A recent illness has forced me not to deny the facts of my apparent mortality any longer. Culturally, through a great deal of our entertainment industry, and throughout the arts, we engage to a large extent in a strenuous effort to deny death. I first became acutely aware of this when I read, 25 years ago, Ernest Becker’s Pulitzer Prize-winning nonfiction book, The Denial of Death. It is a compelling treatise on the stratagems used culturally by our society and other societies to drive the fear of death from our conscious lives. There are very serious resistances which all of us possess individually and collectively to talking about and thinking about death. Death in our society has not yet come out of the closet. Here are my ideas for getting started on this difficult road.
A few years ago a book came out, How and Why We Age, by Leonard Hayflick. In it he reviews what we mean by aging and what we mean by longevity. "Aging represents losses in normal function that occur after sexual maturation and continue up to the time of maximum longevity." What is the story regarding longevity? "Longevity is the period of time that an animal can be expected to live given the best of circumstances." For newborn homo sapiens, average longevity (life expectation) in developed countries is about 75 years and maximum longevity (life span) has an upper limit at the present time of about 120 years.
The death of anyone at any age can occur by accident, murder, suicide, infectious disease, cancer, heart disease, and need not be related in any way whatsoever to aging. Death is linked to aging in the sense that, with age, the probability of death increases for each and every person. Normal age changes include loss of strength and stamina, balding, loss of bone mass, menopause, decrease in height, and changes in the cardiovascular, neuroendocrine, and immune systems. Diseases of the cardiovascular system are the leading cause of death, but they are not a cause of aging. In the case of someone with no cardiovascular disease, aging has no predictable effect on cardiac output. With respect to the immune system, older people tend to be less efficient in mounting an effective response to infection and other foreign proteins.
Like the immune system, the endocrine system affects virtually all the cells in our bodies. It has been considered by some to be a prime candidate for the origin of all age changes. Diminution changes in the endocrine system are reflected in older people by their decreased ability to recover from burns, wounds, the trauma of surgery, or to respond to the stresses engendered by heat and cold.
Bone loss begins by age 50. Men lose about 17 percent of their bone mass, women lose up to a whopping 30 percent. The lifetime loss of height in women is almost two inches, in men about one and a quarter inches. Weight increases in middle years and decreases in old age. Body water in men goes down, as they get older, from 61 to 54 percent, in women from 51 to 46 percent. This helps to explain the increase in use of moisturizing lotions and creams that are designed to prevent aging.
Skin shows discoloration, wrinkles, and deterioration, but one thing nice to know about getting old is that no one dies of old skin.
An interesting change in appearance takes place with the elongation of the nose and ears. The ability to taste holds up well with aging, but the sense of smell gradually declines so that it is harder to perceive and detect odors. The ability to focus closeup is lost, and cataracts develop. Explicit memory is harder to access promptly for older people. Caloric needs decrease, in part because of a decline in physical activity.
Leonard Hayflick writes, "It has now been proved beyond all doubt that aging is one of the leading causes of statistics." In the 4,500 years from the Bronze Age to the year 1900, life expectancy increased 27 years; in the 20th century average life expectancy has more than doubled. It is currently estimated that of all the human beings who have ever lived to be 65 years or older, half are alive today. People over 85 are the fastest-growing segment of the population; in 15 years the percentage of people over 85 in the United States is expected to double, in 40 years to triple.
Daniel Callahan, who wrote The Troubled Dream of Life: Living with Mortality, relates how in the past, prior to advances in medicine—before anesthesia, antibiotics, electrocardiograms, x-rays, intravenous fluids, oxygen machines, CAT scans, and MRIs—death was natural. It was everywhere and affected people of all ages. The French historian Phillippe Aries characterized a death taking place in those times as a "tame death." We have definitely lost that. In those times not so long ago, death was (1) tolerable and familiar, (2) affirmative of the bonds of community and social solidarity, and (3) expected with certainty and accepted without crippling fear. It was familiar, simple, and public.
Modern medicine has done a job with its striking transformation of mortality. But its beneficence has been at a terrible price: the tame death has disappeared and the wild death has come into being. Death, after the onset of modern medicine, ceased to be simple and familiar.
An earlier description of a tame death can be found in John Woolman’s Journal regarding the death of his sister, Elizabeth, in 1747. "Her disorder appearing dangerous that her life was despaired of, and our mother being sorrowful, she took notice of it and said, ‘Dear mother, weep not for me; I go to my God,’ and many times with an audible voice uttered praise to her Redeemer. A friend, coming some miles to see her the morning before she died, asked her how she did. She answered: ‘I have had a hard night, but shall not have another such, for I shall die, and it will be well with my soul,’ and accordingly died the next evening."
Daniel Callahan points out that we cannot reverse the processes that medical science has brought to us. To be sure, we do not want to reverse them. We can’t go back to the tame death of the past. He proposes that we work in society to create the possibility of a peaceful death. And he defines peaceful death in this way (I am condensing and paraphrasing his words): (1) I want to find meaning in my death or, if not a full meaning, a way of reconciling myself to it. Some kind of sense must be made of my mortality. (2) I hope to be treated with respect and sympathy, and to find in my dying a physical and spiritual dignity. (3) I would like my death to matter to others, to be seen in some larger sense as an evil, a rupturing of human community, even if they understand that my particular death may be preferable to an excessive and prolonged suffering, and even if they understand death to be a part of the biological nature of the human species. (4) If I do not want to necessarily die in the public way that marked the era of the tame death, with strangers coming in off the streets, I do not want to be abandoned, psychologically rejected from the community, because of my impending death. I want people to be with me, at hand if not in the same room. (5) I do not want to be an undue burden on others in my dying, though I accept the possibility that I may be some burden. I do not want the end of my life to be the financial or emotional ruination of another life. (6) I want to live in a society that does not dread death—at least an ordinary death from disease at a relatively advanced age—and that provides support in its rituals and public practices for comforting the dying, and, after death, their friends and families. (7) I want to be conscious near the time of my death, and with my mental and emotional capacities intact. I would be pleased to die in my sleep, but I do not want a prolonged coma prior to my death. (8) I hope that my death will be quick, not drawn out. (9) I recoil at the prospect of a death marked by pain and suffering, though I hope I will bear it well if that is unavoidable.
What we have been doing in our present society to deal with the ravages of the technological, wild death is to try in various ways to take control ourselves of dying. We are doing that with living wills, advance directives, and, I believe, with euthanasia and assisted suicide. These are all attempts to deliver some control to the hands of patients and their families. Doctors tend to be unduly vigorous in their determination to meet the challenge of overcoming every illness and disease. Even when there are advance directives many doctors are afraid or resistant to not doing everything possible even though they may readily acknowledge retrospectively the absolute futility of their actions. Sometimes they are afraid of being accused of poor practice or even malpractice.
Death can only be brought back into medicine by a repudiation of the mythical line between illness and death. Each of us will die of a particular illness, not of mortality or aging in general. Death is never vanquished, and death always comes from some illness. With each serious illness, as we get older, the question can be considered whether this illness should be allowed to proceed and become the cause of death. What is sorely needed is an examination of the medical presumption to treat. Given that we are talking about illness in a very old person, does the obligation to preserve life require risking that the patient may suffer a wild, technological death?
Being my Haverford alumni class representative, writing class letters for many years has enabled me to be a part of an altogether special community in many ways. One way I did not foresee—though I should have—has been hearing about the deaths of classmates and doing letter writing and phone calling to dear class members who have been dying. One of them, Bob Parke, had been dealing with non-Hodgkin’s lymphoma since our 45th reunion. He had many courses of chemo-therapy, which were very unpleasant even if life-extending. He had hopes of making our 50th reunion in 2000 in person but died a peaceful death some time before.
Before he died, I received this letter from him: "Dear Woody, May I call upon you to edit, to an appropriate length for our 1950 Class Scrapbook, the enclosed? This is the best way I can think of to get my response to your request off my desk and into your hands while I still have the wit and energy to do it. . . . I wish you a very successful 50th reunion weekend. Sincerely, Bob, Class of 1950." And here is his "Note on Approaching Death":
My death is a new experience. Here is what I have been noticing. People want to know my emotional state, not the state of my health. Everybody takes it for granted that my prospects are cloudy, that is to say, dark and uncertain. People want to register with me their concern for my well-being. I think the best thing I can do is respond in terms of their intent when they ask: to say my morale is good, my appetite is good, and I do not feel burdened by shame or regret. I accept what is happening to me. (I have stopped talking about my illness; now I talk about my death.) Nobody has ever asked me how long the doctors have given me. If they should ask my answer will be, "I haven’t asked."
Everybody says that death is a time for letting go. Just try it! I have done one thing towards letting go that I am proud of. I make no statement of preference with regard to my memorial service except for one—I am proud to say that my brother-in-law will give the eulogy. All other preferences with regard to music, hymns, poems, and participants will be decided by my wife, Anne, in consultation with our ministers and children.
I have learned to accept gifts in a way that lets the giver know that I treasure the gift and the person who gave it. Most of my life I have responded to the words, "Thank you" with "Thank you!" Such a response does not acknowledge the gift. I realized this a week ago when a nephew made a particularly lovely comment about the way I am facing my death. I responded, of course, but not in a way that showed the value I placed on his gift—not even in a way that showed I registered the gift at all. So I interrupted myself and told him that it meant a great deal to me that he should say that about me and I thanked him, and he gave me the proper response, which is, "You’re welcome, Bob." Now I try to make sure that every time I receive such a gift I assure the giver of its value to me and thank them in so many words.
My behavior has become demanding and preemptory in manner. I expect to have everything done all at once at my command. My hospice nurse thinks this is a response to my loss of control. She thinks that what I am doing is an effort to regain some of it. Her suggestion is that I am able to do more for myself than I am doing now. I am within an arm’s reach of many things I need. I have a control for the attitude and altitude of my bed. I have a control for the hi-fi, etc. Another thing I am trying is to think in terms of results I want rather than commands. For example, "Anne, I need to urinate urgently," rather than, "Anne, would you please run and get such-and-such vessel which is at the following location." The idea is to tell my intelligent wife what I want, and let her figure out how to get it.
I had fun the other day talking to Anne about how I envision her in 10 to 15 years: handsome, relaxed, and having the time of her life unburdened by a bossy husband. Anne’s mother underwent a process that might be a model. With some cajoling, the female members of my family got me to talk about how I envision paradise. I envision it as the opportunity to observe the ones I love, to see Anne as I have described her, to relish an awareness of people well loved and work well done. If that is paradise, I am in paradise now for that is what is happening to me. . . .
I approach my death with a feeling of completeness. I have worked long and hard to achieve this. My diagnosis was a wake-up call that alerted me to a need for repair and reconciliation in my relationships and gave me time to do something about them. I have recently concluded the last of my necessary conversations and achieved the results I hoped for.
These are the thoughts that fill my head in the few days before my death. They are happy thoughts and I am happier now than I can ever recall.
—Bob Parke, November 3, 1998
So I telephoned as soon as I got this letter to tell him I would be more than glad to carry through on what he had asked in his letter. His daughter, Mary, answered the telephone. I explained who I was and about the letter I had received a few days earlier from her father. She said that her mother, Anne, was out at the shopping center. Her father had died quietly at home with family around on the evening of November 5. His was a peaceful death.
We can appreciate the effort and work and thought it may take for each of us to realize a peaceful death. There should be no question that it will be the kind of end that each of us would want.
Damon Runyon said in his uniquely pithy way something we should always remember: "All of life is six to five against."