Butler stresses the vital importance of having what she calls a “tribe.” A tribe can be one’s extended family but might also include the neighbors you socialize with, or your bridge club and fishing buddies, or members of your church — in short, the people you care about and who care about you. What matters is that a tribe’s members are mutually sustaining: They help each other out. Loners don’t do well in old age.
The need for a support circle grows particularly important for those who hope to die at home. Hospice care is invaluable — and Butler recommends starting it sooner than most people do — but its visiting providers are overworked, underpaid and too few. So you will need friends, family or hired caregivers to give you painkillers and sips of chicken soup. Of course, a rational society would properly tax its obscenely super-rich if only to pay better, more appropriate wages to hospital and hospice nurses, physician assistants and the aides in dementia wards and long-term nursing facilities. When you need to have your soiled linen changed, you will bless the one who does it.
The actively dying, Butler reminds us, are frequently troubled by unfinished business: They have regrets, want forgiveness, fear being utterly forgotten. Above all, they yearn to know that their lives had meaning. Some solace may be found in having been part of an enterprise larger than oneself — a religious faith, the education of children, the advancement of some area of art, science or scholarship, civic activism, the care of the sick and dying. There will, nonetheless, always be regrets.
Butler’s “The Art of Dying Well” covers much I haven’t touched on, including aging in place, Medicare, assisted suicide and last rites. Her thoughtful book belongs on the same shelf as Atul Gawande’s best-selling “Being Mortal” and Barbara Ehrenreich’s “Natural Causes.”
Michael Dirda reviews books each Thursday in Style.
By Katy Butler
Scribner. 274 pp. $26