Addressing death is an important aspect of public health

We will all someday die. No matter how good our doctors are, how many scans we get, how compliant we are with medications, how many cutting-edge surgeries we undergo, we will all die. That scares us. Most of us fear death: We do everything we can to avoid it, and when it inevitably comes, we struggle and refuse it. Similarly, when someone we love is dying, we want to do everything we can to ward it away, an action that is sometimes futile, sometimes harmful. I see this all the time in the intensive care unit. A family, unwilling to let a loved one pass away, maintains them on life support. A surgeon, unwilling to allow nature to take its course, embarks on a hopeless operation.

The way we die has changed

A century ago, death was different. Most people passed away from infectious diseases in a quick, relatively painless manner.  In fact, pneumonia was nicknamed an “old man’s friend.” Death was tolerable, familiar and understood — we accepted it. The medical advances of the last century have changed that dramatically. We die now of chronic diseases like cancer, heart disease and stroke in a much more protracted time course. Medical interventions can slow the progression of disease, extend its tenure and also draw out death. We have artificial hearts, lungs, kidneys and nutrition, but these technologies may have worsened the experience of death.

What does it mean to die a good death?

How would you like your final days, hours and minutes of your life to pass? Currently, our medical technologies allow us to keep patients alive for weeks to months on a ventilator, in an intensive care unit, on many medications. But perhaps a more idyllic version of dying is to be at home, surrounded by friends and family, conscious and aware. We want dignity, independence and control, yet so many patients die without that.

Doctors don’t deal well with death, either

For many physicians, a dying patient feels like a failure of medicine. We want to be aggressive, to do everything, because letting a patient pass away demonstrates the limits of medical care. I want to change this sentiment. Medicine is not meant to defy death or provide immortality. As physicians, we need to help patients achieve what they want, not only in life but also in their death. Our egos, desires and fervent wishes to keep someone going should not dictate that patient’s care.

Addressing death is an important aspect of public health

Currently, a staggering amount of health care, money and resources go into the very end of life. But if what we’re doing at the end of life isn’t what most patients want, then why are we spending so much on it? To me, public health not only encompasses communicable diseases and health measures, but also tackles the distribution of limited resources. By understanding what patients want at the end of life, we may be able to achieve better care with lower costs if we avoid unnecessary, unwanted aggressive care.

How you can participate in this discussion

Although it isn’t easy, it’s important to think about how you want to die. Some people want everything done, but many realize they would rather die at home, perhaps with palliative care, than in an emergency department surrounded by physicians who attempted CPR. Talk to your family: Make sure the person who would make health care decisions for you if you were unable to do so knows what you want. Surprisingly, most family members and physicians aren’t very good at guessing what their loved ones would have wanted at the end of life. Write it down — an advance health care directive or living will can guide physicians and family in medical decision making.

Have you talked to your family and your doctor about how you want to die?

Craig Chen is an anesthesiology resident.  This article originally appeared in The American Resident Project.

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  • Ron Smith

    Hi, Craig.

    As a context for framing my remarks, I’m 55 and have been practicing Pediatrics now into my 31st year. I have extensive experience with neonatal care prior to and after the advent of lung surfactant. I was practicing when HIV was first discovered and I had to tell a young hemophiliac boy and his parents that he had received the virus through factor 8 concentrate. I have had extensive experience with Pediatric death of all kinds.

    I think many physicians speak of death only up to the point that body functions cease. Yet they seem to think that talking about death and having some understanding, even anticipation of the event, somehow makes it all better?

    I disagree. Death is a stench. It is a shame born by all of humanity. There is nothing, repeat nothing, good about death.

    As I write, my 84 year old Father has stage 4 terminal lung cancer. I know what I’m talking about. The only sense of a ‘good’ death is one that is as painless, and therefore mindless, as possible.

    As much as I appreciate hospice, which was a great help when we watched her Mother pass just this year with Alzheimer’s, her death was relatively painless despite her perpetual urinary tract infection, death even with that support mechanism is never a good death.

    It is at best the lesser of the a range of bad possibles.

    There is no comfort in the words ‘a good death,’ only in hope that there is something beyond death. If there is nothing beyond death, then we do a disservice to our fellow man by making them go through the pain and suffering that we refuse to allow our pets to experience with a fast, painless termination.

    Don’t get me wrong, I’m not for euthanasia. I do believe there is something beyond death. There are better places to discuss what I think that is.

    But let us have no such words that portray some sort of nobility to death. They do not exist in reality.


    Ron Smith, MD
    www (adot) amerechristian (adot) com

  • Karen Ronk

    This is a really well thought out article and I could not agree more with its sentiments. Living life to the fullest is what we should all strive for, to whatever degree we are capable of, not living forever with a body full of artificial parts. I believe there is such a thing as a good death and I know that is what I am hoping for.

    When you look at the amount of money spent on the last years of life, the figures are staggering and disturbing. Imagine if all those resources went to find new ways of treating people who are living with chronic pain or disease during the middle years of their lives. We have to give ourselves permission to accept death, it is natures way of giving new generations a chance to thrive.

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