What is it like to die? According to the author, this question is pertinent because ‘nowadays, very few of us actually witness the deaths of those we love’ (page 8). The book sets out to correct the prevailing societal attitudes to death which it says are moulded by myths and false assumptions. It approached the subject of mortality with a philosophical bent, seeing each death as ‘the triumph of ongoing life‘, and declaring that ‘we die, in turn, so that others may live’ (page 267). The author eloquently describes his personal experience of witnessing several deaths, setting out to dispel what he sees as the myth of dying with dignity (page xvii). The book’s overall objective was to enable people to avert or mitigate the worst of the dying process (page 143).
The author depicts dying as ‘a messy business’. In his experience, the dying ‘rarely go gentle into that good night’, but they are often ‘gutted with mental suffering and physical distress‘ (pages 9 and 143). This is graphically illustrated by his first experience of death, a man having a heart attack who ‘suddenly threw his head back and bellowed out a wordless roar’, and took ‘one immensely long, gurgling breath, and died’ (page 5). Another illustrative description was of a man dying of heart failure who experienced severe air hunger and produced wheezing respirations (page 30). This agony is also a feature of deaths that evolve more slowly as portrayed by the relentlessly progressive course of Alzheimer’s disease, a disorder the author depicts as ‘one of those cataclysms that seems designed specifically to test the human spirit’ (page 105). He accurately portrayed the distressing course of the disease which is marked by anger outbursts, intermittent confusion, paranoia, and eventual death under restraints (pages 92-102).
The book gave an excellent and detailed account of dying from old age, the author describing this as the ‘slow drawing away from life’ during which ‘everything rusts and crusts until life is finally extinguished‘ (pages 47-50 and 80). Epitomising senescence with the poignant example of his own grandmother’s progressive frailty and decrepitude, he said 85% of the elderly will succumb to one or more of ‘the seven horsemen of death‘-the disorders that ‘make up the posse that hunts down and kills the elderly among us’ (page 78). With a dramatic flair, he says ‘the very old do not succumb to disease-they implode their way into eternity‘ (page 83).
The highlight of the book is its representation of the six most common medical causes of mortality, intricately describing how the impairment of vital biological processes result in death (page 67). The author however also reviewed the mechanism of death from unnatural causes. For example, he illustrated death by murder with the tragic story of a young girl who died from haemorrhagic shock after she was repeatedly stabbed by a psychotic man (page 128). He reflected on the paradoxical observation that she died ‘in a state of tranquility and release‘, with ‘no evidence of panic, or even fear‘ (page 129). The book illustrated death by suicide with the example of Nobel Prize winner, Percy Bridgman (pages 152-153), and it meticulously scrutinised the pros and cons of euthanasia (chapters 7). The book also discussed many other related concepts such as apoptosis (page 77), the Hayflick limit (page 75-76), Lazarus syndrome, and near-death experiences (page 137).
The book’s philosophical dimension is reflected in its exploration of what constitutes death with dignity. The author argues that dying is hardly ever a dignified process, and that any dignity in death resides in the ‘honesty and grace of the years of life’. He repeatedly stressed this point, saying that ‘the greatest dignity to be found in death is the dignity of the life that preceded it’; ‘the art of dying is the art of living’; and ‘who has lived in dignity, dies in dignity’ (pages 242 and 268). He supports his position with reference to The Death of Ivan Ilyitch‘, Leo Tolstoy‘s classic work which portrayed what is arguably fiction’s most undignified death, the death that is endured in ‘terrible solitude‘ (page 245).
The book is highly critical of what it sees as the unreasonable attempts by physicians to stop the dying process at all costs, calling this ‘a form of unwilling disservice to patients’ (page 246). The author contends that death is in the best interest of human progress, and he criticised this therapeutic fantasy of ‘staying the hand of mortality‘ (page 86). He acknowledged the natural and powerful instinct of the dying to stay alive, but he urged doctors to disregard this unrealistic expectation of survival which drives futile medical interventions. With a touching reference to the death of his brother, the author exhorted doctors to talk more openly but empathetically about prognosis, to avoid offering false hope, and to restrain themselves from carrying out heroic measures (pages 227-231).
This book discussed the dreaded subject of death with an accurate first-hand account of how it actually evolves. The depictions of the pathophysiology and clinical progression of death are detailed, perhaps excessively so in some places. The author’s language is simple, and his portrayals are illustrated with interesting examples. The book removes the veil shrouding what is, after all, everyone’s profound terminal event. Most of the subjects the book discusses are relevant but some topics, such as AIDS, are no longer contemporarily relevant in discussions about highly mortal diseases. These minor criticisms aside, this is an excellent book which does the subject justice.
This is one of the first books in modern times to frankly discuss death. The author attempted to promote a healthy and philosophical attitude to the feared topic, pointing health care providers to better ways of handling the subject with the dying. It is an important book and I recommend it to all doctors.
Publisher, Place, Year: Vintage Books, New York, 1995
Number of Chapters: 12
Number of Pages: 278
Star rating: 4