It is never easy to contemplate the end-of-life, whether its own our experience or that of a loved one.
This has made a recent swath of beautiful essays a surprise. In different publications over the past few weeks, I've stumbled upon writers who were contemplating final days. These are, no doubt, hard stories to read. I had to take breaks as I read about Paul Kalanithi's experience facing metastatic lung cancer while parenting a toddler, and was devastated as I followed Liz Lopatto's contemplations on how to give her ailing cat the best death possible. But I also learned so much from reading these essays, too, about what it means to have a good death versus a difficult endfrom those forced to grapple with the issue. These are four stories that have stood out to me recently, alongside one essay from a few years ago that sticks with me today.
My Own Life | Oliver Sacks
As recently as last month, popular author and neurologist Oliver Sacks was in great health, even swimming a mile every day. Then, everything changed: the 81-year-old was diagnosed with terminal liver cancer. In a beautiful op-ed, published in late February in the New York Times, he describes his state of mind and how he'll face his final moments. What I liked about this essay is how Sacks describes how his world view shifts as he sees his time on earth getting shorter, and how he thinks about the value of his time.
Before I go | Paul Kalanithi
Kalanthi began noticing symptoms — "weight loss, fevers, night sweats, unremitting back pain, cough" — during his sixth year of residency as a neurologist at Stanford. A CT scan revealed metastatic lung cancer. Kalanthi writes about his daughter, Cady and how he "probably won't live long enough for her to have a memory of me." Much of his essay focuses on an interesting discussion of time, how it's become a double-edged sword. Each day, he sees his daughter grow older, a joy. But every day is also one that brings him closer to his likely death from cancer.
As I lay dying | Laurie Becklund
Becklund's essay was published posthumonously after her death on February 8 of this year. One of the unique issues she grapples with is how to discuss her terminal diagnosis with others and the challenge of not becoming defined by a disease. "Who would ever sign another book contract with a dying woman?" she writes. "Or remember Laurie Becklund, valedictorian, Fulbright scholar, former Times staff writer who exposed the Salvadoran death squads and helped The Times win a Pulitzer Prize for coverage of the 1992 L.A. riots? More important, and more honest, who would ever again look at me just as Laurie?"
Everything I know about a good death I learned from my cat | Liz Lopatto
Dorothy Parker was Lopatto's cat, a stray adopted from a local vet. And Dorothy Parker, known mostly as Dottie, died peacefullywhen she passed away earlier this month. Lopatto's essay is, in part, about what she learned about end-of-life care for humans from her cat. But perhaps more than that, it's also about the limitations of how much her experience caring for a pet can transfer to caring for another person.
Yes, Lopatto's essay is about a cat rather than a human being. No, it does not make it any easier to read. She describes in searing detail about the experience of caring for another being at the end of life. "Dottie used to weigh almost 20 pounds; she now weighs six," Lopatto writes. "My vet is right about Dottie being close to death, that it’s probably a matter of weeks rather than months."
Letting Go | Atul Gawande
"Letting Go" is a beautiful, difficult true story of death. You know from the very first sentence — "Sara Thomas Monopoli was pregnant with her first child when her doctors learned that she was going to die" — that it is going to be tragic. This story has long been one of my favorite pieces of health care journalism because it grapples so starkly with the difficult realities of end-of-life care.
In the story, Monopoli is diagnosed with stage four lung cancer, a surprise for a non-smoking young woman. It's a devastating death sentence: doctors know that lung cancer that advanced is terminal. Gawande knew this too — Monpoli was his patient. But actually discussing this fact with a young patient with a newborn baby seemed impossible.
"Having any sort of discussion where you begin to say, 'look you probably only have a few months to live. How do we make the best of that time without giving up on the options that you have?' That was a conversation I wasn't ready to have," Gawande recounts of the case in a new Frontline documentary.
What's tragic about Monopoli's case was, of course, her death at an early age, in her 30s. But the tragedy that Gawande hones in on — the type of tragedy we talk about much less — is how terribly Monopoli's last days played out.
Americans’ relationship to death has often struck me as being an extension of our puritan attitudes about sex — both are objects of lurid fascination and prudish avoidance. We sentimentalize mortality with tearful, unrealistic deathbed scenes — or dramatic mid-fight demises — in pop culture. Memorial tribute songs, the schmaltzier the better, rocket up the charts. Certain persistent and vocal activist groups tend towards publicly agonizing about the fate of “innocent” human embryos or animals — yet many Americans could care less about the deaths of oppressed people at the hands of the state, or from neglect.
Talking about death in a pragmatic manner, for some reason, is always treated as inciting fear; the mere mention of end-of-life care in healthcare reform debates instigated the noxious “death panel” scare. Our pathology is particularly strong around cancer. We talk about cancer like it’s some sort of tussle or fight, or a video game that we can beat. As painful as this sort of talk can be for those whose cancer is terminal, it also makes little sense for those who achieve remission. The reality is, cancer can never be fully defeated, nor can mortality. Our lives all end. Death is always waiting down the road.
Oliver Sacks, the popular scientific writer who made his name writing “case studies” of people with strange brain conditions that altered their consciousness, passed away this weekend. But we knew he was going to die, because he was remarkably forthright about the end of his life in a series of essays for the New York Times (“My Own Life,” “My Periodic Table,” and “Sabbath“) that repeatedly, bluntly, and honestly referred to his impending death — not only its inevitability, but also the way it increasingly affected his consciousness as he grew sicker and could no longer deny the reality.
For one doctor, writing in the Guardian, this progressive admission wasn’t just touching; it was important. Australian oncologist Ranjana Srivastava felt it had ramifications for her work, and her field. “Now he reminds us with all the poise and dignity we have come to expect of him that there is value in embracing our mortality, that there is an art to dying,” she wrote last month, after reading one of Sacks’ columns.
Srivastava is referring in part to the issue that Atul Gawande also explored in his 2014 book Being Mortal. “Our reluctance to honestly examine the experience of aging and dying has increased the harm we inflict on people and denied them the basic comforts they most need,” Gawande wrote. “Lacking a coherent view of how people might live successfully all the way to their very end, we have allowed our fates to be controlled by the imperatives of medicine, technology, and strangers.” Rather than the kind of palliative care that would allow the dying to sum up their lives and say goodbye, Gawande chronicles how we often opt for invasive treatment that could prolong life, but so often doesn’t.
Americans’ fascination with Brittany Maynard, the young woman who chose to die on her own terms when she was diagnosed with terminal brain cancer, shows that on some level we understand this problem and are seeking examples of dignity in death. And the oncologist Srivastava writes that she thinks that Sacks’ work can actually help both doctors and patients make more honest choices, and have better discussions about those choices:
This recognition allows patients to halt toxic treatment, opt for effective palliation and articulate their goals for the end of life.It permits their oncologist to open up new conversations that don’t include the latest million-dollar blockbuster therapy with a bleak survival curve but do mention the therapeutic benefit of teaming up with hospice workers to write letters, preserve photos and record memories. I would say that this candid admission from a patient is the difference between bemoaning death as a medical failure and viewing life as a welcome gift.
One of the most striking things about Sacks’ pieces is that they are so little occupied with his medical situation, and place much more emphasis on his human one. A few sentences here and there about his various treatments lead him to his most pressing concern: how to find meaning, connection, and some fun in his last months (a trip to visit lemurs, for instance). “Weak, short of breath, my once-firm muscles melted away by cancer, I find my thoughts, increasingly, not on the supernatural or spiritual, but on what is meant by living a good and worthwhile life — achieving a sense of peace within oneself,” he wrote in “Sabbath,” his final essay which reflects on his Orthodox Jewish upbringing, the pain of being rejected by his family for his sexuality, and the joy of a late-life relationship after a period of “monkish” living.
But he also addresses, again and again, the finality of what’s coming. “I have been increasingly conscious, for the last 10 years or so, of deaths among my contemporaries. My generation is on the way out, and each death I have felt as an abruption, a tearing away of part of myself,” he writes in “My Own Life.” “There will be no one like us when we are gone, but then there is no one like anyone else, ever. When people die, they cannot be replaced. They leave holes that cannot be filled, for it is the fate — the genetic and neural fate — of every human being to be a unique individual, to find his own path, to live his own life, to die his own death.”
Death and Dying Media newsletter Oliver Sacks