The Art of Dying Well

Achieving a good death sounds like an oxymoron. Death is final; nothing is good about it. But that hasn't stopped several authors from writing books about preparing for death, both psychologically and realistically, and getting people ready for a loved one's death as well. 

An assortment of books, all with similar themes, explores what it takes to live a satisfying end of life, including "Dying Well" by Ira Byock, "A Beginner's Guide to the End" by B.J. Miller and Shoshana Berger and "Achieving a Good Death: A Practical Guide to the End of Life" by Chris Palmer.

In Byock's introduction to "Dying Well," he notes that as a hospice physician, he's learned "that dying does not have to be agonizing. Physical suffering can always be alleviated. People need not die alone; the calm presence of another can soothe a dying person's anguish."

A retired palliative doctor with the Geisel School of Medicine at Dartmouth, Byock aims to "deliver people from the constraints of their medical maladies so they can turn their limited time and energy toward living as fully as possible." He describes the highest therapeutic goals "for patients to experience a sense of well-being even as they're living the end of their life."

Miller, a physician who runs Mettle Health, a palliative care center in Mill Valley, California, says to die well involves "letting the reality of your mortality into your field of view, so death becomes part of your everyday reality," rather than denying or fighting its inevitability. He adds that "most people's nervous system is wired to run away from death." All too often, the ego gets in the way and the individual won't accept a world going on without them.

Taking care of certain practicalities about the inevitably of death also makes it easier to accept the end game. Establishing advanced directives eases death's burden, Miller notes, by covering a living will for heirs, power of attorney or health care proxy, including who can speak on your behalf if you're incapacitated. He also recommends drafting an "ethical will" or video of your legacy, describing your values to your loved ones.

The planning helps people come to terms with the reality of death, rather than keeping it at arm's length. Accepting the reality is liberating. "It leaves people with more peace, rest and honesty" rather than constantly fighting death off and keeping it at a distance, Miller declares.

To Palmer, "A good death is elusive because we don't prepare sufficiently. We're afraid of death and dying and don't want to think about it or learn about it."

Dying well, Palmer notes, is interconnected with living well. If people live with an abundance of "love, generosity and kindness, they are more likely to have loving friends and family members who will help [them] exit with grace, peace and dignity." Another recommendation: declutter your house or apartment so family or friends don't have to spend days cleaning it out upon your death.

How does one die well? Byock says that derives from people knowing their time on earth is limited, and coming to grips with "What would be left undone if I were to die suddenly today? What business do I need to complete or turn over to others? What would be left unsaid between myself and people I love or once loved?" In certain cases, it may be a time to ask for forgiveness.

If you ask most people facing repeated chemotherapy what matters most to them as they reflect on their life, they invariably reply that it's the people they've loved the most since we live in a "relational reality," notes Byock. Coming to terms with life and impending death is intertwined with closest relatives and friends; it can entail "telling your stories, [being interviewed by a grandchild] and putting on an MP3 recorder at the time of the interview," Byock notes.

Dying well for people who have terminal illnesses can be fraught with extremely complicated treatments and decisions. Byock points out that palliative treatment can extend people's lives "but may come at the cost of substantial pain and discomfort. Treatment can extend life but not making it worth living or living in a way that feels meaningful to them."

In his book, Byock notes, "Our health care system is well-honed to fight disease, but poorly designed to meet the basic safety of seriously ill patients and their families." That's because, as he explains, "American medicine is designed to treat patients with problems, because that's what Medicare and health insurance pays for, rather than to preserve and improve people's well-being."

Several of the authors observed that most physicians, when they are faced with terminal or life-threatening illness, behave in ways different from most of their patients. Most request fewer aggressive interventions, suffer less and make the most of palliative care, including hospice.

Palmer points out that Americans often perceive death as a taboo topic, view it with trepidation and see it as a sign of "defeat and failure." But he added that 80% to 90% of contemporary deaths are due to chronic diseases like heart disease, stroke, cancer and dementia. He also observes that Americans use euphemisms such as "passed away" as if someone was moving on rather than the word "death," which is final and definitive.

In his book, Palmer notes that humor can also coexist with impending death; he cites as an example Dame Maggie Smith's scene in the film "Downtown Abbey: A New Era" when she chides her maid by saying, "Stop crying, Denker. I can't hear myself die."

Dying well, in short, says Byock, revolves around people "acknowledging that we're mortal, we're all going to die, and then get on with living as fully and joyfully as possible."