Is it better to die with a whimper or a bang?

With each new medical innovation, the odds that we will have to confront sudden death decrease. But is this a triumph or a tragedy? Jacob M Appel argues that the way we die now affects how we live

Jacob M. Appel
Monday 12 May 2014 22:18 BST
Saving graces: In the days before defibrillators and sophisticated drugs, sudden death was regarded as a natural part of life
Saving graces: In the days before defibrillators and sophisticated drugs, sudden death was regarded as a natural part of life

My great-grandfather, Simon Litman, Latvian immigrant, secular Jew, inept businessman, gifted egg candler, doting father, cigar-smoker and pint-sized omnivore who (at least in family lore) could devour his own body weight in gribenes, holds the distinction of being the last of my forbears to drop dead.

He made his dramatic exit on a balmy spring evening in 1950, strolling home with his wife from a Saturday supper at my grandmother's house. At the dinner table, he'd appeared in good health and good cheer. Nevertheless, several blocks up the avenue, opposite a fire station, he told my great-grandmother, "I don't feel so good," then clutched one hand to his chest, fell to his knees and stopped breathing. He was 60 years old.

To this day, my 91-year-old grandmother remains livid that none of the firemen responded to her mother's cries for help. "They must have heard her," she says. "How could they not have heard her?" Of course, that was before defibrillators and vasopressors, an era when dropping dead was a natural part of life. If the entire fire department had arrived en masse with paramedics in tow, they'd have had nothing therapeutic to offer.

Six decades after Great-Grandpa Simon plunged off his mortal coil, sudden death now threatens to go the way of rotary telephones and passenger pigeons. The exact rate at which we are not dropping dead is difficult to calculate: while governments keep meticulous records on the causes of our deaths, and the ages at which we perish, it makes no effort to estimate the speed of our grand finales.

Nonetheless, as a physician, my anecdotal sense is that we're not dying nearly as suddenly as we once did. "When I started as an intern," an elderly colleague recently observed at a staff meeting, "most patients only stayed in the hospital for a day or two. Either you got better or you didn't. Lingering wasn't part of the protocol."

Today, in contrast, lingering is the norm. You are forced out of hospital by insurance companies, not rigor mortis. Where, a generation ago, the expectation was for men to retire at 65 and keel over at 67 – the basis for the pension plans now bankrupting local governments – a massive myocardial infarction in one's fifth or sixth decade is no longer inevitable. Stress tests and statins and improved resuscitation methods mean we are more likely to survive to our second heart attack, live beyond our third stroke. Life ends with a whimper, not a bang.

Long and winding road: Lingering is now the norm. You are forced out of hospital by insurance companies, not by rigor mortis

That is not to say that the Grim Reaper never arrives on a bolt of lightning: I've lost a medical-school mentor to a plane crash, a neighbour to suicide, a childhood friend to a brain aneurysm. Thousands of people, smoking less but eating more, still do succumb to heart attacks in their fifties and sixties. But we greet these swift departures not only with grief, as we have always done, but also with a sense of indignation simmering toward outrage. In an age of prenatal genetic testing and full-body PET scans and rampant agnosticism, all varieties of death strike many of us as anathema. Death without fair warning becomes truly obscene.

Increasingly, our first associations with "sudden death" are metaphorical. "Sudden death" terminates World Cup matches, not the lives of our friends and relatives. Some time ago, I had the pleasure of seeing the singer Molly Hager in concert, a woman who embodies my – and many other men's – epitome of feminine beauty, and I made the mistake of observing to my date that Ms Hager was "drop-dead gorgeous". My date replied, acidly: "In that case, keep staring." Needless to say, as forcefully as I ogled, my heart beat only faster; it did not stop. "Drop-dead gorgeous", of course, means far less in a world where people don't actually drop dead. (Insert a comma between "dead" and "gorgeous" and it sounds like a threat Humphrey Bogart might have served up to Lauren Bacall during a spat.) We can speak figuratively about sudden death, trivialise it – even joke about it – because we do not actually expect to confront it. Not now, not soon, not until we've been afforded ample time to prepare. And with each new medical innovation, the odds are more likely that we won't.

My own family doctor has a sign on his office door that reads: "Sudden death is God's way of telling you to slow down." If that is indeed the case, God has been letting us accelerate with impunity for some time now.

In 1958, John Kenneth Galbraith's The Affluent Society reminded us that, for the first time in human history, we lived in a civilisation where a majority of people did not have to worry about basic subsistence. More than five decades later, we find ourselves belonging to the first human civilisation where sudden death is the glaring exception, not the expectation.

The novelty of our position is all too easy to forget; it is even easier to assume without questioning that the present state of affairs reflects progress. After all, which of us wouldn't rather die well-prepared at 90 than suddenly at 55? And yet, the more I see of death, the less convinced I become that, in this medical and social revolution, we have not lost something of considerable value. I certainly don't mean to glorify premature death: I suspect that both "dying with one's boots on" and "living fast, loving hard and dying young" are highly overrated feats. I do not believe that it is either dulce or decorum to die at 25 for one's country.

My concern is also not with the economic effects of the long goodbye: the per cent of healthcare cash spent in the last six months of life, the prospect of every gainfully employed worker supporting two retirees. Rather, my disquiet is principally for lost human dignity. Gloria Taylor, the Canadian right-to-die activist, who suffers from Lou Gehrig's disease, recently wrote: "I can accept death because I recognise it as a part of life. What I fear is a death that negates, as opposed to concludes, my life." Sudden death is a conclusion. Too often, I fear, the long goodbye devolves into a negation.

The contrast between the death of my grandmother's father and that of her husband 58 years later is highly revealing. Grandpa Leo, a Belgian refugee who earned a comfortable living in the jewellery business, developed prostate cancer in his early seventies, survived a mild heart attack at age 77, and by his mid-eighties had trouble remembering the names of his sisters. And then, at 86, he developed a metastatic lesion on the surface of his brain. In 1950, the cancer would have killed him in a matter of months. In 2006, a skilled neurosurgeon managed to scoop out the bulk of the tumour, enabling my grandfather to survive to a series of small strokes a full year later. Once again, these cerebral insults – as the medical chart termed them – would certainly have ended an octogenarian's life in his own father-in-law's generation. But after a two-month-long hospital stay and tens of thousands worth of hi-tech imaging, modern anti-coagulants enabled Grandpa Leo to roll into a nursing home that he actually believed to be his mother's apartment in pre-war Antwerp.

I visited him one afternoon and he announced how much he loved his wife – but he was actually referring to the young West African woman assigned to change his bed linen. It took two intubations, weeks on a ventilator, multiple courses of dialysis and a month of unconsciousness before my grandmother finally brought the process of her husband's dying to a halt. By then, the man I'd worshipped as a child for his vigour and independence had gone nearly a half a year without responding to his own name. When Grandpa Leo died – after the best nursing care imaginable – his entire torso had become one enormous bedsore, his back and shoulders assuming the colour of a side of tenderised beef.

Is my grandfather's longevity a triumph or a tragedy? On the one hand, I am grateful that I had an opportunity to know my grandfather well into my own adulthood – an opportunity that my father never had. On the other hand, faced with the prospect of following in my grandfather's footsteps, I'd much rather drop dead in front of a fire station at 60.

In medical ethics – the field in which I do my academic research and writing – the way we now die has led to the birth of entirely novel schools of thought. When life was truly brutish and short, whether in Hobbes's 16-century London or Great-Grandpa Simon's mid 20th-century New York, the idealistic notion that all life was sacred and must be preserved at any cost carried limited weight in medical and moral circles.

Although we have come to think of the modern era as one in which we tolerate less excess medical care than in past generations, the reality is that physicians and patients were once much more accepting of death than they are now. They had to be. The so-called "culture of life", so recently embraced by the Catholic Church and the Southern Baptist Convention, generally advances the view that life in its essence, rather than its quality, is of paramount value. The impact of this viewpoint upon modern healthcare and medical discourse cannot be underestimated. Yet this dogma is far more a product of technology and material change than of theological evolution. In a world in which people keeled over on street corners without advance notice, the notion of controlling (or even defeating) death made little sense.

The slow demise of sudden death has also reshaped vast aspects of our culture and our iconography with little notice and less comment. How does it alter our society to live in a world influenced by elder statesmen – and then to watch those elder statesmen totter into decrepitude? Franklin Roosevelt will forever be a jaunty 63, Adlai Stevenson a distinguished 65. In contrast, Ronald Reagan, as his memory faded and his world grew smaller, lost much of his magic. Clark Gable didn't lock in his permanent sex appeal as Rhett Butler or Fletcher Christian, but with a catastrophic thrombosis at 59. It's not so clear that an extra two decades enhanced Marlon Brando's legacy.

Whether these changes are beneficial or deleterious, they are likely irreversible – at least by rational planning. Needless to say, we can't ethically go around inducing cardiac arrests in healthy 60-year-olds. What we can do – and what we have not been doing – is pay closer attention to the complex ways in which how we die is transforming how we live.

I fear that the most subtle, yet most pernicious, consequence of a world in which people do not die suddenly is a world in which people do not appreciate life. My great-grandfather's favourite expression – one of the few memories remaining of him to the rapidly shrinking circle of old-timers who still remember his earthly presence at all – was, fittingly: "We're so lucky to be alive!"

Great-Grandpa Simon uttered these words in Yiddish, of course; his limited English was reserved for essential business transactions with gentiles. And coursing through them was clearly not only an awareness of the vagaries of natural death, but also the threat of violent demise at the hands of his fellow human beings, the ever-fresh memory of his baby sisters and their families slaughtered by Nazi Einsatzgruppen in the Daugavpils ghetto. (Ironically and fittingly, a generation later, my Grandpa Leo's favourite expression was: "Where there's life, there's hope.")

Today, a brush with death often drives us to re-examine our lives, the starting point of many a popular movie and middle-age crisis. Half a century ago, men like my great-grandfather didn't require such a brush with death: living past 50 was itself enough of a risk to generate reflection and gratitude.

Jacob M. Appel is an author and bioethicist. His latest book is 'Scouting For the Reaper' (Black Lawrence Press)

A version of this article first appeared as part of Vol XII, No 2 of KROnline, the online journal of 'The Kenyon Review'

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