Some authors indicate that dying is a natural, final event in our lives; it is considered culturally, artistically, and scientifically persuasive. Many elderly patients eventually go through a process of functional decline, progressive apathy, and losing the desire to eat, which result in death, even in the absence of acute illness or severe chronic disease. Despite the similarity between this stage and the psychiatric diagnosis of depression or dementia, the aging process and losing the will to live are the most accurate definitions for the naturalness of dying. This subject directly conflicts with the medicalization and legalization of death, as many believe that disease is causing death, which may be postponed with medications and medical technology.

Specialists in hospice and palliative care cite the COVID-19 pandemic as what brought the reality of death and dying into popular consciousness. We have always known that there is something called death, but this pandemic demands that we internalize it. It is one thing to acknowledge death (of others) but another thing to accept death (for ourselves, it is difficult to conceive because it’s like staring at the sun).

The COVID-19 pandemic has changed the understanding of our mortality. Many of us are watching the news reporting the number of deaths from COVID-19 in the same way we watch the weather channel. As clinical literatures indicated, the cumulative effect of it is numbness or shock. We have two choices: share life with death or be robbed by death. The human being’s reaction to anything that threatens our existence is fight, flight, or becoming immobile as a form of denial. Concerning our own death, we generally select flight, meaning we don’t think about it. But death will come anyway, leaving us with the shell of a body. No pulse, no

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brainwave, no inspiration, no explanation. Death is defined by what it lacks.

A palliative physician, Dr. Miller (December 18, 2020), explains in his New York Times article “What is Death? How the Pandemic is Changing our Understanding of Mortality,” that after death, the body continues to decay until it becomes something else, living on in other forms such as the grass, the trees, or the critters who eat the dead. He indicated that, beyond fear and isolation, there are other things that we can discover. One example is the understanding that living in the face of death can set off a cascade of realization and appreciation. He also mentioned that if the past, present, and future come together, then we should consider death as the process of becoming. But no one has a scientific answer to what or who we are becoming.

Some people are religious and think about other worlds and being immortal after death. Some non-religious scientists feel we are energy, that we can change and transform from one shape to another one, never disappearing. We may become part of a worm who eats a fragment of our body in a grave, or if we are ultra-religious, we see ourselves in the company of angels who are not touchable because they are non-material, such as the soul and the spirit—although non-religious scientists believe the soul/spirit are made of material and brain’s neurotransmitters.

Our Unrealistic Views of Death

For a few Westerners, sophisticated medical advances have made death seem more like an option than an obligation. As Craig Bowron in his Washington Post article “Our unrealistic views of death, through a doctor’s eyes” (February 17, 2012), indicated Western culture has come to view death as a medical and scientific failure rather than as the natural state of life. A few numbers that are interesting to look at are the average U.S. life expectancy, which was 47 in 1900 and 78 as of 2007. So, it seems that there were not a lot of old people in the old days. One wonders if modern medicine invented old age. In 1900, the U.S. infant mortality rate was around 100 infant deaths per 1,000 live births. However, in 2000, the rate was 6.89 infant deaths per 1,000 live births. This improvement was not connected to having open-heart surgery, an MRI, or sophisticated medicine. This improvement was the result of public health measures such as improved sanitation, nutrition, and changing the environment. Also, better obstetrical training and safer deliveries caused a decline in maternal mortality.

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Some writers indicate that one of the factors regarding our “denial of the death” is more because of demographics than advances in medical practice. For example, as stated by Craig Bowron at the beginning of the Civil War, 80% of Americans lived in rural areas while 20% lived in urban areas. As of 2010, 80% of Americans live in urban areas. In 1800s rural areas, there were often three generations living in the same home, no nursing homes or assisted living centers, and people were exposed to the deaths of the grandparents or great-grandparents. Now, we are isolated from death.

Ojibwe Indian Tribe and Death Concept

Many indigenous people look at death as a natural part of life. This opinion is at odds with many Westerners, who believe that death is a failure of healthcare and technology. Research into the Ojibwe Indian tribe indicated that dying is thought of as passing over as opposed to passing away. This approach is also spiritual, as some report of contact between the dying person and their deceased ancestor, which causes a sense of peace within the dying person. Some elder Indians felt that some medical intervention was not compatible with a peaceful dying process. In one example, an elderly dying woman stated “I would just want to die if I am sanctioned to die and I have to go. [If ] it is my turn, don’t hook me up to a machine. Just let me go because that is the natural way… Don’t try to shove tubes in me because I’ve lived a good life so far…. To me, I have served my purpose here on earth already” (Dennis & Washington, 2016, pp. 301, 303).

How Long Will I Be Alive?

Do physicians tell a cancer patient how long he or she will be alive? I attended a medical conference about this subject. A number of doctors participated and most of them indicated that it is the patient’s right to know when he or she will die. However, two physicians objected to that. A religious Muslim cardiologist said that if a patient asked him when he would die, he would answer that it is in the hands of God, as some people with the same disease live a few months and some a few years.

I was the second physician. I discussed an event that happened years ago when a helicopter, which had a few military passengers, crashed in the Persian Gulf in the Middle East. The passengers stayed in the water, holding a piece of wood. After a few hours, most of them decided to swim to the shore and died on the way. Only one stayed in the

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water for 20 hours and was rescued. He was interviewed to discover how he was able to survive in the cold water for 20 hours. He indicated that during all that time, he never let himself think for even one moment about death and dying. The entire time, he was praying and thinking about being back in his home, sitting next to the warm fireplace in his living room with his family and socializing, eating meals, and watching TV.

Is it possible that he survived because he did not let himself think about the issue of death or any negative feelings? From a medical point of view, is it possible that he, by thinking positively, strengthened his body’s immune system, hormonal secretions, and biochemical material, which increased his body’s defense mechanisms? I informed the audience at the conference that since we do not know the impact of positive thinking and imagination on our physiology and immune system, we should not tell the patient when they will die.

Nietzsche said “Die at the right time.” That means possibly being at your home with family. There are indications that when families talk to a dying person, he or she can hear them, even if the dying person is assumed to be unconscious. The delirium that patients may go through during the last moments of their life is a phenomenon that has a waxing and waning quality. So apparently, that may be the “good way” of dying and we also feel the “bad kind” of dying, which may be death in combat, bleeding with no one around, in isolation, filled with hopelessness and helplessness.

The Physical Process of Dying, the Medical Definition of Death, and Conclusion

Physical signs that death is near include: a sudden burst of energy; mottled and blotchy skin (on the hands, feet, and knees); drop in blood pressure, inability to swallow food or medication, producing less urine; potentially restlessness; and some may develop congested lung and difficulty breathing. According to the legislation that is endorsed by both the AMA and the American Bar Association, Australia Health (Health Direct, November 25, 2019) says that death means “irreversible cessation of circulatory and respiratory functions” or “irreversible cessation of all functions of the entire brain, including the brain stem.” That means no heartbeat and no breathing, which is obviously enough for no brain function, which needs electroencephalography. A doctor or a nurse must pronounce the patient as dead for it to be official. Until then, one is legally alive.

The end of life usually feels abrupt, so I will keep this

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conclusion short to illustrate this point. Major religions attempt to mitigate the presence of death anxiety by promising an afterlife. For example, religious suicide bombers believe they will be in heaven after death. Might it be possible that surviving in the face of the anxieties and dangers of our world is in our DNA? Then fearing death should be a normal process backed by our genes. However, we need to acknowledge our death anxiety, accept it, and not let it change our destiny. A proverb says: “getting old is mandated, but getting wise is optional.” To imitate it, one may say dying is mandated, but having death anxiety is optional.

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References:

  • Dennis, M. Kate, & Washington, Karla T. (2016). “Just let me go”: End-of-life planning among Ojibwe elders. The Gerontologist. 58(2), 300-307.
  • Health Direct (November 25, 2019). The physical process of dying. Australia Health.

Authors:

Jamshid A. Marvasti

Jamshid A. Marvasti, MD, is a child and adult psychiatrist practicing at Manchester Memorial Hospital, Manchester, Connecticut. He is a clinical assistant professor of psychiatry at the University of New England College of Osteopathic Medicine. He can be contacted at jmarvasti@aol.com.

How to Cite This:

Marvasti, J. A. (2022). A doctor’s reflections on death and dying. Clio’s Psyche, 28(3), 363-367.

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