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RBC Letter

Vol. 63, No. 1 — May/June 1982 —
Facing Up To Death

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Everyone is bound to die, but the subject of death is still broached in whispers. Lately, the facts of death have been slowly emerging from the shadow of a social taboo. That is a healthy development, because it makes people think about their own mortality. If we learn how to die, we will learn how to live...

The only certainty in anyone's life is that it will end. Death is also something that all human beings have in common. Considering its inevitability and universality, it is remarkable how rarely this dominant fact of nature is ever discussed.

When we do bring ourselves to talk about it, it is usually in euphemisms ("she passed away") or in flippant terms that trigger nervous laughter. In an age of ruthless frankness, dying is one natural function that remains in the shadow of a taboo.

It is not as if the subject were unfamiliar. Everyone past early childhood has known a relative or friend to die. In our mourning, we come face-to-face with the reality that a life which has touched our own has ended. But of our own inexorable end, we try to think little and say less, except when it is clearly in sight.

Our reticence concerning death shows an unwillingness to accept the most obvious of all realities. Though this is irrational, it is understandable enough. We shy away from the idea of death because we dread it. We associate it with the most horrible sensations we know - shedding blood and tears, feeling sick and helpless, being in pain.

Our fear of death is compounded by a fear of the unknown. Religious belief has much to do with the degree of this. Death holds fewer terrors for one who is convinced of a life hereafter than for one who is not.

Among believers, however, few are so constantly without sin that they can be sure of escaping divine punishment if death were to strike without warning. Non-believers who think of death as total extinction may feel an awful sense of doom when they consider that at any time the door could slam shut on their existence for good.

The symbolism of death does nothing to make our approach to it more logical. The thought of it brings visions of grinning skeletons and spooky graveyards shrouded in mist. Death, and our dread of it, is the dramatic core of the adventure thriller, the ghost story and the horror movie. The chills which these works send up our spines emanate from the ancient air of superstition that clings to the subject to this day.

One manifestation of this superstition is that we persist in branding death as evil. At the most, death is the result of evil acts of violence and destruction - the result, mark you, not the cause. But we see death in general as a bad thing because we see life as a good thing, a precious gift to be guarded. Death is therefore the enemy, to be resisted in the spirit of "never say die."

Dr. Lewis Thomas of the Memorial Sloan-Kettering Cancer Institute in New York City says that modern North Americans equate dying with failure. Most people today die in a state of physical deterioration (the average life span in Canada is over 70) which is far removed from the fit and beautiful images of success thrust at us by television, films and magazines. To grow away from the youthful ideal of success as we grow older is, in the subconscious mass mind, to fail by stages. The ultimate failure is to die.

According to Dr. Thomas, we have "lost our respect" for death: "We have become ashamed of it, and we try to hide from it, and hide away from it." Shame of death is nothing new. "Tis the very disgrace and ignominy of our natures, that can so disfigure us, that our dearest friends, Wife, and Children, stand afraid and start at us," wrote the 17th century essayist and physician Sir Thomas Browne. What is new is the hiding of it and the hiding-away from it. In Browne's day, there was nothing anti-social about dying. It was a routine and very frequent occurrence which took place in full public view.

Death is out of sight, and that helps us to keep
it out of mind

Until only three or four generations ago, people usually died at home, surrounded by their families. Children then witnessed first-hand the realization of the Biblical phrase,

"a time to live and a time to die." There were also those who died before their time: infectious diseases, which could not be controlled before antibiotics, killed persons of all ages. Children who saw their brothers and sisters and cousins "carried off by fever" grew up with a healthy awareness of their own mortality.

Now that most people die in hospitals or nursing homes, dying has become a remote, institutionalized phenomenon. It is out of sight, and this reinforces our natural inclination to keep it out of mind.

"Death is a very dull, dreary affair, and my advice to you is to have nothing to do with it," says a character in a Somerset Maugham novel. For the first time in history, people are now able to follow that seductive advice up to a point.

Unless there is a war or some other pressing mortal danger, most young, healthy people can have "nothing to do" with death and get away with it. The prospect of their own deaths is well-nigh inconceivable. From where they stand on the time scale, the average age of death is far, far away.

But as the actuarial odds shorten on a person, it becomes folly to try to evade the reach of mortality. Beyond the age of 35, as Michel de Montaigne put it, "one should always have one's boots on and be ready to go."

Leading the kind of life that you can leave
without reproach

From a practical standpoint, this means having adequate life insurance, having planned your estate, and having made a proper will that can be easily located. It also means having made or dictated your funeral arrangements or other plans for the disposal of your body. Many people prepurchase a coffin and burial plot. Others arrange for cremation, or sign over their remains to medical science.

Such practical precautions are only part of being ready for the one event that you can absolutely count on. They will bring peace of mind to your survivors, but only by clearing your conscience can you achieve the personal peace of mind that will allow you to face your own death with equanimity.

Over the ages, there has been no sounder admonishment than one written by Sophocles 2,600 years ago: "Let every man, in mankind's frailty, consider his last day, and let none presume on his good fortune until he finds life, at his death, a memory without pain."

This amounts to a call to live at all times in such a way that the only bad feelings you leave behind you are feelings of sorrow, which has been described as the price people pay for having loved someone who has predeceased them. If people were to conduct themselves in this fashion, they would lead much more rewarding lives.

The saying that you should live every day as if it were your last has often been taken as an invitation to sensuality. But if it really were your last day, would you waste it? Or would you, in the best sense of the phrase, make up for lost time? Would you not use that day to seek spiritual peace, to heal old wounds, to repair broken communications? Given one last chance, would you not try to leave this world as free as possible from reproach?

Pope John XXIII said that any day is a good day to die. He obviously spoke as a man who had his spiritual and philosophical house in order. To be able to face each day with such confidence would be a great relief to most of us, whether death should come to us tomorrow or 40 years hence.

Still, human nature being what it is, all but a few of us would require more than a day's - much less a moment's - notice. It would be more realistic for us to say that any year would be a good year to die.

Terminally-ill people who have been told that they do not have long to live have testified that it is not as hard to prepare themselves as they had anticipated. One consolation in knowing that death will occur in the near future is that it gives dying people time to settle their affairs and to be with their families. "I don't want to die quickly," a Canadian physician declared. "Too much would be left unsaid."

The well-known Washington columnist Stewart Alsop wrote about the last few months of his life in his 1973 memoir Stay of Execution. An active sportsman and father of six, Alsop was stricken with a rare, uncontrollable form of leukemia. He feared death, but as he was dying, he found that the strength of his fear depended on his current condition. "For people who are sick, to be a bit sicker - sick unto death itself - holds fewer terrors than for people who feel well," he wrote.

'The indescribable process of coming to
terms with death'

He described the contrast between the desperate feeling that came over him when he was first told that he would die soon, and one night much later when "I was so sick, I felt sure that I would die soon, perhaps very soon, within the next day or so." On the second occasion he kissed his wife good night, took a painkiller, and calmly fell asleep.

The difference, he said, was the result of a "strange, unconscious, indescribable process... the process of adjustment whereby one comes to terms with death. A dying man needs to die, as a sleepy man needs to sleep, and there comes a time when it is wrong, as well as useless, to resist."

One observation common to people who have recorded the experience of being mortally ill is that the closeness of death magnifies their appreciation of living. In an article in the Reader's Digest Canadian edition, Jean Cameron tells about rushing outdoors so that snow could fall around her. "As I stood there I wondered: Will this be the last time? This was not a sad experience. It was a joy. I saw those snowflakes in a way that I had never really seen them before."

A Montreal woman who worked as a counsellor to incurable cancer patients before she discovered that she also had terminal cancer, Miss Cameron noted that the old shrinking attitude towards death existed even among co-workers who were accustomed to dealing with the dying. "For many, my role was changing - a colleague was becoming a patient, and sometimes, I felt, an embarrassment. This occurred gradually as my disease spread and people began to realize that it was now appropriate to regard me as 'dying.' And, just like 'cancer,' this label of 'dying' brings about a strong reaction - even in a caring staff of experts. One feels that one is set apart."

Writings by people like Cameron and Alsop - people who know what it is like to die - have lately done much to broaden the public outlook on death and dying. Although there remains a reluctance to discuss the subject in all frankness, death has been emerging from the closet of uncomfortable silence which has hidden it for many years.

It is now widely recognized that the more forthright the society is about death, the better we can all understand the emotional needs of dying persons and their families. Psychiatrist Elisabeth Kübler-Ross was a pioneer in building such understanding. In 1966 she interviewed more than 200 terminally-ill patients in Chicago who talked freely about how they felt on the threshold of death.

Dr. Kübler-Ross found that few among those interviewed had been told that they were soon going to die, and about half had not even been informed of the gravity of their illness. She concluded that it was a serious mistake to keep people in the dark about their condition. It deprived them of a chance to summon up their own emotional strengths.

These strengths, it appears, are usually underestimated. Said Dr. Kübler-Ross: "I have seen people who have been regarded as weak and cowards all their lives, and at the very end they came through beautifully. They were strong and proud and in a peaceful stage of acceptance when they died - more proud and more accepting than they had ever been in their whole lives."

Acceptance is the last of five stages of dying identified by Dr. Kübler-Ross and outlined in her 1969 book On Death and Dying. Broadly, these are: denial ("no, not me"), anger ("why me?"), bargaining ("give me one more year and I'll go to church"), depression ("yes, it's me"), and acceptance ("yes, it's me and I'm ready").

Mixed in with these feelings are changing hopes. Hope does not die in a dying person; it telescopes to fit the time available. Thus a terminally-ill patient will go from hoping to be cured to hoping for a painless and peaceful release. Hope also tends to be transferred from the individual to others. People often breathe their last with high hopes that their children or grandchildren will do well in life.

The more we talk about it, the sooner we kill
the myths

A knowledge of the psychological process of dying is central to the philosophy of the hospice movement, which began in Great Britain. Incurably-ill hospice patients are encouraged to stay at home and lead as normal a life as possible for as long as they can. Both at home and on the hospice premises, drugs are administered to keep patients "one step ahead of pain."

The Palliative Care Service of the Royal Victoria Hospital in Montreal follows hospice principles in a general hospital environment. Its methods have been widely adopted in Canada and the U.S. While the PCS segregates dying patients from others in the hospital, it does not isolate them from their families, who are free to be at the bedside at any time around the clock. Pets are allowed in for visits. The PCS provides home care and follow-up bereavement services. Volunteer workers help to comfort the dying, which makes palliative care a community concern.

Programs of this kind, designed to see people through to their deaths with a minimum of fear and pain, challenge traditional attitudes in the medical profession. Physicians are committed to sustaining life. With the sophisticated medication and technology now available to them, they are able to keep people alive for longer than ever before.

Just how long life should be supported has become a subject of controversy. It has been argued that doctors should withdraw or withhold treatment in cases where all hope of recovery is gone. Some people have taken it upon themselves to dictate the terms of their deaths by making out "living wills" which instruct doctors not to treat them if treatment would only prolong their dying. Living wills have been recognized in "right-to-die" legislation in several of the United States.

Dr. Arnold S. Relman, editor of the New England Medical Journal, has pointed out that right-to-die legislation "inevitably raises the spectre of euthanasia." The legislation generally favours passive euthanasia, which means letting people voluntarily die. Its critics say it is only a short step from there to active euthanasia - mercy killing. Whether passive or active, the same question may be asked about euthanasia as is asked about capital punishment: What if there is a mistake?

The euthanasia issue will come in for further debate as more public attention is paid to death and dying. Now that people feel more free than before to talk about death, the practical, medical and ethical aspects of it can be effectively discussed.

The more that is said about death, the earlier we can remove the needlessly terrifying myths and misconceptions that enshroud the subject. It is healthy for the whole society to give it an airing, if only to instil in people a heightened awareness of their own constant vulnerability, and to encourage them to act accordingly. The world would be a better place if people were to live as if they were ready to die.

 

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