In Elizabeth Gilbert’s book The Signature of All Things a young woman is greatly distressed because her maid’s grandmother has died.1 The young woman had never met the grandmother. She looks to a woman in late middle age for help, and this is what she hears:
“What a great heap of nonsense…At my age, can you begin to imagine how many people’s grandmothers I have seen die? What if I had wept over each one of them? A grandmother’s death does not constitute a tragedy, child—and somebody else’s grandmother’s death from three years past most certainly should not bring on a fit of weeping. Grandmothers die, child. It is the proper way of things. One could nearly argue that it is the role of a grandmother to die…”
I have recently received two missives related to death. One friend thinks it “sad and unfair” that his 70-year-old friend died quickly of pancreatic cancer. Of course, my friend and the family and friends of the man who died are sad. But I don’t find it sad—a quick death at 70 is not the worst way to go. And I certainly don’t think it unfair. Like the woman in the book, I believe it is the job of the old to die, get out of the way, clear the decks. Death at 70 can be seen as a privilege compared with dying young at 40 or at 95 after 15 years of dementia. I’m 71, and my death will not be sad. I’ve had a helluva life, and every day is a bonus—but not to be expected and certainly not a right.
The other missive is one I hear often. It is about a search for a new and experimental treatment for a life-limiting illness. I help all I can and an economist friend of mine says that if you value life—as most people, including me, do—then it is “rational” to spend all you have for extra days. I value life but inside I’m thinking “better to die of the disease than of the treatment.” A friend has chosen this path and has already lived longer than was expected. I think too of the billions of people in the world who get no care at the end of life, let alone a highly expensive treatment.
Because of my reputation as “Dr Death,” I have people write to me asking for advice. Another friend was unexpectedly diagnosed during a routine examination. What did I advise? My immediate thought was that I shouldn’t advise anything, but I had a go:
“You ask me a tough question. After thinking and writing about death so much, I often wonder how I will react when I get the kind of diagnosis you have got. I’m doubtful that how I think now and how I will think then will be the same. Are we ever “prepared”?
What I think now is that I would want the best information I could get on the prognosis with no treatment (except for symptoms) and various treatments. I would hope to prioritise quality ahead of quantity of life. This may mean that I would decline any attempt at treatment that might prolong life a little but mean many side effects and multiple visits to hospital. Thus, I doubt that I would accept any treatment apart from symptomatic treatment for pancreatic cancer.
I would hope as well to relate this to age. I’m 71 and have had a remarkably full life. It’s no tragedy if I die soon, even though I hope for another 10 healthy years. If I was 51, I might think differently. If I get to 81, I hope that I will lean much more towards simply symptomatic treatment.
There are, of course, others to think of, particularly your life partner. I might well think differently if my wife needed my care: I might then put greater emphasis on quantity of life. Sometimes children put pressure on parents to accept treatment that may prolong life. I hope that my children would not do that, but even if they did, I think I would resist.
What I hope for most when my diagnosis comes is that the imminence of death will enhance my appreciation of the world. This is not unusual. There’s a marvellous video of the playwright Dennis Potter talking about how he feels when dying: He describes seeing the “the whitest, frothiest, blossomest blossom that there ever could be.”2 The writer, poet, and broadcaster Clive James describes something similar in his last collection of poems Sentenced to Life.3 He writes of a “vision of a world that shone/ So brightly at the last, and then was gone.”
Even if you have these quintessential moments, there will be times, I’m sure, when you are filled with existential anxiety, no matter what you believe. Even if you believe in heaven, you will at times fear leaving this world and all those you love.
I’m currently beset with stories of older parents, usually mothers in their 90s, collapsing into a terrible state of confusion, agitation, fear, and anxiety and living for a few terrible months before finally dying. My mother spent some 15 years with no short term memory, 10 of which were in a nursing home. She faded away wonderfully. But the younger her, a woman who liked to be in control, would have been horrified by what she became. This fate potentially awaits all of us (dementia/frailty is now the most common cause of death in women in the UK and soon will be for men). Might it be better to die relatively quickly in your 60s or 70s? My father’s death over two months at 81 seems much preferable to my mother’s decline over 15 years.
Ivan Illich wrote that “A society’s image of death, reveals the level of independence of its people, their personal relatedness, self-reliance, and aliveness.”4 Ours is a morbid society that has lost contact with death and its value and paradoxically is deader as a result.
Footnotes
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Competing interests: none declared.
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Provenance and peer review: not commissioned, not peer reviewed.