The Lost Art of Dying

1. Acknowledge Finitude to Prepare for Death

We cannot both cling to the indefinite extension of life and effectively prepare for death.

Confronting mortality. Modern society, obsessed with youth, beauty, and longevity, largely ignores human finitude, making it difficult for individuals to imagine their own deaths. This reluctance to acknowledge mortality, exemplified by patients like Ms. Capella who refused to consider her advanced age in medical decisions, prevents us from preparing wisely for the inevitable. Doctors, too, often struggle to deliver bad news, perpetuating a culture of avoidance.

Historical reminders. Historically, cultures used various prompts to remind people of their mortality. The Roman general had a servant whisper, "Hominem te memento!" ("Remember that you are but human!"), while medieval Europe embraced "memento mori" – visual reminders like skulls in art – to orient life's priorities toward death. These practices were vital tools for living with an awareness of one's finite existence.

The ars moriendi. The medieval "art of dying" literature, born from the horrors of the Black Death, taught that to die well, one must live well by anticipating and preparing for death. It emphasized taking mortality into account, even when death seemed distant, and was intended as a practical guide for everyone, not just the pious. This ancient wisdom challenges us to cultivate a similar readiness today, recognizing that clinging to illusions of immortality hinders a good death.

2. Cultivate Community to Avoid Dying Alone

People who walk toward their mortality without moral support die poorly.

The tragedy of isolation. Dying alone, as seen in the stories of George Bell in New York and Chieko Ito in Japan, is a profound fear for many, often leading to a "lonely death" announced by decay. While being alone is not always loneliness, the absence of community at life's end feels inherently wrong, highlighting our fundamental need for connection. This instinct to be surrounded by others during death is as old as humanity itself.

Community's vital role. The original ars moriendi emphasized community, providing specific instructions for friends and family at the deathbed to offer prayers, avoid false hope, and even rehearse for their own future deaths. This communal engagement extended beyond the deathbed, fostering relationships over a lifetime. Madame de Montespan, a 17th-century French courtier, exemplified this by orchestrating her own death ceremony, surrounded by her servants, transforming her dying into a shared drama.

Three levels of support. Community exists on familial, societal, and biomedical levels, all crucial for dying well. Familial and close friends provide intimate support, while societal networks (like eldercare advisers or volunteer programs) offer broader assistance. The biomedical community, comprising healthcare professionals, also plays a role in accompanying patients. My patient Diana Atwood Johnson, who outlived her prognosis, demonstrated the power of mobilizing all three levels of community to face her finitude with grace.

3. Reclaim Home as the Ideal Place for Dying

Home embraces us, silently consoling us with the knowledge that we belong to this home.

The longing for home. Most Americans envision dying at home, surrounded by loved ones, yet only one in five actually does. Home represents constancy, authenticity, and belonging—a unique space where one can simply "be." This deep connection to place, historically seen in the peasant farmhouse that accommodated both cradle and coffin, makes home the natural and preferred setting for life's final chapter.

The hospital's rise. Historically, hospitals were charitable institutions for the poor, with most people dying at home, supported by domestic medicine and community networks. However, industrialization, urbanization, and medical advancements transformed hospitals into "citadels of science" offering cures and specialized care. This shift, coupled with the burden of caregiving, led to hospitals becoming the default destination for death, relieving families of the "indecency of death" and making it an "unmentionable" topic.

Rethinking the context. While hospitals offer safety and care, especially for those living alone or with complex medical needs, they also present challenges:

• Sterile environments and noisy wards
• Barriers to physical touch from medical equipment
• Restrictions on visitors and family presence
• High costs and potential for new suffering

The stories of Samuel Loeb, who found comfort in returning to a "home" hospital, and Jesse Levine, who meticulously planned to die at home, illustrate that while hospital dying can be artful, strategizing to die at home, if possible, often aligns better with personal wishes and dignity.

4. Confront Fear of Death, Don't Fight or Flee

Perhaps when pushed to extremes, fear of death and desire to live can best be understood as two sides of the same coin.

The grip of fear. Albert Camus's "The Plague" vividly illustrates how disease can transform complacency into a full-throttled fear of death, triggering "fight or flight" responses. In modern medicine, this often manifests as "waging war" on disease, using military metaphors to describe battles against illness. Susan Sontag, terrified of death, pursued brutal experimental treatments, seeing mortality as "unjust as murder," driven by a desire to live that was indistinguishable from her fear of extinction.

Escaping control. Fear also drives people to seek control through "flight," as seen in the rise of physician-assisted suicide. Patients often cite fear of losing autonomy, dignity, and control over bodily functions as reasons for seeking aid in dying. While this offers a sense of control over the timing of death, it ultimately sidesteps the underlying fear of extinction itself, merely extinguishing the person who fears rather than addressing the dread.

Moral beauty in confrontation. The ars moriendi, while not directly addressing fear, focused on virtues like hope and patience, assuming death's inevitability. Christian Wiman suggests that true courage lies not in conquering fear, but in "dying into life" – walking with loved ones toward the terror and sadness, accepting the "terrible holes we leave in the lives of others." This moral work, like Camus's heroes confronting the plague, allows us to engage our fears while connecting with one another, finding a form of survival that love makes possible.

5. Embrace Bodily Decay and Suffering with Solidarity

Sickness shows no restraint in its aptitude for uprooting lives and inculcating fear.

The reality of decay. Our bodies are destined to fail, a truth often ignored until illness strikes. The historical "dancing plague" of Strasbourg, potentially caused by ergot poisoning, and the 1951 Pont-Saint-Esprit incident, illustrate how physical suffering can disfigure and alienate. These events, alongside the Isenheim Altarpiece's depiction of Christ afflicted with St. Anthony's fire, serve as stark reminders of the horror sickness inflicts.

Solidarity in suffering. The Isenheim Altarpiece, originally a therapeutic tool for the sick, assured viewers that Christ understood their pain, his body ruined like theirs. This message of "cosuffering" offers solidarity, countering the feeling of abandonment that illness often brings. The question, "Where were you, O good Jesus, where were you? Why did you not come sooner to help me and heal my wounds?" echoes the universal cry of those in physical anguish, whether directed at God, doctors, or the universe.

Beyond the material. Modern medicine often treats bodies as collections of organs, dismembered and consumed by specialists, ignoring the holistic human being. This chapter urges us to open our eyes to physical suffering, not just to expect it, but to accompany the frail and broken among us. Rituals like Ash Wednesday, with its declaration "Remember that you are dust, and to dust you shall return," encourage reflection on human brokenness, inspiring reverence for the mystery of life and death beyond the purely material.

6. Grapple with Life's Deepest Spiritual Questions

By avoiding questions of the meaning of death, we avoid questions of the meaning of life.

Existential quandaries. As death approaches, many patients, like Edith Blatchley, confront profound existential questions about meaning and purpose, often turning to spirituality or religion. While some embrace "religion lite"—a personalized, dogma-free spirituality—others find it insufficient for life's ultimate mysteries. This generational shift towards being "spiritual but not religious" reflects a desire for freedom from traditional constraints, yet it can also lead to a lack of coherent answers when facing mortality.

The power of tradition. Traditional religions offer comprehensive systems of thought and community that provide overarching narratives for human experience. Critics argue that "do-it-yourself" spirituality, detached from community, lacks the depth to satisfy deepest existential struggles. Religious communities, despite their imperfections, offer a "stuck-with-one-another" family dynamic that forces members to confront shared beliefs and transform individually and communally, often linking directly to questions of meaning in life, death, and the afterlife.

Hope in reversal. Ancient Jewish belief in the bodily resurrection of the dead, a "weight-bearing beam" of rabbinic Judaism, offered hope in the face of death's catastrophe. Early Christians, rooted in Judaism, radicalized this by proclaiming Jesus's resurrection, shifting the concept from a vague future event to a concrete assertion of new life. This hope in death's reversal, in contrast to the modern emphasis on individual self-determination that makes death seem irreversible, suggests that grappling with these ancient questions can provide profound consolation and transform our understanding of "vandalized shalom"—a broken peace.

7. Reinvigorate Rituals for Meaningful Passage

Ritual creates order in the midst of such chaos.

The need for order. Death plunges individuals and communities into emotional, existential, and practical chaos. Rituals, as "social architecture that marks and defines life's phases," provide time-tested scripts and orderly, tradition-based performances to navigate these profound events. They unite matters of body and spirit, offering a roadmap for accompanying the deceased and guiding the living through grief.

Beyond perfunctory acts. Modern hospital rituals, like "pulling the plug" on Ricky Mitchell, while orderly, often lack the depth and communal emphasis of ancient traditions. Embalming, a professionalized practice not universally required or practiced outside North America, further distances families from the intimate care of the deceased. This professionalization, while convenient, can strip away opportunities for personal engagement and meaning-making.

Ancient wisdom in practice. Jewish tahara, the ritual cleansing of a dead body by the chevra kadisha (burial society), exemplifies a profound, community-led ritual. Performed with warmth, modesty, and even a "holy love song," it honors the deceased's dignity and allows community members to be "fully alive on behalf of the dead." Funerals, understood as "theater" where the community "sees" truths about life and death and is "transformed," also serve this purpose, as seen in the powerful, narrative-rich services for Aretha Franklin and John McCain, which reiterated themes of resurrection and hope.

8. Wisely Navigate Medical Interventions and Futility

For some people, CPR imposes far more burden than benefit.

Questioning hospitalization. While hospitals are vital for the acutely ill, they are often not the best place for the mildly sick or definitively dying. Frailty assessments, which consider factors like unintentional weight loss, exhaustion, weakness, slow walking speed, and low physical activity, can help determine when hospitalization or aggressive treatments might cause more harm than good. Prolonged hospital stays can lead to deconditioning, infections, and even death, making it crucial to consider alternatives for frail individuals.

Navigating futile treatments. Doctors, often driven by a "rescue fantasy" and personal anxieties about dying, may offer treatments unlikely to benefit the dying, making it difficult for patients to acknowledge their finitude. Patients must press doctors for clear answers on the benefits and downsides of treatments, asking specific questions like, "Have you ever seen this drug help someone with my stage of cancer?" or "What is the likelihood this treatment will make me too sick to enjoy life?" Sherwin Nuland's regret over persuading a 92-year-old patient to undergo surgery highlights the importance of listening to patients' wishes over medical insistence.

Reconsidering resuscitation. Cardiopulmonary resuscitation (CPR) is often portrayed unrealistically in media, with success rates far higher than the actual 10-20% of patients who survive to leave the hospital. CPR involves rib-fracturing compressions, breathing tubes, and strong medications, imposing significant burdens. Seriously ill patients, when fully informed about CPR's realities, are much more likely to decline it. While CPR is appropriate for some, for the frail and terminally ill, it can lead to a quality of life "worse than death," making a thoughtful decision about its appropriateness a critical part of dying well.

9. Live a Virtuous Life to Flourish in Dying

The art of dying well must necessarily be wrapped up in the art of living.

Purpose in living. Living well, with a clear sense of purpose, is foundational to dying well. Studies show that having purpose is linked to lower cognitive decline, greater happiness, and longer life. This purpose can evolve, as seen in Manny, the retired butcher who found new meaning in checking on elderly neighbors. Determining what truly matters—whether family, career, spirituality, or hobbies—requires forethought and an active response, adjusting life patterns to prioritize these values.

Cultivating virtues. Ancient Greek philosophers like Plato and Aristotle believed that a life of virtue—cultivating excellent habits like courage, justice, and self-control—was essential for human flourishing. The original ars moriendi specifically recommended virtues to mitigate temptations faced by the dying:

• Patience for impatience
• Hopefulness for despair
• Humility for pride
• Faith for disbelief
• Generosity (letting go) for avarice

These virtues, practiced over a lifetime, enable flourishing not only in life but also in death, allowing individuals to navigate decline with serenity and grace.

Preparing for Samarra. The legend of the merchant of Baghdad reminds us that death is an inescapable appointment. The solution is not to flee or seek it, but to prepare for it. My grandmother, who lived a long, virtuous life sustained by faith and family, exemplified flourishing even in her dying, exuding serenity and grace. The art of dying is ultimately the art of living, transforming us through profound experiences, making us wiser, more whole, and helping us find beauty in decay.