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The art of living well and dying well are one.
Death is one of the attributes you were created with; death is part of you. Your life's continual task is to build your death.
Are you ready to die? If not, then you might begin some preparation. Every BMJ reader will die this century, and death is constantly beside us. Montaigne urged, “One should be ever booted and spurred and ready to depart.” Yet that has not been the attitude of the past 50 years, and modern medicine may even have had the hubris to suggest implicitly, if not explicitly, that it could defeat death.1 If death is seen as a failure rather than as an important part of life then individuals are diverted from preparing for it and medicine does not give the attention it should to helping people die a good death. We need a new approach to death, and the debate of the age on older people has provided a clarion call: “We believe it is time to break the taboo and to take back control of an area [death] which has been medicalised, professionalised, and sanitised to such an extent that it is now alien to most people's daily lives.”2
To bring death back to the centre of life would not, of course, be new. Ivan Illich traced the history of death in his critique of modern medicine, Limits to Medicine.1 The dance of the dead painted on a cemetery wall in Paris in 1424 showed each character dancing with his or her own death throughout life. One of the first books published by William Caxton, England's first printer, was a manual of how to die. It remained a bestseller for two centuries. It was not until after the Reformation that European death became macabre, and Francis Bacon was the first to suggest that doctors might hold death at bay. Earlier Arab and Jewish doctors had thought it blasphemous for doctors to attempt to interfere with death. For Paracelsus death was “a return to the womb.” Nevertheless, death has become medicalised, reaching its apotheosis perhaps with the prolonged death, reported minutely by the media, of Spain's dictator General Franco. Most people in Britain today die in hospital, even though they say they would prefer to die at home, and a soulless death in intensive care is the most modern of deaths.
Yet the call from the debate of the age seems to be part of a broader tendency to remove the taboo on death. Elisabeth Kubler-Ross, Cicely Saunders, and other pioneers of palliative care have been arguing for 30 years that special care should be offered to the dying.3,4 There is, however, something paradoxical about creating a specialty to cater for something that happens to us all. The trend now is for the lessons learnt by palliative care physicians to be reclaimed by everybody. We have seen the beginnings with frank accounts of dying by journalists,5 pictures of a person dying on television,6 and guidebooks on dying well.7,8
But what is the state of dying in Britain today? Sadly, nobody can answer that question with confidence. We have reliable and detailed statistics on life expectancy, age at death, and place and cause of death, but we know little about the experience of death. For the minority who die under the care of palliative care teams it is probably good, but there is a suspicion that for the majority who die in acute hospitals or nursing homes the experience is bad. The newspapers are full of anecdotes of bad deaths in British hospitals, and a survey published in the BMJ in 1994 showed that care of the dying in hospital was poor.9 That study was conducted in 1983, and letters after publication debated whether its bleak findings were still true.10,11
Debate over whether people are dying badly or well obviously depends on a definition of a good death. It is clearly more than being free of pain, and three themes that emerged constantly in the debate of the age were control, autonomy, and independence.2 The authors of the final report on The Future of Health and Care of Older People have identified 12 principles of a good death (see box).2 These are excellent principles and should surely be incorporated into the plans of individuals, professional codes, and the aims of institutions and whole health services. Dying and death are being included in national care standards in England, and we clearly need to monitor how people die.
But the focus must not all be on the process of dying. Death should be brought more into life, and the report also recommends how this can be done. One suggestion is to introduce death education into schools. Another is to improve the quality and relevance of funerals. The National Funerals College has introduced the Dead Citizen's Charter, and it criticises many modern funerals for being “hypocritical, bureaucratic, dull, impersonal, and hurried.”12 A good funeral is a life enhancing experience, and I suggest that you think about yours now. “Make way for others,” advises Montaigne, “as others did for you. Imagine how much more painful would be a life which lasts for ever.”