The Art of Dying Well Read online

  HOW THIS BOOK IS ORGANIZED

  This is a step-by-step guide to remaining as healthy and happy as possible, and as medically informed and unafraid, through the predictable health stages of later life, from vigorous old age to final breath. I have devoted one chapter to each stage: Resilience, Slowing Down, Adaptation, Awareness of Mortality, House of Cards, Preparing for a Good Death, and Active Dying. The goal of each chapter is to help you thrive and keep you on a path to a good end of life—however you define it.

  Each chapter will suggest ways to step off the conveyor belt of fast medicine when it no longer serves you, and to find medical allies focused on what matters most to you, be it staying functional, controlling your physical pain, or emotionally supporting you and those whom you love. I hope its true stories will help you understand where each medical choice is likely to lead. Stage by stage, year by year, and decade by decade, you will probably lean more and more on gentle approaches that support a good quality of life, even as it winds down. The balance you strike, and how and when you shift, is up to you.

  This book will, I hope, wherever you are on the journey from birth to death, give a rough sense of the time that remains, and empower you to stay in charge of a changing relationship to medicine. This is the best way I know to make room for your own versions of the rites of passage that our ancestors so prized. The temple of the sacred will be built upon a foundation of the mundane.

  It is my deep hope that you will be peaceful and at ease at the moment of your death. That you may be safe, well supported, and free from fear long before that day comes. That you have what you need—emotionally, medically, spiritually, and practically—to live fully until your last breath. That you and those who love you may be held in the arms of a loving community and a competent medical team.

  That is my desire. I wish this book could guarantee you a vigorous old age, a short decline, and a swift, painless death at home, surrounded by those who love you. But as the eighteenth-century German physician Zacharias Schultz wrote, people have long wished for “a gentle, mild and sweet” death, and feared one that is “arduous, terrible and hard.” This, he said, had long been the focus of people’s pious prayers, as well as their pleas to their doctors. Now more than ever, the way we die can be uncertain, ambiguous, attenuated, and prolonged. No matter how bravely we adapt to loss and how cannily we navigate our fragmented health system, things will not always go as we imagine. And yet if we want to keep shaping our lives all the way to the end, it helps to imagine, to choose, and to plan.

  I am not suggesting we create a new Art of Dying to make death somehow perfect. Perfection is not a goal of art; it is an ambition of technology and science. Arts are improvised out of the limited, imperfect materials at hand. A modern Art of Dying will not make the end of every life painless, but it can make it bearable, shared, and even, in its own way, beautiful. Here is a compass and the beginnings of a map.

  —CHAPTER 1—

  Resilience

  The Wake-Up Call • Building Reserves • Finding Allies in Preventive Medicine • Weighing Medical Risks • Getting to Know the Neighbors • Knowing Your Medical Rights • Caring for the Soul

  The River Grows Wider

  Some old people are oppressed by the fear of death. . . . The best way to overcome it is to make your interests gradually wider and more impersonal, until bit by bit the walls of the ego recede, and your life becomes increasingly merged in the universal life. An individual human existence should be like a river: small at first, narrowly contained within its banks, and rushing passionately past rocks and over waterfalls. Gradually the river grows wider, the banks recede, the waters flow more quietly, and in the end, without any visible break, they become merged in the sea, and painlessly lose their individual being. [Those] who can see life in this way will not suffer from the fear of death, since the things [they care] for will continue.

  —BERTRAND RUSSELL

  You may find this chapter useful if you recognize yourself in some of the following statements:

  • You easily blew out all the candles on your fiftieth or sixtieth birthday cake.

  • Aches, pains, and health problems are annoying but not limiting. You pay your own bills, make your own medical decisions, and generally enjoy life.

  • You wonder why they make the numbers on credit cards so small and fuzzy.

  • Your hair is thinning in familiar places and sprouting in strange ones.

  • You misplace keys—and names. You’re not crazy about technology updates.

  • A late night blows a hole in the next day. Sometimes you’re in bed by nine. You’ve discovered naps.

  • Getting in shape takes longer, and the results are less impressive. You injure more easily and recover more slowly.

  • Some friends have died. You find obituaries interesting.

  • You sometimes sense that your time on earth is limited and precious.

  THE WAKE-UP CALL

  Doug von Koss was born in the Depression and raised on the banks of the Mississippi River in a houseboat his father built from salvaged lumber. In the 1960s he settled in San Francisco, where he and his wife, Clydene, raised their son and daughter. He made his living as a stagehand, theater carpenter, light board operator, and set dresser for films like George Lucas’s Return of the Jedi. He’s now eighty-five, tall, elegant, and commanding. Widowed for a decade, he lived in a neat, rented bungalow on a hilly San Francisco street.

  In his fifties, while he was working as prop master for the San Francisco Opera, he led a workshop in mask making at a men’s conference in the redwoods of northern California. The men, who’d just met, nervously labored over their masks in silence, with pinched faces and little joy. The poet Robert Bly, one of the conference organizers, nudged Doug’s arm and said, “Get them singing.” Doug drew the men outside. After twenty minutes of belting out camp songs under the redwoods, the men loosened up, started talking with each other, and returned to sculpting their masks with abandon. Ever since, Doug has been flying around the country, helping groups build community by leading them in traditional songs, chants, and poems that he’s gathered from cultures around the world.

  Not long after his seventy-ninth birthday, Doug found the steps up to his front door growing steeper by the day. At first, he brushed off his fatigue and breathlessness as normal aging. Then one midsummer afternoon, as he was pushing a shopping cart through the supermarket, he felt light-headed, dizzy, and short of breath. He trundled over to the one place where he could sit down: the do-it-yourself blood pressure machine near the pharmacy. He doesn’t remember now whether his reading was too high or too low, only that it wasn’t good.

  The next morning in a medical building downtown, his doctor stopped in the middle of recording Doug’s electrocardiogram and called an ambulance. EMTs took Doug down the elevator on a gurney. Twenty-four hours later, in a cardiac lab at a nearby hospital, doctors inserted a small tubular metal cage called a stent into an artery leading to the heart’s largest blood vessel. “One of the main vessels was plugged,” Doug said. “I could have gone belly up.” He’d been millimeters from a heart attack.

  The stent pushed aside a clump of fatty plaque, propped open the artery walls, and increased the flow of oxygen-rich blood to Doug’s heart, body, and brain. He found it almost instantly easier to climb his front stairs. “Life became incredibly sweet,” he remembered. “I could stop and look at a tree, look at a flower, and really see it. I felt really alive, and at the same time very fragile.”

  The stent, he sensed, was a temporary reprieve. Why, he wondered, had fat, cholesterol, and calcium congealed in his arteries? He didn’t smoke or drink, never touched bacon, and rode his bike in Golden Gate Park three times a week. “But I got the message,” he said. “Pay more attention, Doug. There’s a line between disease and optimum wellness, and you’re sliding into disease.”

  His hospital offered a four-month program of intensive cardiac rehabilitation, paid for by Medicare. Three times a week a
t a rehab center, he strapped on a heart monitor and pedaled a stationary bicycle while a physical therapist helped him gradually increase his heart rate. A dietician nudged him toward the Mediterranean Diet—less meat, dairy, sugar, and packaged foods; more vegetables, whole grains, olive oil, fish, and fruit. That, combined with more strenuous exercise, halved Doug’s risk of having a heart attack or dying within five years—and more importantly, it substantially extended the years he will probably spend thriving.

  When the cardiac program ended, Doug joined a Y and started running on a treadmill three times a week. At eighty-two, he began lifting weights. “I looked around the gym and saw men and women, whom I knew were as old as I was, walking very vigorously,” he said. “I wanted that, too.” He built muscle and improved his balance—crucial capacities, given that muscles naturally wither with age, agility lessens, bones grow brittle, and independence can be devastated by a fall. “It started a great wellness loop,” Doug said. “More exercise, healthier eating, better sleep, and an improved sense of well-being.” At a recent checkup, his doctor said, “Don’t change a thing.”

  The health stage I call Resilience, sometimes called “young” or healthy old age, is a time when you still have the physical capacity to reverse substantial health problems. Most people in the Resilience stage are in their fifties, sixties, and early seventies, but some are exceptionally athletic older people, like Doug von Koss. Length of life is impossible to predict precisely, but people at this stage usually have at least another decade left to live.

  This is the time to take inventory, build reserves, and assess what needs shoring up. The major threats to your future well-being will be: physical weakness, isolation, heart disease, lung disease, diabetes, and dementia. You can build bulwarks against them—and prolong your time in Resilience—by exercising, eating better, and widening your circle of friends and passionate interests. Lifestyle habits—especially smoking, being sedentary, eating poorly, and drinking too much alcohol—are responsible for 70 percent of the degenerative diseases that make later life difficult. Change these habits, even after the age of fifty-five, and you can cut your health risks as much as sevenfold—a better payoff than almost all drugs.

  I don’t mean to suggest that food asceticism and strenuous exercise will ward off death and decline forever. They won’t really make you younger next year, though they may keep you happier, stronger, and more functional. Given that our bodies age at the cellular level in more than five thousand specific ways, there’s little point in strengthening physical muscles without developing the spiritual and social strength to cope with the inevitable loss of powers, and with death itself. But before you must accept the things you cannot change, you can seize the time to prepare for what’s ahead, and to change the things you can.

  BUILDING RESERVES

  In developed countries, few people die of disease in the first half of life. Most early deaths result from accidents, violence, drug overdoses, and suicide. In late midlife, the picture changes. Cancer becomes a major cause of death in the mid-forties and continues to climb throughout the fifties and sixties. Deaths from heart disease rise in the sixties and seventies, from lung disease in the eighties, and from dementia in the nineties. All cause physical suffering long before they kill, and all are profoundly shaped by how you live.

  I suggest you begin by doing what requires the most of you and the least of medicine. The most effective first step (other than quitting smoking) is to walk energetically every day. People over sixty-five who do so increase their lung capacities, get more oxygen to the brain, and expand the size of the hippocampus, a brain organ crucial to memory. As a side benefit, walking around malls, Farmers Markets, and to downtown coffee shops amplifies social connections, another delightful way of improving health, brain function, and happiness. Most of this is not news. But if you’ve forgotten the deep pleasure and self-confidence that can follow half an hour or more of aerobic exercise, especially in nature or with a friend, consider reacquainting yourself. Even late in the game, getting more active has huge health benefits.

  Exercise becomes more challenging as joints grow creaky and minor injuries heal more slowly. Improvise, adapt, and overcome: get moving in any way that makes you break a sweat and gives you joy. Many people find delight in ballroom dancing, biking, or swimming; others find it easier to get started—and to keep going—by scheduling a regular exercise date with a friend. If your feet or knees hurt, consider upgrading shoes or improving your posture or gait with the help of a podiatrist, a physical therapist, or a practitioner of an alternative approach, like Feldenkrais or the Alexander Technique. Stay flexible and be willing to substitute a new activity whenever one falls by the wayside: if you can’t run anymore, try water aerobics; if you lose your partner, explore group activities like Greek or country line dancing. No matter what happens, keep going.

  * * *

  The body’s capacity to heal, even at this relatively late date, is astounding. Tom Murphy, a former Associated Press journalist who’d once run a marathon, was sixty-two when he was diagnosed with diabetes. He’d been working a stressful and unsatisfying job and, he said, had “fallen into my mom’s habit of eating mostly cookies and ice cream, frozen pizzas, Danishes, and lots of bread.”

  He took a new job and moved from the San Francisco suburbs to rural Mendocino county. By the time he met his new primary care doctor, he weighed 225 pounds and had a trifecta of late-life warning flags: high cholesterol, high blood pressure, and high blood sugar. His alarmed physician recommended he see a cardiologist immediately and start taking a cholesterol-lowering statin, a blood pressure–reducing diuretic, and the blood sugar–lowering drug metformin.

  Tom looked at his friends and family, many of whom were already on these drugs, and saw his own future. “I have a friend who went blind from diabetes, another who can’t walk, and a third who died of a heart attack,” he said. “All could have changed their diets in their fifties, but waited too long. I wasn’t going to make the same mistake.”

  He took blood pressure medication to lower his stroke risk, but asked for a grace period before adding other medications. What followed was, he said, “a very emotional three months. Changing how I lived and ate became more important than work, friends, reading, even my marriage.” He jogged a mile and a quarter every morning, starting at a snail’s pace and gradually increasing his speed and distance. He stopped eating all foods with added sugar, and other “things that had made my life ‘richer.’ ”

  He struggled to change his sleep patterns. He experienced the highs of exercise and the lows of accompanying muscle pain. He wrestled with the drug-like withdrawal effects of quitting sugar, and, as he put it, “the stress of facing multiple life-threatening diseases.” To keep going he kept a diary of what he ate and when he exercised, and turned for support to his wife and to a friend who successfully managed her Type 1 diabetes without medication.

  Three months later, his cholesterol level was normal for the first time in his life, and so was his blood pressure. His blood sugar levels have fallen more than a third and are now just a hair above normal. His diet is based on fresh vegetables from his wife’s garden and smaller amounts of lean turkey, cheese, brown rice, whole wheat bread, and sugar-free jam. Every day he jogs two miles and rides his bike. He weighs 170 pounds and takes no medications. “Yes, it was hard,” he said. “It’s still hard. But my doctor is very happy and I’m never going back.”

  FINDING ALLIES IN PREVENTIVE MEDICINE

  The most helpful physician at this stage is a good primary care doctor who will coach you to prevent disease. It’s not enough to get a yearly lecture on smoking, drinking, or your weight. You want someone who will enthusiastically refer you to physical therapy, or to an effective support group, such as Alcoholics Anonymous, a smoking cessation group, or the diabetes prevention classes offered at many local Ys and covered by Medicare. If your blood pressure, cholesterol, or blood sugar remain high despite lifestyle changes, talk to your doctor about
medication: the payoffs are significant for people with a decade or more of life ahead.

  The need for a geriatrician—a physician who specializes in the aging body—may not yet seem urgent. But one way or another, it’s crucial to find a doctor who cares about you as a whole person long before a health crisis. Many fine doctors who refuse new Medicare patients will continue to treat older people with whom they have established relationships. Look for someone who genuinely cares about his or her patients—and if you’re not happy, switch. Now is the time to find someone who will be with you for the long haul.

  If your primary care doctor is older than you are, consider finding someone younger who won’t retire before you die and has an office close by. (The same goes for dentists, hairdressers, and car mechanics: a twenty-mile drive that is easy today may be harder tomorrow.)

  Take advantage of every opportunity to establish rapport with a single doctor who will act as your point person in the world of fragmented medicine that most of us encounter. Ask your doctor to look up from the computer, and to give you a full physical examination. Medicare and some private insurance now reimburse for various “wellness” appointments, including an introductory visit, yearly cognitive assessments, and advance care planning. Use them to help your doctor get to know you well, and to make sure that you share the same goals.