What is Death Exactly? And What’s It Like?
“A User’s Guide to Death and Dying” — Part 1 of 2
It’s still October, Respect Life month, and so we’re naturally focused on the gift of life. But it’s also the threshold of November, the month of All Souls, prayers for the dead, and the liturgy getting all dark and apocalyptic – an annual reminder that the world will end and that each of us faces his own mortal end as well.
But we Catholics hear about death all the time. It’s right there in our liturgy, our creed, and even our routine devotional prayer – like the Hail Mary: “…now and at the hour of our death.” It even came up pretty early in our catechetical formation when we learned about the Four Last Things: judgment, heaven or hell, but first death – for everyone, regardless of where we end up for eternity. Death is the great leveler, the one thing that all of us, unquestionably and without exception, have in common.
And yet we still studiously avoid thinking about our mortality – an attitude on display in Roz Chast’s book about her parents’ final years, Can’t We Talk About Something More Pleasant? Death is so dark and mysterious – the great unknown. “It is in regard to death that man’s condition is most shrouded in doubt,” reads the Catechism (§1006). But we’re Christians, and so we know the end of the story. “I came that they may have life, and have it abundantly,” Jesus tells us. It’s an assurance that leads St. Paul, quoting a pagan poet, to boast, “O death where is thy victory? O death, where is thy sting?” Following Paul’s example, we too can laugh at death, make fun of it, because it is beaten – we’ve already won! Indeed, according to Ven. Solanus Casey, it can even be a celebration. He wrote that death “can be very beautiful – like a wedding – if we make it so.”
So, how do we make it so?
What is it?
First things first: What is death exactly? It depends on whom you ask. Medically, we think of death as the end of physical life. Traditionally, it was defined by common sense observations: We know that we need air to breathe and blood to circulate to live, so people naturally interpreted a lack of breath and a lack of a heart beat as signs that life has ended – or what one standard medical reference defines as “the permanent cessation of all vital functions” (Taber). In simple terms, it’s the absence vital signs – no heart beat or blood pressure, and no spontaneous breathing, which means that body tissues can’t get the oxygen required for cellular function.
Since the 1960s, we’ve also come to accept lack of brain function as a sign of death, even when the heart continues beating and the lungs continue processing oxygen delivered through artificial ventilation. It’s still controversial and hotly debated, especially with reference to vital organ transplantation that brain death makes possible, but it’s a definition largely accepted in clinical practice.
What the two medical definitions of death have in common is an assumption that death is somehow natural, that it’s somehow “a part of life,” but it only seems that way and we know better. “Even though man’s nature is mortal, God had destined him not to die” (CCC 1008). Thus, the Church’s definition of death makes it plain that it’s not natural at all. It’s a “departure” when the “soul is separated from the body” (CCC 1005). In fact, it’s a punishment, and it’s what God warned our first parents would result from their disobedience and sin—original sin, that is.
They chose sin anyway, resulting in the Fall, and since we’re all sons of Adam and daughters of Eve (as they’d say in C.S. Lewis’s Narnia), we all inherit that same condition and its ultimate consequence.
Consequently, death is truly a foe, having entered the world in the first place due to man’s disobedience, but also our ongoing disobedience. “Bodily death, from which man would have been immune had he not sinned” is “the last enemy” of man left to be conquered (CCC 1008).
What’s it like?
So, what do we know about this enemy? Medically speaking, it’s manageable failure under the best circumstances. Regardless of what precipitates the dying process – trauma, disease, or just things wearing out – the body systems shut down one by one. It’s a domino effect that culminates in heart and respiratory collapse, and since it’s ultimately unstoppable, we care for those in the last stages of life by focusing on managing symptoms – optimizing comfort, that is, instead of seeking a cure.
Physical comfort takes precedence here, particularly aggressive pain control, but we’re also attentive to breathing, the skin, digestion and elimination, and other body systems. At the same time, we also strive to meet the dying individual’s psychosocial needs, addressing their fears and anxieties, helping them make satisfying final connections with loved ones, and generally fostering what we call a “good death” – that is, a comfortable leave-taking that includes making peace with God and man.
For Christians, that final peacemaking with God points to a more theologically nuanced understanding of the dying process, for we are confident that “Jesus has transformed the curse of death into a blessing” (CCC 1009). In fact, the baptized have already experienced a sacramental death, and our physical death ought to be its ratification. “f we die in Christ’s grace, physical death completes this ‘dying with Christ’ and so completes our incorporation into him in his redeeming act” (CCC 1010). This is so much the case that we shouldn’t be surprised when we read of the saints (or hear our dying loved ones) express a yearning for physical death. “[T]he Christian can experience a desire for death like St. Paul’s: ‘My desire is to depart and be with Christ’” (CCC 1011).
What can we do about it?
Here’s the nub: We know we’re going to die, so what’s to be done about it? Let’s consider this question from three different angles – that is, what we can’t do, what we must do, and what we ought to do.
What we can’t do
The Church provides us with all kinds of specific guidelines in this regard, but the bottom line is this: First, do no harm – the axiomatic healthcare principle of primum non nocere. It’s a principle that accords with the Fifth Commandment: Thou shalt not kill – thou shalt not murder, that is, thou shalt not intend another’s death. That seems pretty straightforward, but as we all know our culture in general, and our healthcare culture in particular, has lost sight of this – or has at least twisted and obscured it to the point that it has little meaning any more.
The most obvious example is the broader healthcare industry’s insistence on framing elective abortion as a “medical intervention” – a preposterous notion. Equally preposterous is attempting to frame intentional killing at the end of life as medical treatment. No appeal to “mercy” or “futile care” can disguise an intentional, willful act directed toward hastening the dying process as legitimate medicine. This includes physician assisted suicide, for we are “stewards, not owners, of the life God has entrusted to us,” the Catechism teaches us. “It is not ours to dispose of” (CCC 2280), and we cannot cooperate with anyone’s designs along those lines.
Neither can we practice “euthanasia” (ERD 60) – a funny word that literally means “good death.” On the one hand, we do want to foster good deaths for those we care for, but euthanasia, in practice, is never truly a good death because it is always homicide, and therefore absolutely contrary to the Fifth Commandment.
We tend to think of euthanasia as any medical intervention that directly leads to death – usually an injection of some kind, generally some kind of overdose. These are acts of commission, or examples of what we call active euthanasia, but euthanasia can be practiced by omission as well – that is, by willfully leaving off doing something that should be done. The withholding of what is considered ordinary care and the ordinary means of preserving life, with the intent of bringing about death, would be considered an passive euthanasia.
Active euthanasia is still outlawed in this country, but passive euthanasia happens all the time, although it is not often identified as such. The reason for this is that the healthcare industry has re-defined any kind of assisted eating and drinking as medical intervention, and thus something that can be discontinued by a physician once it is determined to be superfluous.
However, providing food and water, no matter how delivered, should always be seen as part of ordinary care for those at the end of life. It’s a default requirement, even for those who require tube feedings, as long as the gastrointestinal tract is functional (ERD 58). Starvation and dehydration should never be the cause of anyone’s death.
Here the ethical principle of proportionality comes into play. If someone’s GI system can no longer absorb food and fluids, especially when their continued provision becomes excessively burdensome to the individual, then they may be legitimate reason to withhold them – especially in the final hours and days of a terminal illness. The benefit of continuing such feedings, in other words, could be viewed as no longer providing proportionate benefit since they can’t accomplish what they’re intended to do – namely, the nourishing of the person.
In most cases, however, assisted nutrition and hydration, including tube feedings, are pretty low-maintenance and not excessively burdensome. It’s simply using readily available medical technology to deliver essential food and fluids to someone who can’t get it otherwise – like when we feed a toddler and help him to take a drink. Even a baby bottle is technological and “assisted,” in a sense, and we’d never consider withholding that.
To be continued…
“A User’s Guide to Death and Dying” — Part 2 of 2
This is the second part of a two-part series. The first part can be read here.
“I will then prepare myself for that hour,
and I will take all possible care to end this journey happily.”
~ St. Frances de Sales
We know we’re going to die – that’s a given. We also know that hastening our deaths or the deaths of those we care for is absolutely forbidden – also a given.
So what can we do?
Let’s consider that question from two different angles: That which we must do and that which we ought to do.
What we must do
The Church teaches us that we are always obliged to make use of ordinary means of preserving human life and that we are bound to deliver ordinary care until natural death.
First, ordinary means. In sorting out what means are “ordinary” as opposed to “extraordinary” (and thus optional), Catholic ethicists rely on the idea of proportionality. “Proportionate means are those that in the judgment of the patient offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or the community (ERD 56). The judgment of the patient himself is instrumental, for his “reasonable will and legitimate interests must always be respected” (CCC 2278). The same deference ought to be accorded to the patient’s legal representative when the patient himself is no longer capable of making decisions for himself.
Take chemotherapy, for example, or perhaps a major surgery of some kind. The patient can take into account the encumbrance and/or risk of undergoing such interventions and weigh those against prospective outcomes. A patient in good conscience can refuse either one as long as he is not intending to hasten his own death. In so doing, he is merely accepting “one’s inability to impede” death (CCC 2278), and is making a reasonable and morally licit calculation as to how best to spend his remaining days.
However, that doesn’t mean we should jump at the chance to discontinue anything and everything that appears burdensome or expensive. Given our belief in the value of redemptive suffering, it may be that we can accomplish a great deal of spiritual good if we choose to extend our lives by means of extraordinary treatments – not to mention the value of continued relationship (and reconciliation if necessary) with our loved ones.
What’s more, as our Lord clearly taught in the Parable of the Good Samaritan, our needs and vulnerability can be an opportunity for others to practice virtue through their sacrificial service. This is especially true for our offspring, who are in any case bound by the 4th Commandment: “Honor your father and mother” (CCC 2218). Robust and generous attention to the needs of aging and infirm parents will redound to our adult children’s own sanctification, and our living longer just might help them save their souls.
So, then, what of ordinary care? Regardless of our choices regarding extraordinary means of preserving life, we all should avail ourselves of uninterrupted care as we approach death – and we must provide for others. Commonly understood, ordinary care encompasses what is everywhere considered routine humane treatment: safety, warmth, shelter, hygiene, preservation of dignity, and (as a default) the provision of food and water.
Preeminent among these efforts is aggressive pain management. Similar to our refusal to allow anyone to die from dehydration is our refusal that they should have to endure intolerable pain in their final days (CCC 2279). Good pain control is absolutely essential, and it is virtually always possible today. In fact, aggressive pain management is even morally permissible when it may “indirectly shorten the person’s life so long as the intent is not to hasten death” (ERD 61) – an example of what philosophers call the principle of double effect.
Pain control is a core element of palliative care – a healthcare specialty oriented to providing whatever is required to the dying “so that they can live with dignity until the time of natural death” (ERD 60). It’s central to the modern hospice care movement, which holds up comfort, instead of cure, as the expected outcome. Authentic, ethical hospice care neither hastens nor postpones death, but provides relief of symptoms experienced by the dying (like nausea, anxiety, shortness of breath) while providing thoroughgoing emotional and spiritual support.
Although doctors are involved in this care, it’s the particular provenance of hospice nurses, whose constant bedside presence and attentiveness have earned them the moniker of “midwives of the soul.” Like midwives at the beginning of life, hospice nurses stand by to assist, to guide, to support, to facilitate a passage – in this case, from life to a good death. When hospice care is provided in the home setting, as is preferred, family members themselves become the primary providers of palliation and support. They, too, become facilitators and midwives of their loved one’s good death, and can justly say with Servant of God Rose Hawthorne, a turn-of-the-century pioneer in hospice nursing, that “if our Lord knocked at the door we should not be ashamed to show what we have done.”
What we ought to do
We turn then from what is demanded of us at the end of life to what is eminently advisable – namely, to make adequate preparations for death (ERD 55).
First off, in practical terms, we owe it to those who’ll be caring for us at the end of life to let them know our wishes and preferences – particularly with regards to ordinary means and care. This puts us square in the territory of “advance directives,” and there are numerous instruments and legal arrangements to choose from. True “advance directives” are just that: Binding documents that tell caregivers what we want and what we don’t want when it comes to end-of-life care. This category includes “living wills,” which have been around for a while, as well as the more recent Physicians’ Orders for Life-Sustaining Treatment (POLSTs). These are static documents that are supposed to legally “speak” for us when we become incapacitated. Although you can tailor advance directives to conform with Catholic teaching, they can’t possibly address all future healthcare contingencies. Plus, they’re open to broad interpretation on the part of those implementing them, and so the values of physicians who end up caring for us will ultimately take precedence over our own.
Consequently, most Catholic ethicists, along with our bishops, urge the appointing of a trusted healthcare proxy or a durable power of attorney for healthcare. This would be someone you designate who would be legally authorized to make healthcare decisions for you when and if you’d become unable to do so for yourself. By appointing someone who shares or at least respects your sincerely held Catholic beliefs, you can be confident that he or she would seek to make decisions on your behalf that are both in your best interests and also accord with Church teaching. And we shouldn’t be put off by the idea that it might be a nuisance or a bother for others to act as such. As philosopher Gilbert Meilaender noted in a justly celebrated reflection on these matters, “I hope…that I will have the good sense to empower my wife, while she is able, to make such decisions for me….” Meilaender went on to explain:
No doubt this will be a burden to her. No doubt she will bear the burden better than I would. No doubt it will be only the last in a long history of burdens she has borne for me. But then, mystery and continuous miracle that it is, she loves me. And because she does, I must of course be a burden to her.
Once you have your advance directives out of the way, whatever form they take, then you can get down to the real nitty-gritty of death preparations. As I noted in Part One of this “Guide,” Solanus Casey likened death to a wedding. They’re both cause for celebration because both mark an end and a beginning. “What we call the beginning is often the end,” writes T.S. Eliot in his Four Quartets, “and to make an end is to make a beginning. The end is where we start from.” For newlyweds, singleness, with its concomitant freedoms and loneliness, comes to an end. Simultaneously, a new permanent coupling, founded on love, filled with mystery, and laden with all kinds of new responsibilities and joy, commences.
Similarly, death is a conclusion and a commencement. One’s physical life on earth, its triumphs and disappointments, not to mention its inevitable frailties, is completed just as one surrenders to whatever comes next – God willing, a glorious flourishing. “Lord, for your faithful people life is changed, not ended,” is how the funeral liturgy expresses it. “When the body of our earthly dwelling lies in death we gain an everlasting dwelling place in heaven” (CCC 1012).
To be sure, that heavenly destination isn’t something we can take for granted, and so, as with a wedding, the Church would have us adequately prepare while we have the chance. “Every action of yours, every thought, should be those of one who expects to die before the day is out,” Thomas à Kempis advised. “If you aren’t fit to face death today, it’s very unlikely you will be tomorrow” (CCC 1014). Chief among such lifelong preparations would be regular reception of the sacraments, daily prayer, practicing the spiritual and corporal Works of Mercy according to one’s state of life, and faithfully living out one’s vocation.
And when we reach the threshold of death itself, our prayer turns more fervent, sealing our fealty to the Lord and helping us guard against despair and anguish. We lean more surely on our heavenly friends, especially St. Joseph, “the patron of a happy death” (CCC 1014), and St. Benedict of Nursia, the patron of the dying. St. Francis of Assisi, too, who memorably came to terms with his mortality by dubbing it “Sister Death.”
Moreover, we eagerly receive the sacraments, particularly the anointing of the sick, when the “whole Church commends those who are ill to the suffering and glorified Lord, that he may raise them up and save them” (CCC 1499). Our last confessions clear the decks of our consciences and our last Holy Communions are like food for the journey. It’s as if we’re provisioning for a journey, and the Catechism even draws a parallel between the sacraments of initiation we received at our beginnings to these latter sacraments at the end of life “that complete the earthly pilgrimage” and “prepare for our heavenly homeland” (§1525).
It’s a homeland worth looking forward to – not the caricatures that we’re used to from comics and the movies: angels flitting around from cloud to cloud with harps and happy grins and nothing much to do. No, heaven will be an adventure – the greatest adventure. If we’re counted among the saints, we’ll find ourselves united with our resurrected bodies, and we’ll launch expeditions into the reality of the Trinity and the infinitude of the divine which no chronicle could ever record and no poet could ever imagine.
But I believe C. S. Lewis came pretty close. In the last paragraph of The Last Battle, Lewis sketched out his own vision of the heavenly campaign that awaits:
All their life in this world and all their adventures in Narnia had only been the cover and the title page: now at last they were beginning Chapter One of the Great Story which no one on earth has read: which goes on forever: in which every chapter is better than the one before.
Doesn’t that sound fabulous? And the great thing is that the reality, as Mr. Lewis would’ve no doubt acknowledged, has to be still more wonderful, still more enticing than even he could’ve imagined. Whatever it is, it’ll be an end and a beginning well worth preparing for… END QUOTES