Death and Dying in America

Life is a journey. Enjoy it; the destination is certain death.

Since antiquity, cultural representatives have commented on the inevitability of death in a variety of ways.

Confucius: If we don't know life, how can we know death?
Quran al-Imran 3:185 Every soul shall taste death.
Buddha: Life is uncertain; death is certain.
Genesis 3:19: ...Dust thou art, and unto dust shalt thou return.
Paul, writing to the Hebrews 9:27: It is appointed unto men once to die and after that, the judgment.
Shakespeare, in Hamlet, Act 3: To be, or not to be.
Benjamin Franklin: Nothing is certain but death and taxes.
Mao's Little Red Book seems mute to death, but its author was certainly no stranger to the process and outcomes.
Irish writer Kevin Toolis, in My Father's Wake: The world makes sense to us because we die, not because we don't.

Many historic quotes about death seem to stem from philosophies or religions. How does religion differ from philosophy? Mostly I see them as indistinguishable. But a religion includes dogma and ritual, and for some the notion of, or even the belief in, an afterlife.

Facing the End of Life

Most of us don't know when or how we will die.

In a poignant Medscape essay, Dr Mark Williams writes of "The Peculiar Timing of Death," telling the true story of two young physicians who died unexpectedly, one from disease and one from trauma, close in time to each other. Williams' essay prompted many readers to comment on the fragility of life and share their own stories of sudden, unexpected death.

Richard Smith, chair of the Lancet Commission on the Value of Death and former editor of the BMJ, writing for Curious Dr George at Cancer Commons, stated, "Firstly, death, many would argue, is the most important event in our lives." Smith further argued that cancer may be the best way to die — better than sudden unexpected death from whatever cause, or death from organ failure or prolonged dementia.

Does our DNA define us as preprogrammed to die? As a molecular pathologist, I would like to know the answer to that. It would seem to be yes, but perhaps by repeated cellular damage rather than specific self-destruct programming.

As you approach the end of your life, please fully comprehend that while the outcome is nonnegotiable, some elements of its structure and process may be subject to change. Kubler-Ross's five stages of dealing with grief (notice of impending death) offer avenues: denial, anger, bargaining, depression, and acceptance.

Planning for the end of life should be a requirement. I have had a living will, also known as a "durable power of attorney," for many decades, filed for ready reference with my spouse, lawyer, and physician. I trust you do as well.

In 2015, the Institute of Medicine (IOM) published a 500-page, richly referenced book: Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. It is a definitive tome, and its recommendations differ vastly from typical American end-of-life practices.

I admire Atul Gawande's human-facing writings so much that it is difficult to choose his best, but his 2014 book, Being Mortal: Medicine and What Matters in the End , must be among his finest works. I reviewed it here on Medscape in 2015. It is worth repeating Gawande's "Five Key Questions at the End of Life":

What is your understanding of your current health or condition?
If your current condition worsens, what are your goals?
What are your fears?
Are there any tradeoffs you are willing to make?

And perhaps later:
What would a good day be like?

It's been 6 years since the IOM and Gawande books came out. As a culture and as a profession, we have learned much more about death from the 600,000-plus "excess mortalities" from COVID, most of which were unexpected and relatively sudden. I hope our readers will weigh in on whether we are doing better when it comes to death, and in what ways. Or have we still a long way to go to properly manage death and dying in America?

That's my opinion, and I would like to hear yours. I'm Dr George Lundberg, at large for Medscape.

George Lundberg, MD, is contributing editor at Cancer Commons , president of the Lundberg Institute, executive advisor at Cureus, and a clinical professor of pathology at Northwestern University. Previously, he served as editor-in-chief of JAMA (including 10 specialty journals), American Medical News, and Medscape.

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