Pros and cons—mostly cons.

For years I have run a clinic for people who suffer from hypochondriasis and other related conditions. Usually they worry about an illness that can lurk invisibly but that has the potential to be fatal, such as AIDS or pancreatic cancer. Since these conditions often cause no symptoms until they are well advanced, the absence of symptoms does not reassure them. They daydream painfully about how it would be if they were to suffer from these conditions. Often they tell me, “Wouldn’t it be terrible to die in that way from that disease.” Or in another way from another particular disease. Patients tend to have favorite diseases to worry about, perhaps because someone else in the family has been sick from them. Sometimes they focus on a particular illness for even less reason—because they read about some celebrity their age who has just developed that disease. “Wouldn’t it be awful to die like that from pancreatic cancer which is incurable and spreads all over in a matter of months.” or “Wouldn’t it be awful to die from burns all over your body where your mind is clear but you know you are going to die in just a few days.” Or “I would hate to die in my sleep without even knowing that I’m going to die.”

Certain patients who are phobic imagine particular deaths: sitting in an airplane when the wings break off so that they fall through the sky for a full minute, knowing they are about to die. Or, they may think about falling out of a tall window, their fingers scraping at the side of the building. Sometimes they imagine themselves impulsively jumping off a railing or swallowing a bottle of Drano that they happen to be holding, or stabbing themselves with a scissors that rests in front of them on the desk. Although it is true that some people commit such violent acts, they are not those obsessional individuals who are afraid of committing them.

After listening to these concerns over and over again, I find myself driven to ask, “Well, just in what way do you want to die?”

Invariably, I get a startled response. “Well, I don’t know… but I know I don’t want to die that way!”

Sometimes I suggest a possible death. “Suppose you were in heart failure, and you died after years of retreating slowly from physical activity, but you were still able to read and enjoy music until the very end?”

That wouldn’t be so bad, one patient in the group replies. Another disagrees. “I don’t want to slow down so I can’t do anything physically.”

Someone mentions sex: “I don’t want to live if I am never going to have sex again.” Everyone laughs, particularly the older patients.

Long list of ways someone definitely does not want to die: (according to my patients.)

Being shot in the face by an intruder. Drowning in the ocean. Unable to breathe. (emphysema or heart failure.) Trapped in a car that falls off a bridge. Crushed by a stampeding mob. Radiation poisoning. (Usually, but not always, from a terrorist bomb. Radon poisoning is no good also.) Bitten by a rabid animal. (foaming at the mouth, convulsing uncontrollably, etc.) Anaphylaxis from a bee bite or from drugs. (a variation on not being able to breathe.) Poisoning from contaminated vegetables or chicken that has not been handled properly. Alzheimer’s disease. (not being able to remember family, not being able to talk.) Brain tumors. (uncontrollable headaches, convulsions, operations, pain.) AIDS (slow wasting away, an embarrassing disease, prolonged course.) Multiple sclerosis. (losing bodily functions, one after the other, crippled, blind, prolonged course.) Diabetes. (amputations, blindness, untreatable ulcers, kidney dialysis.) A complication of surgery (going to sleep and expecting to wake up, but not waking up.) A pointless, sudden accident, such as getting hit by a bus that jumps the curb. Gastrointestinal diseases that cause incontinence. Or other such deaths that are undignified and embarrassing.

Also, in general, unattractive deaths include any that cause pain, or sleeplessness, or discomfort for family members, or chemotherapy, or endless tests and tubes, or dying far from home. Premature deaths are upsetting also: patients want to live long enough for their children to marry, or their grandchildren to be born or graduate high school, or for their grandchildren to marry, and so on. I congratulate myself every day that I no longer have to worry about dying prematurely.

There are, of course, some afflicted individuals who indicate clearly how they wish to die. They are those who are suicidal; and they may choose to kill themselves with guns, or by taking sleeping pills, or, less commonly, by jumping out of windows or by throwing themselves in front of trains, or by driving their cars into a tree. I think there are different meanings to these different choices, but that is a story for a different time. The basic common denominator of all suicide attempts is the wish to die promptly. Now.

An issue that comes up frequently in the context of choosing the best way to die, is, how long someone wants to linger before expiring. I placed myself among those who do not want to die all at once. I thought I would like to have a few weeks or somewhat longer to tidy up my affairs and to say a few last things to my family. When I had to confront this possibility more realistically a number of years ago, after developing a cancer (as “big as a grapefruit), I realized I had nothing to say to my family that I had not said many times before. I am now in the camp of those who would like to die without warning in my sleep.

It usually turns out that patients who are preoccupied and afraid of dying are really afraid of circumstances they associate with dying: being alone and being helpless. If they can be helped to overcome these more mundane fears, they usually lose their fear of death. For that reason, and others, the elderly are usually less afraid of dying than young people.

Conversations about the disadvantages of one death over another do not usually interest patients. They are more concerned about the disadvantages of the particular disease they feel is pursuing them. If I persist in asking them exactly how they want to die—given the fact that they will, like everyone, die someday—they usually respond, chuckling feebly, that they do not want to die at all. Some, indeed, have fantasies of a cure for death arriving suddenly, at the last minute, possibly provided by a visitor from outer space.

I cannot promise them a last minute cure, but I try to reassure them about the process of dying. In my experience—in the hospital setting—most deaths are more easily managed than many of the other difficulties the dying person has experienced throughout life. Managed properly, the pain should not be especially severe. Most deaths are very uncomfortable, rather than painful. And at the end, those who are dying are not likely to die alone. In fact, the dying patients I have spoken to confide in me that they wish all the members of their families would not bother to come visiting every day and then talk among themselves at the foot of the hospital bed. It is nice to see them and know that they care; but they would prefer to take a nap. And it is usually during one of these quiet naps that they depart once and for all. (c) Fredric Neuman