"That's morbid", a student blurted out when, during a lecture on geriatric mental health policy, I commented on the inevitability of death and the need for older people -- such as myself -- to prepare for it. "Literally true," I responded. "Death is morbid, but coming to terms with it is a key developmental challenge of old age and a major challenge for our health and mental health systems."
My student's horror at an open discussion of death reflects widespread difficulty accepting mortality in our society. For example, news reports about people who die after long illnesses almost always state that death came "after a long battle", making it seem that everyone fights death to the bitter end and that no one dies at peace.
Dylan Thomas articulates this sensibility in a frequently quoted poem to his dying father:
"Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light."
This sense that we ought to fight death makes it difficult for people to die well -- to be open about the fact that they are dying; to say goodbye to, and to accept loving goodbyes from, those they care about; to let go of hope for their personal future and to value the future of their children and grandchildren and the generation that will survive them; to accept or even take pride in who they have been; and to be at peace with the fact that all human lives end in death.
Many, but not most, people take practical steps to prepare for the inevitable. They make wills, choose health proxies, and leave directions about whether and how long to prolong their lives if they are terminally ill and unable to communicate. But often these actions are rational rather than visceral. Many of us imagine ourselves at our own funerals. Many of our eulogizers will say, "I am sure that s/he is looking down from heaven now..." This cliché conveys how hard it is to imagine a person gone. For those who believe in an afterlife with continuing consciousness, it may not be necessary to accept ultimate non-being. But for those who believe that immortality is found in memory or non-conscious merger with the universe, there is no presence at one's own funeral, no looking down from heaven, no final reunion with those we love.
It is not easy for those of us who are old and coming closer and closer to the end of our lives to accept the inevitable. Some of us live in denial. Some of us are afraid. Some of us are angry. Some of us grieve for ourselves and for the people we will lose when we are dead. Some of us achieve a state of peace about death. Some of us never do.
Actually, most of us don't think much about death unless our health is poor or someone we care about is in terminal condition or has died. In fact, if we did think frequently about death it would be a symptom of depression. What is best for those of us who are old is to live as fully as we can.
Still, there are at least two practical steps we should all take whether death is much on our minds or not.
- Complete legal advance directives that will hopefully assure that we are treated at the end of our lives and in death as we want.
- Talk openly to those who have to carry out our wishes. We need to be specific about when to withhold further treatment if that's what we want or to be kept alive by all means if that's what we want. We also need to be specific about the disposition of our bodies -- whether to donate organs, whether to let our body be used for teaching in a medical school, whether to be buried or cremated, what kind of service we want to have, and so forth.
In addition, work needs to be done to ensure that health care reform will make it easier than it now is for people to die well. This includes access to information about options at the end of life; greater respect for advance directives; enhanced access to palliative care; more health care in the home so that people are not forced into strange and frightening environments as they approach death; greater comfort and privacy in health care facilities and not just in hospices, and greater respect for, and greater access to, spiritual conversation and guidance within the health system for those who will find this comforting.
Facing the fact of mortality may be morbid, as my student suggested, but it is also a critical need during this time of the aging of America.