By Invitation

The art of dying well

"I'm not afraid of death," Woody Allen had once said. "I just don't want to be there when it happens."

Alas, death does come looking for us. Despite being a practising doctor for many years and having lived through more than half my expected lifespan, I am still surprised at how uneasy I am when confronted with dying and death.

There is a rather fanciful theory that thanatophobia, the fear of death, is particularly prevalent among doctors and that it operates as an unconscious motive for them to take up medicine in the first place: Being engaged in battle with this ultimately unbeatable foe is a means of assuaging this deep-seated fear. (One is reminded of that adage that medicine is to immortality what law is to justice: The path of each is a little crooked and always ends up way off the mark).

In the years of seeing patients die and having had to experience the dying and death of friends and relatives, there remains within me - perhaps growing even more acute with the receding years - that abiding death anxiety.

In Philip Larkin's great but chilling poem Aubade, a man woke at 4 in the morning and agonised fearfully about "unresting death". At the crux of his terror is that annihilation of consciousness and awareness: "That this is what we fear - no sight, no sound,/No touch or taste or smell, nothing to think with,/Nothing to love or link with,/The anaesthetic from which none come round."

Secular philosophers through the ages have, however, exhorted that none should fear this absolute dissolution since being dead is akin to a state of dreamless sleep or being unborn - a perpetual nothingness.

The focus, hence, ought to be on living and that includes dying since dying, too, is an act of living.

"True philosophers," Plato wrote, "are always occupied in the practice of dying."

In a 2014 essay in the New York Times, Dr Paul Kalanithi, a 36-year-old doctor who was at the cusp of finishing his training in neurosurgery, wrote of that moment of confirmation (he had been suspecting it for some time, with his excruciating backache, weight loss and fatigue) that he had Stage 4 lung cancer.

As he methodically scrutinised the CT films that revealed the cancer mottling his lungs and eating into his liver and spine, he registered his initial feeling. "I wasn't taken aback. In fact, there was a certain relief," he wrote. "The next steps were clear: Prepare to die. Cry. Tell my wife that she should remarry, and refinance the mortgage. Write overdue letters to dear friends. Yes, there were lots of things I had meant to do in life, but sometimes this happens…"

He spent the remaining 22 months of his life learning how to die - or in the words of journalist and polemicist Christopher Hitchens, "living dyingly".

Dr Kalanithi did not divorce his wife; they chose to have a child. Distilling his experiences and thoughts on his own dying into an autobiographical book entitled When Breath Becomes Air, which was published early this year. It was the first and only book that he had written. He wrote it for his only child and daughter and for other people "to understand death and face their mortality" and to get them into his shoes and "walk a bit, and say, 'So that's what it looks like from here… sooner or later I'll be back here in my shoes'… Not the sensationalism of dying, and not exhortations to gather rosebuds, but: Here's what lies up ahead on the road".

After trying whatever treatments he could find tolerable and acceptable, and having made a decision together with his family and his attending doctors not to carry on any further, he died with his family at his bedside.

If there can ever be one, Dr Kalanithi's death could possibly be called "a good death" or at least a good enough death.


What a good death is is pretty much in the eye of the beholder but it is a safe bet that when asked, most people would say that it is a sudden and painless death - and would probably add that this is what they would want for themselves.

I was told of a seemingly apocryphal (it turned out to be true) story of an apparently hale and healthy middle-aged man who was taken out for lunch on his birthday by his colleagues. Back in the office and replete after an extravagant meal, he was in the middle of telling a joke when he keeled over and died.

Many who turned up at the wake murmured to the still-shocked and grieving widow that it was good that he did not suffer and that it was a good death.

But is it? Such a sudden and unexpected death would usually leave behind a detritus of unfinished and unresolved matters, and a clutch of traumatised survivors who had been denied of being able to express or hear what they have meant to that person, robbed of any opportunity to express gratitude or regrets, and deprived of any hope of reconciliation.

If it is any consolation, most of us would not go this way; we would have to endure that variable period of dying. The intervention of modern medicine can drag this process for months or even years with a progressive accretion of debilities and miseries.

It might seem, then, that most of us would have the time to plan for our imminent death: to grieve, to come to terms with things, to provide for others, to try to live out the remaining time with some purpose and meaning, to voice our preference for life support or not, and plan for our funeral - but we often do not do many of these.

In mediaeval Christian Europe, it was widely subscribed that the preparation for one's earthly death and the celestial judgment that would follow were matters of immense importance.

Such preparation was even celebrated in the arts and literature as Ars moriendi, the art of dying. The Ars moriendi provided practical guidance on reaffirming one's faith in God, remembering the right values and taking the right attitude in composing oneself to meet death fearlessly and stoically.

Today, we are a "death avoidance" society. Perhaps we are less religious now; maybe our blind faith in medical advances has given us that illusion that we can postpone death each time it comes threateningly close, and our various superstitions and cultural aversion towards death have certainly not made discussion of dying and death any easier.

Since 2006, the Lien Foundation has been at the vanguard of efforts to get some conversation going on end-of-life issues with commissioned studies, campaigns, and media coverage.

Despite these valiant efforts, it does seem to be a lone voice in the wilderness as its own research has shown that most people (doctors included) continue to be reluctant to talk about death, even to a terminally ill patient. It is also very likely that the public still possess little information - let alone knowledge - of end-of-life options, including hospice and palliative care, and the legal rights to refuse or withdraw life-prolonging treatments.

We talk about active ageing but ageing, whether active, well or otherwise, would eventuate in death - yet there is no talk of "dying well". Granted that it is difficult to attend to the thoughts and concerns of the dying when it is often difficult to be certain of when one actually starts dying; not to discuss it is to ignore - using that stock phrase - that 800-pound gorilla in the room. Unless we are content to put up with its heavy, oppressive and ominous presence, we ought to do something.

Perhaps, together with active ageing, we should also start talking about our own updated secular or otherwise version of the Ars moriendi.

•The writer is vice-chairman of the medical board (research) at the Institute of Mental Health.

A version of this article appeared in the print edition of The Straits Times on July 26, 2016, with the headline 'The art of dying well'. Print Edition | Subscribe