The Importance of Preparing for Death

Deaths from COVID-19 reached 1 in 500 U.S. residents this week. For all the debate surrounding vaccines and masks, one conversation has been notably absent—how to prepare for death. Whether or not we’re vaccinated, all of us will eventually die. So why don’t we prepare?

After a visit to Texas in July, I’ve watched coronavirus case numbers climb steadily and have reflected on my own care of COVID-19 patients in New York City during the first wave. Patient after patient came through the emergency room doors, shocked by how sick they felt, surprised to find themselves confronting questions about CPR and life support. It was as though they had given no thought to the reality that all living creatures die.

It shouldn’t take a pandemic for us to arrange for the inevitable. If we know we must eat next week, we don’t wait until we’re starving to purchase groceries. If we hope to retire one day, it’s foolish to wait until we’re jobless to save for retirement. How might we similarly anticipate our mortality? History gives us a clue.

When the Bubonic Plague swept through Western Europe in the mid-1300s, it claimed the lives of up to two-thirds of Europe’s population. People were not ignorant of the threat of death, but never before had it come so fast and so greedily. Many of the dead did not receive proper funerals or burials. Fearing the fate of the departed, survivors began petitioning social authorities for guidance on how to prepare for death. They wanted to be able to do this work themselves.

By the early 1400s, there began circulating handbooks on the preparation for death known as the ars moriendi, or “art of dying.” These books offered practical instruction on how to live well in order to die well. They described the sort of character traits people might cultivate—hopeful, faithful, patient, humble. They emphasized the role of communities in preparing well. They encouraged generosity, recognizing that no one takes their money and possessions to the grave. They also understood that death is a mystery, and dying well requires more than solely physical preparation.

The ars moriendi handbooks circulated widely and remained immensely popular for more than 500 years. Their decline coincided, in part, with the twentieth century rise of modern medicine.

As a medical doctor, I affirm the goodness of modern medicine. Chemotherapy, organ transplantation, and prevention of heart disease can add years to life. But the profession of medicine cannot ultimately reverse death. Although I’ve successfully resuscitated a few patients over the years, no doctor has ever brought a four-day-dead Lazarus back from the dead.

To revive the ars moriendi, then, and to start the lifelong work of preparing for death, I tell my patients about the 3 H’s: Health, Home, Hope. Health refers to one’s physical well-being. What do you understand about your diagnoses? Are you frail or robust? Have you talked with your doctors about life support?

Second, Home. I ask my patients to imagine who they want at their deathbed and then to assess the status of those relationships now. With whom do you need to reconcile? What relationships require nurture? What rituals and practices help your community navigate difficult circumstances?

Third, Hope. What gives your life meaning and purpose? What are you doing now to nurture that meaning and to live a purposeful life?

Delta is leveling off, and the mu variant has reached Texas. There’s much about this pandemic that remains uncertain. But there’s one thing we know for sure. One way or another, death takes us all. We must prepare.

This was also published in the Austin American-Statesman.