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By Tom Smith, Ph.D.
“Ring around the rosy
Pocket full of posy
Ashes, ashes
All fall down”
Approximately 4,126,000,000 people have died during the 20th Century from all causes. 185,000,000 have been caused by fellow human beings. During the last decade of the 20th Century approximately 513,000,000 people died worldwide. Obituaries appear in the newspaper every day. Death is everywhere all the time.
Often, when we hear that someone has died, one of the first questions that is at least though about, if not asked, is “How did he die?” or “What did she die of?”. At first, the question may seem macabre or asked out of morbid curiosity. But, perhaps it is asked because when we hear of another’s death we briefly or for a longer period of time think of our own end. Just how will it all end? How will I die?
Most of the time, death occurs because it is part of the natural order of things: We are born; we live and we die … usually of old age or one of the more common ailments of old age, be it heart disease, cancer, Alzheimer’s, stroke or other problems that occur when the body has worn out or run its course. Sometimes we hear of that person who says, “Darling, I am tired now and think I shall take a nap.” and then we check on them later and they have gone. They just lied down and died.
Deaths can be easy or hard, simple or complicated, with or without drama. The most important point to be made here is that each death of every human being is unique and original just as each of our lives is unique and original. Nevertheless, most of the time we avoid talking about or discussing this subject and protect ourselves from its emotional impact by erecting cultural barriers of misconception and propriety.
It is likely that no one has approached discussing how we die more honestly than Sherwin B. Nuland in his book How We Die: Reflections on Life’s Final Chapter. He goes on at length to describe in straightforward and clinical detail the end of our biological processes by so called natural ways and the not-so-natural. The most disturbing aspect of his book is that death is described as messy a process as birth. Maybe the last moments are tranquil and full of dignity, but more often than not that singular point in time is preceded by months or weeks of uncomfortable or painful, serious deterioration and suffering. So be it; death is necessary for life to continue for humankind. It clears the way for others to come. But most importantly, it is not so much how we die that matters, but how we live.
Nuland presents the unpleasant facts of death in a simple way that most anybody can understand with a compassion that eases the impact of learning about this inescapable reality. He debunks the myths that “death is too frightening to talk about” or “it is not normal to talk about death” or “people die as they have lived” or “dying is always painful” or “dying is beautiful and we all go toward the white light”. Again, and as I have witnessed many, many times, more often than not we die without much dignity. So the message is the dignity in which we have lived our life is the dignity in which we die: The art of dying is in the art of living.
So, considering “natural” death, how does it happen? How can I recognize when death is approaching? Signs of approaching death are vary greatly from person to person; however, there are some common characteristics.
Physical changes can be observed up to three months before death: Firstly, there is a decrease in activity, a withdrawal from the world and people. Death is a letting go and we being in this way: Letting go of friends, relatives, activities of daily living, life’s interests, things, and control over our environment and our own bodies. Later there is a subsiding of interest in eating and diminished intake of food and increase in sleep and less communication. This can go on for quite a while.
One to two weeks before death there can be observed a disorientation and agitation, confusion or even talking with the unseen … people who have died, faraway relatives, angels or demons. Then there are the physical signs of lowered body temperature, and a gradual decline in blood pressure. Circulation to the extremities is lessened and the hands and feet feel cool. Breathing changes from a normal rate to a rhythm characterized by several rapid exhalations and inhalations followed by a period of no respiration. Skin color changes to a pale or bluish hue. There may be increased perspiration. Eating virtually ceases and there is a decrease in fluid intake. Verbalization diminishes or ceases entirely. There may be lung congestion.
Weeks, days or hours before death coma may ensue and there is an intensification of the above signs. Or, counter intuitively, a surge of energy may occur. Eyes may appear teary or glassy or half closed. Breathing becomes very irregular. A person’s state of consciousness may change as the central nervous system shuts down. Even though the person cannot speak, they may still hear what is being said. Sensory illusions; the misperceptions of ordinary sensations, delusions; often of persecution; i.e., fears that others or the doctors are trying to inflict injury, or hallucinations; hearing voices or seeing things not present or feeling things not present, may occur.
Minutes before death breathing may become very labored and the person cannot be awakened. Of course, many of these symptoms and signs can be subdued or masked by morphine or other medications.
Finally, it must be said that “natural death” can occur through active and passive death process interventions. We are now able through technological means; respirators, ventilators, feeding tubes and I.V. lines filled with drugs, to direct or delay the inevitable. This situation includes death by active or passive euthanasia (euthanasia coming from the Greek meaning “good death”, sometimes referred to as mercy killing or allowing to die) or assisted suicide. There is great controversy over these ways of dying. We are able to hasten or delay death. Sedating and calming the person with morphine can, in the end, result in a more rapid death. Conversely, ventilators and feeding tubes can prolong life unto death almost indefinitely.
Nevertheless, there is no need for the person to suffer. Usually when attending impending death, morphine and other analgesics can be administered to alleviate any pain or discomfort. Under these circumstances, sometime we may just look away and upon turning to face the person again, we may see that they have died. Breathing ceases and there is no pulse; the eyes do not move or blink; the mouth is slightly open; the contents of the bladder and bowel, if any, are expelled; the person is no longer responsive to touch or being spoken to; they are dead. Relief and grief begin.
Now, let us consider what I refer to as the “stigmatic deaths”; mostly, these deaths are sudden, unexpected and filled with drama. For these reasons they are the deaths that may scare us the most. We do not see it coming or, perhaps worse, we see it coming and there is nothing we can do about it.
Accidents can happen to anybody and everybody. The most common accidental death by far is automobile accidents: Approximately 44,000 per year by head-ons, sideswipes, roll-overs, pedestrian takedown and … just read today’s newspaper. This is followed by falls, 15,000; poisoning, 9,500; drowning,3,500; fires and burns, 3,750; suffocation, 3,300; firearms, 1,130; medical and surgical complications, 3,000; and finally, air, water and rail transport, 2,350. Often, a major stigmatic difficulty of accidental death is the disfiguring, dismemberment or loss of the body. This can be a major issue for the victim’s survivors. There, but for the grace of God, go I.
Suicide, the taking of one’s own life due to depression, despair, hopelessness, alienation, uncontrollable urges and myriad other concerns is the eleventh most common cause of death in the United States and is a leading cause of death in youths and teens 10 – 19 years of age! In 1999, the Surgeon General of the United States issued a “Call to Action to Prevent Suicide” defining it as a public health hazard. No one really knows why people commit suicide, least of all the victim at the moment of the decision.
Suicide is stigmatic in that it is very difficult to understand and greeted with the confusing and competing attitudes of bafflement, dismissal, heroic glorification (the suicide bomber), sympathy, anger, and moral and religious indignation and condemnation. Sometimes considered a noble act, suicide is nevertheless heavily imbued by negative emotional or moral connotations. Its aftermath lingers long after the act and it raises, especially now during the modern controversies over voluntary euthanasia and assisted suicide, a large number of moral, theological, philosophical and psychological questions that are outside the scope of this discussion. Let it suffice to say that suicide has tremendous impact on survivors; The family, friends, associates and neighbors. All are left with the question “Why?”
Homicide by definition is stigmatic, marked by disgrace and reviled by all civilized people. Homicide is violent, often criminal, but not always, usually irrational, rarely justified and contrary to the natural order of things. Like suicide, its aftermath is felt long after the act. Remarkably, homicide is the second leading cause of death among Americans 15-24 years of age and incredibly, the third leading cause of death among children 5-14!!
Homicide is committed by and upon both genders, transgenders, homosexuals, heterosexuals, all ages, races, ethnicities, the rich, the poor and in between. Culpable and negligent criminal homicide include infanticide (some may include abortion here), fratricide, patricide, matricide, eldercide, familicide (murder suicide by family member of entire family), genocide, homicide between intimates, between children; and between gangs. Even at that, most homicides are committed by males and are most often committed with handguns. There is voluntary and involuntary manslaughter that does not amount to murder with malice aforethought; but is nevertheless homicide. Finally, there is state sanctioned homicide in the name of capital punishment and war.
Probably not since the Great Influenza Epidemic of 1918 has the world feared disease more than HIV/AIDS. Without treatment it is a death sentence. Since 1981, when it was first identified, over one half million people in the United States have died of AIDS and its complications and countless more worldwide. This very day 8,000 people will die of AIDS. The terms strikes fear into people as well as other illness such as cancer, SARS or now, Avian Influenza (bird flu) and multi-resistant Tuberculosis. We are filled with dread and consternation when faced with an affliction for which we have no cure. The stigma can be overwhelming and the death horrific. In her book, The Coming Plague, Laurie Garret describes the return of infectious disease and the global threat of epidemic and pandemic. For the past 50 years, disease in the developed world has usually been thought of as manageable. Disease comes when a person gets old and very infrequently when one is vigorous and young. This is no longer the case.
Grief and bereavement becomes much more complicated when multiple deaths occur due to natural disaster, accidents or more tragically, when due to mass murder as that which occurred most recently at Virginia Tech or the Columbine High School massacre; and now, with a protracted war in Iraq, when death occurs due to IEDs or suicide bombers. This is especially true when it involves family members or friends. We are left bereft of psychological and social structure and sometimes wish that we would have died also. We do not know where to start to grieve or for whom.
Even when it does not involve someone close to us, we have all had the above experience. Usually, we stay in a state of “healthy denial” of this possibility until something most terrible happens, like the Twin Tower terrorist attack September 11, 2001 in New York City. Remember, that at that time the entire nation was touched by death and a death that was so unexpected and ugly. All of us, at that time, were touched by this type of stigmatic death.
Death also occurs to the very young and sometimes before we are “born”. Do not the parents grieve over a miscarriage or a stillborn birth? It is not unheard of for a woman to grieve over her aborted fetus, whether it is her choice or not to terminate the pregnancy. It seems so contrary for a fetus, an infant, toddler, child or teen to die. It is not supposed to be that way. It is so unfair. Again, we are left with the confusing suspension of the question, “Why?”.
Finally, the world, and that includes your neighborhood, is filled with political or criminal gangland terrorism and war. Currently, there are over 30 declared wars in the world not to mention the undeclared conflicts that spread death on a massive scale! There are drug and turf wars on the streets of every major city in the world. Chances are that you or one of your friends knows some one who has been touched by terrorism and war. And lest we forget, the world is still threatened by nuclear holocaust. There are anywhere from seven to ten nations that possesses nuclear weapons. The bomb that was dropped on Hiroshima can now fit into a container the size of a suitcase.
Even though all of Europe and most countries of the world reject and abhor capital punishment, it still remains the ultimate power of the state. These wars, declared and undeclared, urban and rural are rife with sanctioned and unsanctioned execution. In the United States, we still put people to death for their warlike activities on the community. At three o’clock in the morning, Saddam Hussein was taken to the execution chamber and hung on the gallows for his genocide. Today, there are people pulled from their homes and put to death on the streets of Iraq, Afghanistan, Gaza, Brazil, Chechnya, Columbia, Somalia, Sudan, Nigeria and too many other places.
So, all over the world, death comes like a thief in the night. We do not know, usually, the day or the hour. How will I die?
REFERENCES
https://users.erols.com/mwhite28/warstat8.htm Retrieved 7-31-07
How We Die: Reflections on Life’s Final Chapter, Nuland, Sherwin B., Alfred A. Knopf, New York, 1993.
https://www.hospicefoundation.org/endOfLifeInfo/signs.asp Retrieved 7-31-07
U.S. Census Bureau, Statistical Abstract of the United States:1999, p.106.
https://www.surgeongeneral.gov/library/calltoaction/default.htm Retrieved 7-31-07
https://www.nlm.nih.gov/medlineplus/suicide.html Retrieved 7-31-07
https://www.ojp.usdoj.gov/bjs/homicide/overview.htm Retrieved 7-31-07
https://www.cdc.gov/hiv/topics/surveillance/resources/reports/2004report
amFar Report 2007 Retrieved 7-31-07
https://www.lauriegarrett.com/index.php/en/books/2586/2747/ Retrieved 7-31-07