Learning How to Die

The latest issue of the New Yorker has an excellent piece on the current sorry state of end-of-life care in this country — and not because of politics, or insurance companies, or any of the usual culprits. Rather, Dr. Atul Gawande says that, however good modern medicine has become at prolonging life, we are more lost than ever when it comes to how to die.

“We are having more conversation now about what patients want for the end of their life, by far, than they have had in all their lives to this point,” my friend said. “The problem is that’s way too late.” In 2008, the national Coping with Cancer project published a study showing that terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions. And, six months after their death, their caregivers were three times as likely to suffer major depression. Spending one’s final days in an I.C.U. because of terminal illness is for most people a kind of failure. You lie on a ventilator, your every organ shutting down, your mind teetering on delirium and permanently beyond realizing that you will never leave this borrowed, fluorescent place. The end comes with no chance for you to have said goodbye or “It’s O.K.” or “I’m sorry” or “I love you.” . . .

In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality, and created a new difficulty for mankind: how to die.

One of the problems seems to be that, with each new drug or treatment possibility, doctors and patients alike are losing the perspective to know when to say “enough is enough.” Patients generally have a rough idea of how they would like their last days to play out — but when do you know that you’re in your last days? How can you tell the difference between “living through” something and “dying from” something, making the mental shift required to accept that fate?

It can be equally hard for doctors to let go, Gawande says:

There is almost always a long tail of possibility [for recovery], however thin. What’s wrong with looking for it? Nothing, it seems to me, unless it means we have failed to prepare for the outcome that’s vastly more probable. The trouble is that we’ve built our medical system and culture around the long tail. We’ve created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets—and have only the rudiments of a system to prepare patients for the near-certainty that those tickets will not win. Hope is not a plan, but hope is our plan.

The stories Gawande relates from his personal experience as an oncologist — and one who has been just as guilty of perpetuating lottery-ticket thinking in his patients — as well as his visits to various ICUs and hospice-care facilities, are eye-opening, to say the least. In many cases, accepting the reality that a terminal illness was terminal often meant that patients lived longer or more comfortably in hospice care than they ever did “fighting” the disease — the “zen” lesson, as Gawande puts it, that “you live longer only when you stop trying to live longer.”

Our faith tells us that death is not the end, but it can be difficult to fight that animal instinct for survival at all costs. It’s worth assessing now just what costs we are willing to bear to cling to life, and when letting go is the wiser choice.