When I began as a medical student on the wards, I discovered that there was a word that physicians almost never used. In fact, they often played elaborate language games to avoid it. My first encounter with this occurred one night on call. The resident and I were eating dinner in the cafeteria when he got a page. He excused himself saying, “I need to go declare a patient …” I remember thinking, “You need to ‘declare’ a patient … what?” He avoided saying that he was going to declare a patient dead.
Not long after that, during morning rounds, I noticed that a patient who had been in our section the day before had disappeared. I didn’t think there had been plans to discharge him, so I asked, “What happened to Mr. Jones?” Matter-of-factly, the resident physician said, “He expired last night.” I remember thinking: “He … expired?” Coupons expire. Milk expires. But people die. There was that word again — the “d” word — being carefully avoided by doctors who dealt with death routinely.
Of course, doctors are not the only ones who avoid the subject. We now live in a death-denying culture. We worship the cult of youth, spending billions of dollars every year on products that promise to help us live longer or that at least hide the effects of aging and decline. We avoid even thinking about our mortality, much less talking about death and dying. As Woody Allen quipped, “I’m not afraid of dying; I just don’t want to be there when it happens.”
[Other perspectives: Independence is overrated. There’s courage in depending on others in life and in death.]
We can try to avoid it. We can try to deny it. But there is no escaping it. Medicine will continue to improve over the next 50 years — new cures, better surgical techniques, therapies that we have not yet imagined. But I hope that the biggest advances will emerge in our ability to accept medicine’s limitations.
Doctors need to learn to accompany their patients through the dying process. If death is seen as the last enemy of medicine, then doctors will lose every time. The human mortality rate continues to hold steady at 100 percent and shows no signs of changing. Our next medical innovation — the acceptance of our mortality — will not come as a technical solution to a scientific problem. It will have to be a more human approach to a deep mystery of every life — the mystery of being mortal.
The movement to legalize assisted suicide is a symptom of the current problems that plague end-of-life care. On the surface, allowing doctor-assisted suicide might seem like a step toward accepting our mortality. But this proposed “solution” is actually just another form of denial. It solves nothing, because it is premised on the false assumption that our autonomy has no inherent limits.
Ironically, death is the one event in our life that finally reminds us of our lack of complete control, yet our denial becomes apparent at both extremes when it comes to end-of-life care: on the one hand, attempting to completely control circumstances of one’s death through the ingestion of a deadly drug at a time of one’s choosing; on the other, the futile attempt to continue aggressive treatment that only prolongs the dying process without providing medical benefit.
Providing all Americans access to good palliative care is absolutely necessary, but is only a starting point. We need also to relearn what used to be called the ars moriendi — the art of dying, and of tending to the dying. This involves much more than a prescription: It means the opportunity for a person to rectify past wrongs, to reconcile broken relationships, to reorient his or her priorities — to say and to do what really matters in the end.
It’s not comfortable to watch a loved one die. But those who have died well show us that in the midst of suffering and decline we can still find courage, hope and even beauty. True compassion and mercy involve walking this difficult journey with our patients and with our loved ones — a journey in which there simply are no shortcuts.
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