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Looking for a recipe for a good death

everyone will need this recipe


Recently, I heard on the CBS news that 2,000,000 people in this country are over 90.  Dr. Jon LaPook, CBS medical correspondent, was asked whether the health care system could handle it and he essentially said no. This piece of information resonated deeply with me.

 I have so often felt that there are questions on this topic that really need to be asked.  The Medicare system has been very successful in helping many older people achieve a longer, healthier life. It is remarkable to see a government program working so well, but don't we all have questions about Medicare's sustainability?  It seems that the success of government provided healthcare for the elderly is having unintended, or at least unsustainable, consequences.  The extension of the human lifespan, while appearing to be an amazing achievement, presents many challenges.  Have we really thought about the philosophical and financial underpinning for this ongoing social program?  With the additional years at the end of life have come a societal cost that is often greater than had been imagined.  As we have made progress in care to elders, we haven't offered the same to other age groups.  Though likely unintended, this is the choice we have made de facto.

Well-meaning policies to extend the lifespan and improve health of our elders, when unconsidered and open ended, can lead to diminishing returns. Our elders often languish, no longer enjoying life.  Some are lonely, depressed or in deteriorating health. Visiting the doctor may appear to be the place to turn for advice and support. This has a cost attached which may not be apparent to the user.  At the same time, for the doctor's practice, each visit or procedure is a billable event. Though reassurance and attention are legitimate needs, the current medical system is not an efficient way to provide companionship, understanding, and encouragement. Often, in the attempt to "do something" for the patient, the medical personnel turn to costly pharmaceuticals, the magic potions of our times. Today, there are few elders who do not have pill dispensers filled with these drugs.  If the the lion's share of the cost is covered by Medicare, where is the disincentive? The doctor, the patient, and the pharmaceutical industry may feel better off, but the scale on which this is happening is leaving society holding an ill-considered and unsustainable bill.

If we assume that every health concern can/should be treated by a doctor, how do we begin the process of preparing for an inevitable end of life?  Supporting and encouraging acceptance of this inevitability would make a more helpful and realistic social policy. No one lives forever.  As a society, can we afford to deny our mortality?  Acceptance of mortality, our own and that of our loved ones, should not be an unspeakable taboo in our families and our public discourse.   Last July, David Brooks wrote in the New York Times opinion piece Death and Budgets, "The fiscal implications are all around. A large share of our health care spending is devoted to ill patients in the last phases of life. This sort of spending is growing fast."

Our politics is permeated by arguments calling themselves "Pro-Life" and, when unexamined, they sound attractive. This pro-life stance may also be clouding our thinking about death.  It has almost attained mythical status, but when you look and question a little beyond the labels, what passes as being pro-life is somewhat arbitrary. What does it really mean to be pro-life? While respecting life is a worthy goal, as individuals, and even less as a society, it is not easy or even possible to consistently support life.  It would be helpful to define and choose some parameters for our ethic of life. We might discover that there are no black or white choices and every choice involves trade offs.  We don't provide every life saving option that our amazing medical system has in it's arsenal for every human being.  We don't provide pro-life government subsidies for healthcare for everyone, regardless of age.  Do we value older people more than other people as the current Medicare offerings seem to suggest?

It appears that the current Medicare system is not based upon any clearly defined, consistent or commonly held philosophy of the American people.  Rather it seems to be a privilege for a certain class of Americans which has become entrenched and now is vigorously defended by a politically powerful constituency.  Though Medicare, in its current iteration, is commonly accepted as being fiscally unsustainable, politicians are all too aware of its political potency and seem to lack the courage to fix it. The nagging and unresolved questions remain:  How long can we continue to go down our current path? Where will the money come from?  Should the Government be in the business of subsidizing health care? Why for some and not for others?  Does the current situation lead to inequity, injustice and, in some cases, resentment between generations?

These are all public policy questions worth pondering. We need to clear away our preconceived notions and to put everything on the table for thoughtful discussion.  But it is unlikely that as a people we will be able to begin this dialogue as long as each of us is unable to think about his/her own death without turning away out of fear.

If anyone is not dying please raise your hand.

This topic is personal. It is not about somebody else but about you and your loved ones.  We are a society accustomed to relying on experts and we have a whole industry of experts, many with access to the public purse, showing us ways not to die...yet we all must die.

We really don't like that idea.  Our society seems to be in denial about death and few have the will to make any plans about how we might face death.  Again we find many questions that are not receiving enough consideration:  Is it really so great to be a centenarian or a nonagenarian?   Is life without end really our cultural gold standard?    At what cost to your what cost to society?  Are people in this country, especially older people, interested in providing health care that targets the greatest good for the greatest number? Does unexamined fear cause those receiving benefits to appear uncaring..."I've got mine and devil take the hindmost"? 

The time has come to talk about how and when we can have a good death.  We need to examine new choices.  It would be helpful to shift some resources to public funding for counseling and support services that would address the questions and needs of the elderly in non-medical settings whenever possible.  Similar proposals were eliminated from the new healthcare law as a result of the "death panel" slogan made up by political scaremongers. Under the "pro-Life" guise they  poison the public discourse.   How do we combat this political self destruction?  Can we, as a society, afford to avoid these questions?   As a nation, we should stop burying our heads in the sand for fear of facing our own mortality.

Do you have a bucket list?

Ever since the movie "Bucket List" came out a few years ago, I have heard many not-so-young people talking about their bucket list.  I have been somewhat uneasy and perplexed by this concept.  Perhaps it is a good idea to think about what you want to accomplish with your remaining days so that you can use your time more wisely, but I'm afraid that it often becomes just another marketing ploy for encouraging dissatisfaction and neediness and exploiting self-indulgence.

Do we really need to see the Pyramids or drive race cars to have lived a fulfilling life? Can we ever truly be happy/satisfied if happiness and satisfaction are external goals, out there somewhere where we are not and cannot reach them? Can we ever have enough?  Enough stuff, enough time, enough years?

It is possible that we may have an opportunity for satisfaction in writing the last chapters of our life ourselves.  Our greatest achievement might be the dignity and self restraint with which we surrender to the end.  Our death may be the chance for heroic acts that may have been eluding us all our lives.  Baby-boomers have a chance to be another "Greatest Generation".  While I have not been very comfortable about the hyperbole of labeling a whole generation "the Greatest" retrospectively, I think that trying to be great prospectively might improve and focus our actions.  We should consider going forward with purpose and sacrifice for the common good, instead of fear and self pity.

"Ask not what your Country can do for you, but what you can do for your Country."  John F. Kennedy

Clearly, we are avoiding the subject of our deaths like the plagueIt feels so far beyond our personal control Some time ago, our medical system, with the cooperation of the government, engaged us in a costly war against death and did so for reasons that we can all appreciate. Everyone supports longer and healthier lives.  But, we are coming to the point where it is more than we can manage and we don't know how to say that we want to set strategic limits to this war.  It seems even more difficult to curb than the War on Terror.  In fact, it is a lot like the War on Terror, in that it could spend unlimited resources fighting on an undefinable, scary enemy, but with even less likelihood of success. 

For those who are currently very elderly, any change to the status-quo that is allowing them to hang on is really scary and provokes a fear-triggered, irrational reaction which is cynically exploited by politicians of both the left and the right.   Any change to the system going forward will need a proactive, individual approach.  Rather than waiting passively until you are one of the old and diminished, powerless and fearful, we need to give those coming into old age another choice.

For more than a century, since William James' essay on The Moral Equivalence of War , we have heard many cries rallying us to campaigns for national causes and some of those campaigns have had unintended consequences. But there is truth to the idea that we instinctively feel called to respond to a cry to save our country. Since we all must die; and since the current system is bankrupting the country; and may also be causing those of advanced age to accept or even demand fruitless treatment and needless suffering, this may, indeed, be a cause worthy of sacrifice.  The only context in which it seems to be acceptable to encourage a person to die voluntarily is a war.  In such a context, willingness to make a personal sacrifice becomes a glorious personal commitment, to "be willing to die for your country".  I would much rather pledge to give "my last full measure of devotion" to forgo costly medical intervention after a certain age, than be a fearful "patient" languishing in doctor's waiting rooms, emergency rooms or ICUs enduring any costly and debilitating treatments for the chance to hang on for of a few more weeks or months.

I propose a new opportunity to benefit our community. By pledging that after, say, age 85 whenever a new---possibly terminal---condition is diagnosed, a person would be prepared to choose to accept only comfort care leading to a natural death, an ending which will preserve the dignity of the dying person.  Out of caring for this country and for posterity, it would also leave unspent the countless dollars now being spent on intrusive attempts to defy a natural, and inevitable end of life.  In the words of Steve Jobs, "No one wants to die. Even people who want to go to heaven don't want to die to get there. And yet death is the destination we all share. No one has ever escaped it. And that is as it should be, because Death is very likely the single best invention of Life. It is Life's change agent. It clears out the old to make way for the new."

Those making this commitment could feel themselves to be a part of a corp of brave patriots.  They could choose a slogan. I would suggest the words of that famous philosopher, Yoda, "Death is a natural part of life. Rejoice for those around you who transform into the Force." This opportunity could also offer possibilities for community and support organizations for those who are aging toward their end.  It could offer camaraderie and pride at the time in life when it is most needed.

To  give this option recognition and support, some legislation could be enacted, possibly just a clause in current law, which would offer those who are pledged to avoid medicalization of their last years, comfort care and counseling support, similar to the current hospice provisions, at their time of need.   We could also establish a form of recognition to those who choose to make this commitment.

 Befriending your death...the new "Do it yourself" project.

I have tried to talk about this subject with many people and I find, more often than not, that fear makes people want to turn from the subject. When I was having my babies, I went to childbirth class so that I could overcome my fears and be prepared to be an active participant in a major life experience. I think that it would be a wise use of resources to prepare classes where we can educate ourselves to let go of our lives.  It is time to ask society to help us to reclaim the role of wise elders. We can learn and model dignity and acceptance using the available resources both medical/scientific and mythic, artistic and poetic. We can learn to talk with our dear ones so that they will understand our wishes and fears and hopes.

 One would think that religious people would be more prepared to have something positive to say about their inevitable death, but that has not been my observation (a study of this might be interesting).  Whether we are actually religious or not, we all have our personal myths.   Since no myth is meant to be factual or scientific, there is no impediment to imagining our death in poetic terms. We can choose a version that resonates in positive terms with our personal beliefs and in this way we could face our fears and create a story that gives a meaning to our final adventure. I like the words of Nathaniel Hawthorne, "We sometimes congratulate ourselves at the moment of waking from a troubled dream: it may be so the moment after death."   Those who would argue that this is self-delusion, know no better than you and I do what happens at the time of death.  To me they are just kill joys and downers. Since I will die, I prefer to see it as the final adventure, or the doorway to a new beginning. 


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