Only Three Ways To Die

"The absolute truth, Dr. Lickerman?" Emily (not her real name) said to me, tears sliding down her red, swollen cheeks. "It was a relief."

She wasn't referring to being fired from a job she secretly despised or having a divorce finalized from a husband she no longer loved. She was describing instead how she felt about the death of her mother.

Her mother had been diagnosed with Alzheimer's dementia ten years earlier and had finally died after a short seven day stretch of refusing to eat or drink. Emily had debated whether or not to have a feeding tube placed in her mother's stomach to keep her alive but ultimately decided doing so would only prolong her death rather than provide more meaningful, quality-filled days of life.

And yet, Emily confessed to me, she now felt horrible guilt, not just for having chosen not to prolong her mother's life, but for feeling relief at her passing. She'd known she'd feel both before she made her decision but had made it anyway, thinking it truly the most compassionate thing she could do for her mother, whom she loved, who by then had become bed-bound, non-verbal, and entirely dependent on others for every aspect of her care and survival.

As she talked about all the emotions she was feeling, she fleetingly expressed a wish that the end had come abruptly, perhaps in the form of a heart attack, rather than at the end of ten long years of decline with all it had entailed, both for her mother and herself. After our discussion, her wish got me thinking about which of the three ways we die is actually best.

SUDDENLY

Death comes to many without warning, as a mid-sentence interruption (sometimes literally). We're simply here one minute and gone the next. Though this seems at first glance a horrible fate, there are some benefits to dying this way, including being able to avoid:

1. The stirring up of the fear of death. Most of us live by denying the possibility of death or at least by ignoring it. This enables us to function without fear that might otherwise significantly reduce the quality of our lives. How lucky to be able to die without having this fear stirred up at all.
2. Prolonged physical suffering. Most people seem to fear this more than death itself. I've certainly seen my share of horrible suffering at the end of life and how it tears patients and their families apart almost more than dying itself.
3. Anticipatory dread of your death on the part of your family and friends. The shock of losing a loved one suddenly, especially out of turn, is great. And yet even when anticipated, the shock is rarely diminished. How much better for your family to be able to avoid the active anticipation of your death. People often report anticipating something good is often better and anticipating something bad often worse than the actual experience of either.

Unfortunately, the drawbacks are significant and include:

1. Important work is often left undone. Certainly, if you remain vital up until the moment of your death, work will always be left undone, but a sudden death may steal from you a wonderful sense of completeness and closure to which a life fully and well lived entitles you.
2. Important things are often left unsaid. The greatest drawback, it seems to me, of an unexpected death.

SLOWLY WHILE AWARE

Unfortunately, many become aware of their impending death months or even years in advance of it. The drawbacks of dying this way are obvious:

1. Fear of death often compromises the quality of life remaining. Many of my dying patients seem to navigate this with aplomb far greater than I expect of myself. And yet some are absolutely overwhelmed by it, unaided by encouragement, religious beliefs, counseling, or medications.
2. The loss of ability to care for oneself accompanying many types of terminal illnesses is often embarrassing, humiliating, and depressing. I've had more patients complain about this than almost any other aspect of dying.

There is, however, one great benefit:

1. Being given the opportunity for closure. Closure with respect to ongoing projects (personal or work-related), with respect to experiences you still want to have, and most importantly, with respect to relationships you want to repair.

SLOWLY WHILE UNAWARE

More and more people are dying either from or with dementia that prevents them from being aware that they're terminal. While at first glance this would seem the worst of the three ways to die, like the other two ways to die, some benefit exists: the patient him or herself doesn't usually suffer the emotional trauma or fear that accompanies an impending death. Many patients are in fact what we describe in the medical world as "pleasantly demented"—often quite blissfully unaware and even happy. The people who suffer most in this situation are the family members and friends who watch it, frequently finding themselves left with memories of their loved one they don't want, guilt over how they felt and treated their dying loved one (for a more thorough discussion of this topic see Letter To A Widow), and an inability to come to closure regarding rifts in relationships.

The point here of course is that no one can predict or determine which of the three ways they'll die. So if you want to die without regret, you must prepare yourself for all three possibilities. To do so, ask yourself the following questions:

1. Are you living fully the life you want to live right now? If you're given the chance will you find yourself looking back over your life when its end lies in plain sight and regret the way you spent it? To me this seems the worst fate possible. I try to summon up a fear of it daily to combat my fear of taking the risks living my dream life entails.
2. Do you have a will? Are instructions in place for someone to conclude all your business if you die suddenly and can't yourself?
3. Does someone know all your passwords, projects, obligations, and people to contact upon your death? Do you, for instance, have a blog an audience will miss (hopefully) when you die?
4. Does your family know your wishes about heroic measures to be taken or not in case of catastrophic illness? Living Wills are fine and good but the stark reality is that most physicians never read them, and those who do are often not present when decisions about heroic measures are being made (eg, in the emergency room or ICU). We in the medical profession invariably turn to family first when patients can't verbalize their wishes themselves.
5. Will your dependents be secure without you? And I don't mean just financially. Think creatively about what they may need from you in the future (especially if they're still young now). Perhaps letters or even video recordings with words of wisdom, encouragement, or support you'd like to impart in anticipation of future struggles they might have to face without you.
6. Do the people you love know what you want them to know about you and how you feel about them? Have you said everything you want them to have heard? This is perhaps the most critical task to accomplish if you want to die without regret. So, children, speak to your parents. Parents, speak to your children. Brothers talk to sisters and sisters talk to brothers. It may seem awkward and feel uncomfortable to draw attention to the finite aspect of your lives and the state of your relationships with the ones you love. You may put it off, thinking there will always be time. But there's often not. So say it now. Say it today.

Emily told me she'd never come to closure regarding certain aspects of her relationship with her mom. She'd simply never had the discussion before she'd become demented. "So I had it with her after," she said. She'd told her mom she forgave her for all the mean things she'd ever said to her about her weight, that she loved her, flaws and all, and that she'd make sure her own kids remembered the best about her rather than the worst. The conversation, Emily told me, had taken place in quiet tones, in her mother's hospital room, the two of them alone. Her mother, Emily was certain, had understood none of it.

If you enjoyed this post, please feel free to explore Dr. Lickerman's home page, Happiness in this World.