how to end an essay about death

Essays About Death: Top 5 Examples and 9 Essay Prompts

Death includes mixed emotions and endless possibilities. If you are writing essays about death, see our examples and prompts in this article.

Over 50 million people die yearly from different causes worldwide. It’s a fact we must face when the time comes. Although the subject has plenty of dire connotations, many are still fascinated by death, enough so that literary pieces about it never cease. Every author has a reason why they want to talk about death. Most use it to put their grievances on paper to help them heal from losing a loved one. Some find writing and reading about death moving, transformative, or cathartic.

To help you write a compelling essay about death, we prepared five examples to spark your imagination:

1. Essay on Death Penalty by Aliva Manjari

2. coping with death essay by writer cameron, 3. long essay on death by prasanna, 4. because i could not stop for death argumentative essay by writer annie, 5. an unforgettable experience in my life by anonymous on gradesfixer.com, 1. life after death, 2. death rituals and ceremonies, 3. smoking: just for fun or a shortcut to the grave, 4. the end is near, 5. how do people grieve, 6. mental disorders and death, 7. are you afraid of death, 8. death and incurable diseases, 9. if i can pick how i die.

“The death penalty is no doubt unconstitutional if imposed arbitrarily, capriciously, unreasonably, discriminatorily, freakishly or wantonly, but if it is administered rationally, objectively and judiciously, it will enhance people’s confidence in criminal justice system.”

Manjari’s essay considers the death penalty as against the modern process of treating lawbreakers, where offenders have the chance to reform or defend themselves. Although the author is against the death penalty, she explains it’s not the right time to abolish it. Doing so will jeopardize social security. The essay also incorporates other relevant information, such as the countries that still have the death penalty and how they are gradually revising and looking for alternatives.

You might also be interested in our list of the best war books .

“How a person copes with grief is affected by the person’s cultural and religious background, coping skills, mental history, support systems, and the person’s social and financial status.”

Cameron defines coping and grief through sharing his personal experience. He remembers how their family and close friends went through various stages of coping when his Aunt Ann died during heart surgery. Later in his story, he mentions Ann’s last note, which she wrote before her surgery, in case something terrible happens. This note brought their family together again through shared tears and laughter. You can also check out these articles about cancer .

“Luckily or tragically, we are completely sentenced to death. But there is an interesting thing; we don’t have the knowledge of how the inevitable will strike to have a conversation.”

Prasanna states the obvious – all people die, but no one knows when. She also discusses the five stages of grief: denial, anger, bargaining, depression, and acceptance. Research also shows that when people die, the brain either shows a flashback of life or sees a ray of light.

Even if someone can predict the day of their death, it won’t change how the people who love them will react. Some will cry or be numb, but in the end, everyone will have to accept the inevitable. The essay ends with the philosophical belief that the soul never dies and is reborn in a new identity and body. You can also check out these elegy examples .

“People have busy lives, and don’t think of their own death, however, the speaker admits that she was willing to put aside her distractions and go with death. She seemed to find it pretty charming.”

The author focuses on how Emily Dickinson ’s “ Because I Could Not Stop for Death ” describes death. In the poem, the author portrays death as a gentle, handsome, and neat man who picks up a woman with a carriage to take her to the grave. The essay expounds on how Dickinson uses personification and imagery to illustrate death.

“The death of a loved one is one of the hardest things an individual can bring themselves to talk about; however, I will never forget that day in the chapter of my life, as while one story continued another’s ended.”

The essay delve’s into the author’s recollection of their grandmother’s passing. They recount the things engrained in their mind from that day –  their sister’s loud cries, the pounding and sinking of their heart, and the first time they saw their father cry. 

Looking for more? Check out these essays about losing a loved one .

9 Easy Writing Prompts on Essays About Death

Are you still struggling to choose a topic for your essay? Here are prompts you can use for your paper:

Your imagination is the limit when you pick this prompt for your essay. Because no one can confirm what happens to people after death, you can create an essay describing what kind of world exists after death. For instance, you can imagine yourself as a ghost that lingers on the Earth for a bit. Then, you can go to whichever place you desire and visit anyone you wish to say proper goodbyes to first before crossing to the afterlife.

Every country, religion, and culture has ways of honoring the dead. Choose a tribe, religion, or place, and discuss their death rituals and traditions regarding wakes and funerals. Include the reasons behind these activities. Conclude your essay with an opinion on these rituals and ceremonies but don’t forget to be respectful of everyone’s beliefs. 

Smoking is still one of the most prevalent bad habits since tobacco’s creation in 1531 . Discuss your thoughts on individuals who believe there’s nothing wrong with this habit and inadvertently pass secondhand smoke to others. Include how to avoid chain-smokers and if we should let people kill themselves through excessive smoking. Add statistics and research to support your claims.

Collate people’s comments when they find out their death is near. Do this through interviews, and let your respondents list down what they’ll do first after hearing the simulated news. Then, add their reactions to your essay.

There is no proper way of grieving. People grieve in their way. Briefly discuss death and grieving at the start of your essay. Then, narrate a personal experience you’ve had with grieving to make your essay more relatable. Or you can compare how different people grieve. To give you an idea, you can mention that your father’s way of grieving is drowning himself in work while your mom openly cries and talk about her memories of the loved one who just passed away. 

Explain how people suffering from mental illnesses view death. Then, measure it against how ordinary people see the end. Include research showing death rates caused by mental illnesses to prove your point. To make organizing information about the topic more manageable, you can also focus on one mental illness and relate it to death.

Check out our guide on  how to write essays about depression .

Sometimes, seriously ill people say they are no longer afraid of death. For others, losing a loved one is even more terrifying than death itself. Share what you think of death and include factors that affected your perception of it.

People with incurable diseases are often ready to face death. For this prompt, write about individuals who faced their terminal illnesses head-on and didn’t let it define how they lived their lives. You can also review literary pieces that show these brave souls’ struggle and triumph. A great series to watch is “ My Last Days .”

You might also be interested in these epitaph examples .

No one knows how they’ll leave this world, but if you have the chance to choose how you part with your loved ones, what will it be? Probe into this imagined situation. For example, you can write: “I want to die at an old age, surrounded by family and friends who love me. I hope it’ll be a peaceful death after I’ve done everything I wanted in life.”

To make your essay more intriguing, put unexpected events in it. Check out these plot twist ideas .

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How to Conclude an Essay (with Examples)

Last Updated: July 22, 2024 Fact Checked

Writing a Strong Conclusion

What to avoid, brainstorming tricks.

This article was co-authored by Jake Adams and by wikiHow staff writer, Aly Rusciano . Jake Adams is an academic tutor and the owner of Simplifi EDU, a Santa Monica, California based online tutoring business offering learning resources and online tutors for academic subjects K-College, SAT & ACT prep, and college admissions applications. With over 14 years of professional tutoring experience, Jake is dedicated to providing his clients the very best online tutoring experience and access to a network of excellent undergraduate and graduate-level tutors from top colleges all over the nation. Jake holds a BS in International Business and Marketing from Pepperdine University. There are 8 references cited in this article, which can be found at the bottom of the page. This article has been fact-checked, ensuring the accuracy of any cited facts and confirming the authority of its sources. This article has been viewed 3,218,224 times.

So, you’ve written an outstanding essay and couldn’t be more proud. But now you have to write the final paragraph. The conclusion simply summarizes what you’ve already written, right? Well, not exactly. Your essay’s conclusion should be a bit more finessed than that. Luckily, you’ve come to the perfect place to learn how to write a conclusion. We’ve put together this guide to fill you in on everything you should and shouldn’t do when ending an essay. Follow our advice, and you’ll have a stellar conclusion worthy of an A+ in no time.

Tips for Ending an Essay

• Rephrase your thesis to include in your final paragraph to bring the essay full circle.
• End your essay with a call to action, warning, or image to make your argument meaningful.
• Keep your conclusion concise and to the point, so you don’t lose a reader’s attention.
• Do your best to avoid adding new information to your conclusion and only emphasize points you’ve already made in your essay.

• “All in all”
• “Ultimately”
• “Furthermore”
• “As a consequence”
• “As a result”

• Make sure to write your main points in a new and unique way to avoid repetition.

• Let’s say this is your original thesis statement: “Allowing students to visit the library during lunch improves campus life and supports academic achievement.”
• Restating your thesis for your conclusion could look like this: “Evidence shows students who have access to their school’s library during lunch check out more books and are more likely to complete their homework.”
• The restated thesis has the same sentiment as the original while also summarizing other points of the essay.

• “When you use plastic water bottles, you pollute the ocean. Switch to using a glass or metal water bottle instead. The planet and sea turtles will thank you.”
• “The average person spends roughly 7 hours on their phone a day, so there’s no wonder cybersickness is plaguing all generations.”
• “Imagine walking on the beach, except the soft sand is made up of cigarette butts. They burn your feet but keep washing in with the tide. If we don’t clean up the ocean, this will be our reality.”
• “ Lost is not only a show that changed the course of television, but it’s also a reflection of humanity as a whole.”
• “If action isn’t taken to end climate change today, the global temperature will dangerously rise from 4.5 to 8 °F (−15.3 to −13.3 °C) by 2100.”

• Focus on your essay's most prevalent or important parts. What key points do you want readers to take away or remember about your essay?

• For instance, instead of writing, “That’s why I think that Abraham Lincoln was the best American President,” write, “That’s why Abraham Lincoln was the best American President.”
• There’s no room for ifs, ands, or buts—your opinion matters and doesn’t need to be apologized for!

• For instance, words like “firstly,” “secondly,” and “thirdly” may be great transition statements for body paragraphs but are unnecessary in a conclusion.

• For instance, say you began your essay with the idea that humanity’s small sense of sense stems from space’s vast size. Try returning to this idea in the conclusion by emphasizing that as human knowledge grows, space becomes smaller.

• For example, you could extend an essay on the television show Orange is the New Black by bringing up the culture of imprisonment in America.

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• Always review your essay after writing it for proper grammar, spelling, and punctuation, and don’t be afraid to revise. Thanks Helpful 0 Not Helpful 0

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• ↑ https://www.uts.edu.au/current-students/support/helps/self-help-resources/grammar/transition-signals
• ↑ https://owl.purdue.edu/owl/general_writing/common_writing_assignments/argument_papers/conclusions.html
• ↑ http://writing2.richmond.edu/writing/wweb/conclude.html
• ↑ https://writingcenter.fas.harvard.edu/pages/ending-essay-conclusions
• ↑ https://www.pittsfordschools.org/site/handlers/filedownload.ashx?moduleinstanceid=542&dataid=4677&FileName=conclusions1.pdf
• ↑ https://www.cuyamaca.edu/student-support/tutoring-center/files/student-resources/how-to-write-a-good-conclusion.pdf
• ↑ https://library.sacredheart.edu/c.php?g=29803&p=185935

About This Article

To end an essay, start your conclusion with a phrase that makes it clear your essay is coming to a close, like "In summary," or "All things considered." Then, use a few sentences to briefly summarize the main points of your essay by rephrasing the topic sentences of your body paragraphs. Finally, end your conclusion with a call to action that encourages your readers to do something or learn more about your topic. In general, try to keep your conclusion between 5 and 7 sentences long. For more tips from our English co-author, like how to avoid common pitfalls when writing an essay conclusion, scroll down! Did this summary help you? Yes No

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Writing about death is one of the hardest, most valuable things journalists do — here’s how to do it correctly. 

Alma matters: journalism resources for professors and students during the covid-19 pandemic.

Welcome to Alma Matters, a regularly updated feature on Poynter.org to assist educators and student media organizations.

Struggling and need advice? Have a tip or tool you want to share with others? Email me at [email protected] .

Reminder: All News University self-directed courses and webinars are free until May 31. Use the discount code 20college100 

One of the toughest rites of passage for young journalists is writing about someone who just died.

For many working journalists, interviewing distraught loved ones and grieving friends is a hard but necessary part of the job — and something we’re used to.

The nation’s student journalists are about to face this nearly alone.

The in-person support network that a college newsroom used to offer is gone, replaced by teleconferencing and texts.

Advisers and experienced student editors should be mindful of their staff members as the death toll for COVID-19 mounts, keeping an eye out not just on deceased community members but the students who are being asked to cover their deaths.

Here are my best tips for dealing with death. I hope you won’t need them.

A hard necessity

First and foremost, understand that writing about a person who has died is important and meaningful. You cannot skip this part of the job because it’s intimidating. Telling stories of people’s lives and deaths is a way that journalism connects humanity, and that’s more important now than ever.

An easy litmus test: Think of someone you truly hold dear, and imagine them dying (unpleasant, I know). Now imagine that a local TV station airs a long story about this person without ever talking to you. How do you feel about being excluded from this process to tell stories and celebrate the life of your loved one? Carry that thinking with you throughout your reporting process. It will help you always do the right thing.

Make a plan

If they haven’t already, student media organizations should get a plan in place. Consider:

• Who will write profiles of the deceased?
• Who will edit and fact-check them?
• Has your staff been briefed on how to deal with grieving sources?
• Will you treat students, faculty, staff, donor and alumni deaths the same or differently?
• Where will these stories reside? Are you creating a special page?
• Who will gather photos and perhaps audio/video?

Interview skillfully

Interviewing the bereaved is hard enough in person, but this time it’s going to be even harder without the body language and potential physical contact you can have with sources.

You should do it anyway.

Arrange a time and place for a phone call, Facetime, Zoom, or Google Hangout, or whatever technology you’re most comfortable with and are assured the other party can use. Encourage your source to pass the phone/device around and talk to as many loved ones as you can if there are multiple people at the home.

Loved ones congregating at one home may not happen now, so be sure to get as many names and numbers as you can from your initial source so you can call other people.

As with most journalism, a richer and more full story emerges as you talk to more people. Do not rely on texts or emails for these stories if at all possible. Really attempt personal connection, even if it’s virtual.

Where to start with sources

A cardinal rule of death writing is that you must talk to the family and friends — you cannot rely on loving social media posts or online funeral home memory books.

The best sources for stories about death are immediate family — spouses, children, parents. Start there and move outward toward siblings, friends, cousins and coworkers.

Call the funeral home. Often there’s a person designated there to be a contact for the family, and the funeral home will let that person know there’s a media inquiry into their loved one’s death. Some funeral homes understand the important role journalism plays in mourning; others don’t. Don’t be intimidated either way.

What to ask

Do research beforehand. Your list of questions should attempt to answer some basic biographical questions: the decedent’s birthplace/hometown, where they grew up, where they moved around to and settled or lived when they died, where they went to high school and/or college, their major, the date they graduated or were set to graduate, where they worked and in what industry, the name of their spouse(s), the year they got married, names and birth years of children. You should also ask about hobbies, interests, extracurriculars or volunteer work. The more questions about their life you have going into an interview, the smoother it will go.

Use other published material and social accounts to fact-check and backup your story.

Don’t forget the pictures

Get photos. Publish several. Write good cutlines on each one.

It’s preferable to ask for family photos than to take them from social media profiles, but you can also ask permission to use social photos. Sharing a photo on social media does not waive ownership, and it’s not an invitation for you to copy and republish it, experts say.

Style and accuracy check

As hard as it is sometimes, we always say that someone died, not that they “passed away” or “passed on.” You can certainly use this language in your questions, but when it comes time to write the story, stick to “died.”

Generally, obits and death stories focus on the positive parts of a person’s life. That’s generally OK.

Bear in mind that a project like this is an important historical work that may be kept in the family for generations to come. Often, this is the single bit of press a person will get in his or her lifetime.

Self-care matters

Despite what we might have heard from older generations of journalists, you shouldn’t tough this out alone. There’s absolutely no shame in having and sharing serious emotions around death, and your experiences as you gather news around that topic. You want to maintain a level of professionalism, but even the pros can become distraught on the job .

The Dart Center for Journalism and Trauma offers the tip sheet Covering Breaking News: Interviewing Victims and Survivors that’s worth reading in its entirety, and Poynter has this advice for self-care for journalists.

Here are highlights from the Dart Center’s tip sheet:

• Be transparent, calm and soft-spoken.
• Identify who you are, what organization you represent, what will happen with the information you collect from the interview, how it might be used and when it will appear.
• Tell them why you want to talk with them.
• If they are open to an interview, then proceed. If not, then leave your contact information with them and ask them to contact you anytime if they would like to talk.
• If they are not interested in talking, or willing to speak on the record, there will be another opportunity to find another source.
• Don’t patronize.
• Don’t ask “How do you feel?”
• Don’t say “I know how you feel,” or “I totally understand,”  because in most cases nobody truly knows what somebody else is going through.
• “So what you’re saying is…”
• “From what you’re saying, I can see how you would be…”
• “You must be …”
• Give ample time for the interview – you may need more time than you think.
• Record the interviews so you can always go back and listen – in case you missed something in your notes.
• Don’t take things personally. Sometimes sources may be going through interpersonal responses to trauma and may not be showing you signs in the interview of interaction – don’t take this personally, it may be the way they are dealing with the situation.

Don’t bottle up your feelings. Don’t forget that covering a traumatic event can impact you, too. Be sure to find ways to talk about the experience with your friends, family, adviser or editor. They may have covered something similar and/or can just be a listening ear. You should not keep your emotions bottled up; sharing your experience is one way of coping with witnessing and reporting on such a difficult event.

Send me your questions, ideas, solutions and tips. I’ll try to help as much as I can in a future column. Contact me at [email protected] or on Twitter at barbara_allen_

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Reflections on Death in Philosophical/Existential Context

• Symposium: Reflections Before, During, and Beyond COVID-19
• Published: 27 July 2020
• Volume 57 , pages 402–409, ( 2020 )

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• Nikos Kokosalakis 1  

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Is death larger than life and does it annihilate life altogether? This is the basic question discussed in this essay, within a philosophical/existential context. The central argument is that the concept of death is problematic and, following Levinas, the author holds that death cannot lead to nothingness. This accords with the teaching of all religious traditions, which hold that there is life beyond death, and Plato’s and Aristotle’s theories about the immortality of the soul. In modernity, since the Enlightenment, God and religion have been placed in the margin or rejected in rational discourse. Consequently, the anthropocentric promethean view of man has been stressed and the reality of the limits placed on humans by death deemphasised or ignored. Yet, death remains at the centre of nature and human life, and its reality and threat become evident in the spread of a single virus. So, death always remains a mystery, relating to life and morality.

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What a piece of work is a man! how noble in reason! how infinite in faculty! In form and moving, how express and admirable! In action, how like an angel! in apprehension, how like a god! the beauty of the world! the paragon of animals! And yet, to me, what is this quintessence of dust? William Shakespeare ( 1890 : 132), Hamlet, Act 2, scene 2, 303–312.

In mid-2019, the death of Sophia Kokosalakis, my niece and Goddaughter, at the age of 46, came like a thunderbolt to strike the whole family. She was a world-famous fashion designer who combined, in a unique way, the beauty and superb aesthetics of ancient and classical Greek sculptures and paintings with fashion production of clothes and jewellery. She took the aesthetics and values of ancient and classical Greek civilization out of the museums to the contemporary art of fashion design. A few months earlier she was full of life, beautiful, active, sociable and altruistic, and highly creative. All that was swept away quickly by an aggressive murderous cancer. The funeral ( κηδεία ) – a magnificent ritual event in the church of Panaghia Eleftherotria in Politeia Athens – accorded with the highly significant moving symbolism of the rite of the Orthodox Church. Her parents, her husband with their 7-year-old daughter, the wider family, relatives and friends, and hundreds of people were present, as well as eminent representatives of the arts. The Greek Prime Minister and other dignitaries sent wreaths and messages of condolences, and flowers were sent from around the world. After the burial in the family grave in the cemetery of Chalandri, some gathered for a memorial meal. This was a high profile, emotional final goodbye to a beloved famous person for her last irreversible Journey.

Sophia’s death was circumscribed by social and religious rituals that help to chart a path through the transition from life to death. Yet, the pain and sorrow for Sophia’s family has been very deep. For her parents, especially, it has been indescribable, indeed, unbearable. The existential reality of death is something different. It raises philosophical questions about what death really means in a human existential context. How do humans cope with it? What light do religious explanations of death shed on the existential experience of death and what do philosophical traditions have to say on this matter?

In broad terms religions see human life as larger than death, so that life’s substance meaning and values for each person are not exhausted with biological termination. Life goes on. For most religions and cultures there is some notion of immortality of the soul and there is highly significant ritual and symbolism for the dead, in all cultures, that relates to their memory and offers some notion of life beyond the grave. In Christianity, for example, life beyond death and the eternity and salvation of the soul constitutes the core of its teaching, immediately related to the incarnation, death, and resurrection of Christ. Theologically, Christ’s death and resurrection, declare the defeat of death by the death and the resurrection of the son of God, who was, both, God and perfectly human (theanthropos). This teaching signifies the triumph of life over death, which also means, eschatologically, the salvation and liberation of humankind from evil and the injustice and imperfection of the world. It refers to another dimension beyond the human condition, a paradisiac state beyond the time/space configuration, a state of immortality, eternity and infinity; it points to the sublimation of nature itself. So, according to Christian faith, the death of a human being is a painful boundary of transition, and there is hope that human life is not perishable at death. There is a paradox here that through death one enters real life in union with God. But this is not knowledge. It is faith and must be understood theologically and eschatologically.

While the deeply faithful, may accept and understand death as passage to their union with God, Sophia’s death shows that, for ordinary people, the fear of death and the desperation caused by the permanent absence of a beloved person is hard to bear – even with the help of strong religious faith. For those with lukewarm religious faith or no faith at all, religious discourse and ritual seems irrelevant or even annoying and irrational. However, nobody escapes the reality of death. It is at the heart of nature and the human condition and it is deeply ingrained in the consciousness of adult human beings. Indeed, of all animals it is only humans who know that they will die and according to Heidegger ( 1967 :274) “death is something distinctively impending”. The fear of death, consciously or subconsciously, is instilled in humans early in life and, as the ancients said, when death is near no one wants to die. ( Ην εγγύς έλθει θάνατος ουδείς βούλεται θνήσκειν. [Aesopus Fables]). In Christianity even Christ, the son of God, prayed to his father to remove the bitter cup of death before his crucifixion (Math. 26, 38–39; Luke, 22, 41–42).

The natural sciences say nothing much about the existential content and conditions of human death beyond the biological laws of human existence and human evolution. According to these laws, all forms of life have a beginning a duration and an end. In any case, from a philosophical point of view, it is considered a category mistake, i.e. epistemologically and methodologically wrong, to apply purely naturalistic categories and quantitative experimental methods for the study, explanation and interpretation of human social phenomena, especially cultural phenomena such as the meaning of human death and religion at large. As no enlightenment on such issues emerges from the natural sciences, maybe insights can be teased out from philosophical anthropological thinking.

Philosophical anthropology is concerned with questions of human nature and life and death in deeper intellectual, philosophical, dramaturgical context. Religion and the sacred are inevitably involved in such discourse. For example, the verses from Shakespeare’s Hamlet about the nature of man, at the preamble of this essay, put the matter in a nutshell. What is this being who acts like an angel, apprehends and creates like a god, and yet, it is limited as the quintessence of dust? It is within this discourse that I seek to draw insights concerning human death. I will argue that, although in formal logical/scientific terms, we do not know and cannot know anything about life after/beyond death, there is, and always has been, a legitimate philosophical discourse about being and the dialectic of life/death. We cannot prove or disprove the existence and content of life beyond death in scientific or logical terms any more than we can prove or disprove the existence of God scientifically. Footnote 1

Such discourse inevitably takes place within the framework of transcendence, and transcendence is present within life and beyond death. Indeed, transcendence is at the core of human consciousness as humans are the only beings (species) who have culture that transcends their biological organism. Footnote 2 According to Martin ( 1980 :4) “the main issue is… man’s ability to transcend and transform his situation”. So human death can be described and understood as a cultural fact immediately related to transcendence, and as a limit to human transcendental ability and potential. But it is important, from an epistemological methodological point of view, not to preconceive this fact in reductionist positivistic or closed ideological terms. It is essential that the discourse about death takes place within an open dialectic, not excluding transcendence and God a priori, stressing the value of life, and understanding the limits of the human potential.

The Problem of Meaning in Human Death

Biologically and medically the meaning and reality of human death, as that of all animals, is clear: the cessation of all the functions and faculties of the organs of the body, especially the heart and the brain. This entails, of course, the cessation of consciousness. Yet, this definition tells us nothing about why only the human species, latecomers in the universe, have always worshiped their gods, buried their dead with elaborate ritual, and held various beliefs about immortality. Harari ( 2017 :428–439) claims that, in the not too distant future, sapiens could aim at, and is likely to achieve, immortality and the status of Homo Deus through biotechnology, information science, artificial intelligence and what he calls the data religion . I shall leave aside what I consider farfetched utopian fictional futurology and reflect a little on the problem of meaning of human death and immortality philosophically.

We are not dealing here with the complex question of biological life. This is the purview of the science of biology and biotechnology within the laws of nature. Rather, we are within the framework of human existence, consciousness and transcendence and the question of being and time in a philosophical sense. According to Heidegger ( 1967 :290) “Death, in the widest sense, is a phenomenon of life. Life must be understood as a kind of Being to which there belongs a Being-in-the-world”. He also argues (bid: 291) that: “The existential interpretation of death takes precedence over any biology and ontology of life. But it is also the foundation for any investigation of death which is biographical or historiological, ethnological or psychological”. So, the focus is sharply on the issue of life/death in the specifically human existential context of being/life/death . Human life is an (the) ultimate value, (people everywhere raise their glass to life and good health), and in the midst of it there is death as an ultimate threatening eliminating force. But is death larger than life, and can death eliminate life altogether? That’s the question. Whereas all beings from plants to animals, including man, are born live and die, in the case of human persons this cycle carries with it deep and wide meaning embodied within specific empirical, historical, cultural phenomena. In this context death, like birth and marriage, is a carrier of specific cultural significance and deeper meaning. It has always been accompanied by what anthropologists refer to as rites of passage, (Van Gennep, 1960 [1909]; Turner, 1967; Garces-Foley, 2006 ). These refer to transition events from one state of life to another. All such acts and rites, and religion generally, should be understood analysed and interpreted within the framework of symbolic language. (Kokosalakis, 2001 , 2020 ). In this sense the meaning of death is open and we get a glimpse of it through symbols.

Death, thus, is an existential tragic/dramatic phenomenon, which has preoccupied philosophy and the arts from the beginning and has been always treated as problematic. According to Heidegger ( 1967 : 295), the human being Dasein (being-there) has not explicit or even theoretical knowledge of death, hence the anxiety in the face of it. Also, Dasein has its death, “not in isolation, but as codetermined by its primordial kind of Being” (ibid: 291). He further argues that in the context of being/time/death, death is understood as being-towards-death ( Sein zum Tode ). Levinas Footnote 3 ( 2000 :8), although indebted to Heidegger, disagrees radically with him on this point because it posits being-towards death ( Sein zum Tode) “as equivalent to being in regard to nothingness”. Leaving aside that, phenomenologically the concept of nothingness itself is problematic (Sartre: 3–67), Levinas ( 2000 :8) asks: “is that which opens with death nothingness or the unknown? Can being at the point of death be reduced to the ontological dilemma of being or nothingness? That is the question that is posed here.” In other words, Levinas considers this issue problematic and wants to keep the question of being/life/death open. Logically and philosophically the concept of nothingness is absolute, definitive and closed whereas the concept of the unknown is open and problematic. In any case both concepts are ultimately based on belief, but nothingness implies knowledge which we cannot have in the context of death.

Levinas (ibid: 8–9) argues that any knowledge we have of death comes to us “second hand” and that “It is in relation with the other that we think of death in its negativity” (emphasis mine). Indeed, the ultimate objective of hate is the death of the other , the annihilation of the hated person. Also death “[is] a departure: it is a decease [deces]”. It is a permanent separation of them from us which is felt and experienced foremost and deeply for the departure of the beloved. This is because death is “A departure towards the unknown, a departure without return, a departure with no forward address”. Thus, the emotion and the sorrow associated with it and the pain and sadness caused to those remaining. Deep-down, existentially and philosophically, death is a mystery. It involves “an ambiguity that perhaps indicates another dimension of meaning than that in which death is thought within the alternative to be/not- to- be. The ambiguity: an enigma” (ibid: 14). Although, as Heidegger ( 1967 :298–311) argues, death is the only absolute certainty we have and it is the origin of certitude itself, I agree with Levinas (ibid: 10–27) that this certitude cannot be forthcoming from the experience of our own death alone, which is impossible anyway. Death entails the cessation of the consciousness of the subject and without consciousness there is no experience. We experience the process of our dying but not our own death itself. So, our experience of death is primarily that of the death of others. It is our observation of the cessation of the movement, of the life of the other .

Furthermore, Levinas (Ibid: 10–13) argues that “it is not certain that death has the meaning of annihilation” because if death is understood as annihilation in time, “Here, we are looking for other dimension of meaning, both for the meaning of time Footnote 4 and for the meaning of death”. Footnote 5 So death is a phenomenon with dimensions of meaning beyond the historical space/time configuration. Levinas dealt with such dimensions extensively not only in his God, Death and Time (2000) but also in his: Totality and Infinity (1969); Otherwise than Being, or Beyond Essence (1991); and, Of God Who comes to mind (1998). So, existentially/phenomenologically such dimensions inevitably involve the concept of transcendence, the divine, and some kind of faith. Indeed, the question of human death has always involved the question of the soul. Humans have been generally understood to be composite beings of body/soul or spirit and the latter has also been associated with transcendence and the divine. In general the body has been understood and experienced as perishable with death, whereas the soul/spirit has been understood (believed) to be indestructible. Thus beyond or surviving after/beyond death. Certainly this has been the assumption and general belief of major religions and cultures, Footnote 6 and philosophy itself, until modernity and up to the eighteenth century.

Ancient and classical Greek philosophy preoccupied itself with the question of the soul. Footnote 7 Homer, both in the Iliad and the Odyssey, has several reference on the soul in hades (the underworld) and Pythagoras of Samos (580–496 b.c.) dealt with immortality and metempsychosis (reincarnation). Footnote 8 In all the tragedies by Sophocles (496–406 b,c,), Aeschylus (523–456 b. c.), and Euripides (480–406 b.c.), death is a central theme but it was Plato Footnote 9 (428?-347 b.c.) and Aristotle Footnote 10 (384–322 b.c.) – widely acknowledged as the greatest philosophers of all times – who wrote specific treatises on the soul. Let us look at their positions very briefly.

Plato on the Soul

Plato was deeply concerned with the nature of the soul and the problem of immortality because such questions were foundational to his theory of the forms (ideas), his understanding of ethics, and his philosophy at large. So, apart from the dialogue Phaedo , in which the soul and its immortality is the central subject, he also referred to it extensively in the Republic , the Symposium and the Apology as well in the dialogues: Timaeus , Gorgias, Phaedrus, Crito, Euthyfron and Laches .

The dialogue Phaedo Footnote 11 is a discussion on the soul and immortality between Socrates (470–399 b.c.) and his interlocutors Cebes and Simias. They were Pythagorians from Thebes, who went to see Socrates in prison just before he was about to be given the hemlock (the liquid poison: means by which the death penalty was carried out at the time in Athens). Phaedo, his disciple, who was also present, is the narrator. The visitors found Socrates very serene and in pleasant mood and wondered how he did not seem to be afraid of death just before his execution. Upon this Socrates replies that it would be unreasonable to be afraid of death since he was about to join company with the Gods (of which he was certain) and, perhaps, with good and beloved departed persons. In any case, he argued, the true philosopher cannot be afraid of death as his whole life, indeed, is a practice and a preparation for it. So for this, and other philosophical reasons, death for Socrates is not to be feared. ( Phaedo; 64a–68b).

Socrates defines death as the separation of the soul from the body (64c), which he describes as prison of the former while joined in life. The body, which is material and prone to earthly materialistic pleasures, is an obstacle for the soul to pursue and acquire true knowledge, virtue, moderation and higher spiritual achievements generally (64d–66e). So, for the true philosopher, whose raison-d’être is to pursue knowledge truth and virtue, the liberation of the soul from bodily things, and death itself when it comes, is welcome because life, for him, was a training for death anyway. For these reasons, Socrates says is “glad to go to hades ” (the underworld) (68b).

Following various questions of Cebes and Simias about the soul, and its surviving death, Socrates proceeds to provide some logical philosophical arguments for its immortality. The main ones only can be mentioned here. In the so called cyclical argument, Socrates holds that the immortality of the soul follows logically from the relation of opposites (binaries) and comparatives: Big, small; good, bad; just, unjust; beautiful, ugly; good, better; bad; worse, etc. As these imply each other so life/death/life are mutually inter-connected, (70e–71d). The second main argument is that of recollection. Socrates holds that learning, in general, is recollection of things and ideas by the soul which always existed and the soul itself pre-existed before it took the human shape. (73a–77a). Socrates also advises Cebes and Simias to look into themselves, into their own psych e and their own consciousness in order to understand what makes them alive and makes them speak and move, and that is proof for the immortality of the soul (78ab). These arguments are disputed and are considered inadequate and anachronistic by many philosophers today (Steadman, 2015 ; Shagulta and Hammad, 2018 ; and others) but the importance of Phaedo lies in the theory of ideas and values and the concept of ethics imbedded in it.

Plato’s theory of forms (ideas) is the basis of philosophical idealism to the present day and also poses the question of the human autonomy and free will. Phaedo attracts the attention of modern and contemporary philosophers from Kant (1724–1804) and Hegel (1770–1831) onwards, because it poses the existential problems of life, death, the soul, consciousness, movement and causality as well as morality, which have preoccupied philosophy and the human sciences diachronically. In this dialogue a central issue is the philosophy of ethics and values at large as related to the problem of death. Aristotle, who was critical of Plato’s idealism, also uses the concept of forms and poses the question of the soul as a substantive first principle of life and movement although he does not deal with death and immortality as Plato does.

Aristotle on the Soul

Aristotle’s conception of the soul is close to contemporary biology and psychology because his whole philosophy is near to modern science. Unlike many scholars, however, who tend to be reductionist, limiting the soul to naturalistic/positivistic explanations, (as Isherwood, 2016 , for instance, does, unlike Charlier, 2018 , who finds relevance in religious and metaphysical connections), Aristotle’s treatment of it, as an essential irreducible principle of life, leaves room for its metaphysical substance and character. So his treatise on the soul , (known now to scholars as De Anima, Shields, 2016 ), is closely related to both his physics and his metaphysics.

Aristotle sees all living beings (plants, animals, humans) as composite and indivisible of body, soul or form (Charlton, 1980 ). The body is material and the soul is immaterial but none can be expressed, comprehended or perceived apart from matter ( ύλη ). Shields ( 2016 ) has described this understanding and use of the concepts of matter and form in Aristotle’s philosophy as hylomorphism [ hyle and morphe, (matter and form)]. The soul ( psyche ) is a principle, arche (αρχή) associated with cause (αιτία) and motion ( kinesis ) but it is inseparable from matter. In plants its basic function and characteristic is nutrition. In animals, in addition to nutrition it has the function and characteristic of sensing. In humans apart from nutrition and sensing, which they share with all animals, in addition it has the unique faculty of noesis and logos. ( De Anima ch. 2). Following this, Heidegger ( 1967 :47) sees humans as: “Dasein, man’s Being is ‘defined’ as the ζωον λόγον έχον – as that living thing whose Being is essentially determined by the potentiality for discourse”. (So, only human beings talk, other beings do not and cannot).

In Chapter Five, Aristotle concentrates on this unique property of the human soul, the logos or nous, known in English as mind . The nous (mind) is both: passive and active. The former, the passive mind, although necessary for noesis and knowledge, is perishable and mortal (φθαρτός). The latter, the poetic mind is higher, it is a principle of causality and creativity, it is energy, aitia . So this, the poetic the creative mind is higher. It is the most important property of the soul and it is immaterial, immortal and eternal. Here Aristotle considers the poetic mind as separate from organic life, as substance entering the human body from outside, as it were. Noetic mind is the divine property in humans and expresses itself in their pursuit to imitate the prime mover, God that is.

So, Aristotle arrives here at the problem of immortality of the soul by another root than Plato but, unlike him, he does not elaborate on the metaphysics of this question beyond the properties of the poetic mind and he focuses on life in the world. King ( 2001 :214) argues that Aristotle is not so much concerned to establish the immortality of the human individual as that of the human species as an eidos. Here, however, I would like to stress that we should not confuse Aristotle’s understanding with contemporary biological theories about the dominance and survival of the human species. But whatever the case may be, both Aristotle’s and Plato’s treatises on the soul continue to be inspiring sources of debate by philosophers and others on these issues to the present day.

Death in Modernity

By modernity here is meant the general changes which occurred in western society and culture with the growth of science and technology and the economy, especially after the Enlightenment, and the French and the Industrial Revolutions, which have their cultural roots in the Renaissance, the Reformation and Protestantism.

It is banal to say that life beyond death does not preoccupy people in modernity as it did before and that, perhaps, now most people do not believe in the immortality of the soul. In what Charles Taylor ( 2007 ) has extensively described as A SECULAR AGE he frames the question of change in religious beliefs in the west as follows: “why was it virtually impossible not to believe in God in, say, 1500 in our western society, while in 2000 many of us find this not only easy, but even inescapable?” (p. 25). The answer to this question is loaded with controversy and is given variously by different scholars. Footnote 13 Taylor (ibid: 65–75, 720–726) shows how and why beliefs have changed radically in modernity. Metaphysical transcendent beliefs on life and death have shrunk into this-worldly secular conceptions in what he calls, “the immanent frame”. As a consequence, transcendence and the sacred were exiled from the world or reduced to “closed world structures”. Footnote 14 In this context many scholars spoke of “the death of God” (ibid: 564–575).

In criticizing postmodern relativism, which brings various vague conceptions of God and transcendence back in play, Gellner ( 1992 :80–83) praises what he calls Enlightenment Rationalist fundamentalism, which “at one fell swoop eliminates the sacred from the world”. Although he acknowledges that Kant, the deepest thinker of the Enlightenment, left morality reason and knowledge outside the purview of the laws of nature, thus leaving the question of transcendence open, he still claims that Enlightenment rationalism is the only positive scientific way to study religious phenomena and death rituals. This position seems to be epistemologically flawed, because it pre-empts what concerns us here, namely, the assumptions of modernity for the nature of man and its implications for the meaning and reality of death.

In rejecting religion and traditional conceptions of death, Enlightenment rationalism put forward an overoptimistic, promethean view of man. What Vereker ( 1967 ) described as the “God of Reason” was the foundation of eighteenth century optimism. The idea was that enlightened rationalism, based on the benevolent orderly laws of nature, would bring about the redeemed society. Enlightened, rational leaders and the gradual disappearance of traditional religious beliefs, obscurantism and superstitions, which were sustained by the ancient regime, would eventually transform society and would abolish all human evil and social and political injustice. Science was supportive of this view because it showed that natural and social phenomena, traditionally attributed to divine agencies and metaphysical forces, have a clear natural causation. These ideas, developed by European philosophers (Voltaire 1694–1778; Rousseau, 1712–1778; Kant, 1724–1804; Hume, 1711–1776; and many others), were foundational to social and political reform, and the basis of the French Revolution (1789–1799). However, the underlying optimism of such philosophical ideas about the benevolence of nature appeared incompatible with natural phenomena such as the great earthquake in Lisbon in 1755, which flattened the city and killed over 100,000 people. Enlightenment rationalism overemphasised a promethean, anthropocentric view of man without God, and ignored the limits of man and the moral and existential significance of death.

In his critique of capitalism, in the nineteenth century, Marx (1818–1883), promoted further the promethean view of man by elevating him as the author of his destiny and banishing God and religion as “the opium of the people”. In his O rigin of the Species (1859), Charles Darwin also showed man’s biological connections with primates, thereby challenging biblical texts about the specific divine origin of the human species. He confirmed human dominance in nature. Important figures in literature, however, such as Dostoevsky (1821–1881) and Tolstoy (1828–1910), pointed out and criticised the conceit and arrogance of an inflated humanism without God, promoted by the promethean man of modernity.

By the end of the twentieth century the triumph of science, biotechnology, information technology, and international capitalist monetary economics, all of them consequences of modernity, had turned the planet into a global village with improved living standards for the majority. Medical science also has doubled average life expectancy from what it was in nineteenth century and information technology has made, almost every adult, owner of a mobile smart phone. Moreover, visiting the moon has inflated man’s sense of mastery over nature, and all these achievements, although embodying Taylor’s ( 1992 ) malaise of modernity at the expense of the environment, have strengthen the promethean view and, somehow, ignored human limits. As a consequence, the reality of death was treated as a kind of taboo, tucked under the carpet.

This seems a paradox because, apart from the normal death of individuals, massive collective deaths, caused by nature and by hate and barbarity from man to man, were present in the twentieth century more than any other in history. The pandemic of Spanish flue 1917–1919 killed 39 million of the world’s population according to estimates by Baro et al. (2020). In the First World War deaths, military and civilians combined, were estimated at 20.5 million (Wikipedia). In the Second World War an estimated total of 70–85 million people perished, (Wikipedia). This did not include estimates of more than seven million people who died in the gulags of Siberia and elsewhere under Stalin. But Auschwitz is indicative of the unlimited limits, which human barbarity and cruelty of man to man, can reach. Bauman ( 1989 :x), an eminent sociologist, saw the Holocaust as a moral horror related to modernity and wrote: “ The Holocaust was born and executed in modern rational society, at the high stage of our civilization and at the peak of human cultural achievement, and for this reason it is a problem of that society, civilization and culture. ”

Questions associated with the mass death are now magnified by the spread of the coronavirus (Covid-19). This has caused global panic and created unpredictability at all levels of society and culture. This sudden global threat of death makes it timely to re-examine our values, our beliefs (secular or religious), and the meaning of life. Max Weber (1948: 182), who died a hundred years ago in the pandemic of great influenza, was sceptical and pessimistic about modernity, and argued that it was leading to a cage with “ specialists without spirit, sensualists without heart; this nullity imagines that it had attained a level of civilization never before achieved. ”

So, what does this examination of philosophical anthropology illuminate in terms of questions of human nature and life and death in deeper intellectual, philosophical, dramaturgical context? Now, we are well into the twenty-first century, and with the revolution in information science, the internet, biotechnology and data religion , the promethean view of man seems to have reached new heights. Yet, massive death, by a single virus this time, threatens again humanity; are there any lessons to be learned? Will this threat, apart from the negativity of death, bring back the wisdom, which T. S. Elliot said we have lost in modern times? Will it show us our limits? Will it reduce our conceit and arrogance? Will it make us more humble, moderate, prudent, and more humane for this and future generations, and for the sake of life in this planet at large? These are the questions arising now amongst many circles, and it is likely that old religious and philosophical ideas about virtuous life and the hope of immortality (eschatologically) may revive again as we are well within late modernity (I do not like the term postmodernity, which has been widely used in sociology since the 1980s).

The central argument of this essay has been that death has always been and remains at the centre of life. Philosophically and existentially the meaning of death is problematic, and the natural sciences cannot produce knowledge on this problem. Religious traditions always beheld the immortality of the soul and so argued great philosophers like Plato and Aristotle. Modernity, since the Enlightenment, rejected such views as anachronistic and advanced an anthropocentric promethean, view of man, at the expense of the sacred and transcendence at large. Instead, within what Taylor (1967: 537–193) has described as the immanent frame, it developed “closed world structures,” which are at the expense of human nature and human freedom. One consequence of this has been massive death during the twentieth century.

Following Levinas ( 2000 ), I argued that death should not be understood to lead to nothingness because nothingness means certitude and positive knowledge, which we cannot have existentially in the case of death. In this sense the reality of death should not be understood to lead to annihilation of life and remains a mystery. Moreover, the presence and the reality of death as a limit and a boundary should serve as educative lesson for both the autonomy and creativity of man and against an overinflated promethean view of her/his nature.

David Martin ( 1980 :16) puts the matter about human and divine autonomy as follows: “Indeed, it is all too easy to phrase the problem so that the autonomy of God and the autonomy of man are rival claimants for what science leaves over”. This concurs with his, ( 1978 :12), understanding of religion, (which I share), as “acceptance of a level of reality beyond the observable world known to science, to which we ascribe meanings and purposes completing and transcending those of the purely human realm”.

We do not know how and when human beings acquired this capacity during the evolutionary process of the species. It characterises however a radical shift from nature to culture as the latter is defined by Clifford Geertz (1973:68): “an ordered system of meanings and symbols …in terms of which individuals define their world, express their feelings and make their judgements”.

For a comprehensive extensive and impressive account and discussion of Levinas’ philosophy and work, and relevant bibliography, see Bergo ( 2019 ).

Perhaps it is worth mentioning here that the meaning of the concept of time, as it was in Cartesian Philosophy and Newtonian physics, has changed radically with Einstein’s theories of relativity and contemporary quantum physics (Heisenberg 1959 ). Heisenberg’s uncertainty principle (Hilgervood and Uffink, 2016 ) is very relevant to non- deterministic conceptions of time/space and scientific and philosophical discourse generally.

Various religions articulate the structure of these meanings in different cultural contexts symbolically and all of them involve the divine and an eschatological metaphysical dimension beyond history, beyond our experience of time and space.

Ancient Egyptian culture is well known for its preoccupation with life after death, the immortality of the soul and the elaborate ritual involved in the mummification of the Pharaohs. See: anen.wikipedia.org/wiki/Ancient_ Egyptian_ funerary_ practices). Also the findings of archaeological excavations of tombs of kings in all ancient cultures constitute invaluable sources of knowledge not only about the meaning of death and the beliefs and rituals associated with it in these cultures but also of life and religion and politics and society at large.

For an extensive account of general theories of the soul in Greek antiquity see: Lorenz ( 2009 ).

For a good account on Pythagoras’ views on the transmigration of the souls see: Huffman ( 2018 ).

For a recent good account on the diachronic importance of Plato’s philosophy see: Kraut ( 2017 ).

For a very extensive analytical account and discussion of Aristotle’s philosophy and work with recent bibliography see: Shields ( 2016 ).

For an overview of Phaedo in English with commentary and the original Greek text see: Steadman ( 2015 ).

See, for instance, Wilson ( 1969 ) and Martin ( 1978 ) for radically different analyses and interpretations of secularization.

Marxism is a good example. God, the sacred and tradition generally are rejected but the proletariat and the Party acquire a sacred significance. The notion of salvation is enclosed as potentiality within history in a closed system of the class struggle. This, however, has direct political consequences because, along with the sacred, democracy is exiled and turned into a totalitarian system. The same is true, of course, at the other end of the spectrum with fascism.

Further Reading

Baro, R. Ursua, J, Weng, J. 2020. Coronovirus meets the great influenza pandemic. https://voxeu.otg/article/coronovirus-meets-great-influenza-pandemic .

Bauman, Z. 1989. Modernity and the Holocaust . Cambridge: Polity Press

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Charlier, P. 2018. The notion of soul and its implications on medical biology. Ethics, medicine and public health June 2018, pp. 125–127. https://doi.org/10.1016/j.jemep.2018.05.005 .

Charlton, W, 1980, Aristotle’s definition of the soul. Phonesis, vol. 25, no. 2, pp. 170–186.

Garsey-Foley, K. 2006. Death and Religion in a Changing World . MC Sharpe.

Geertz, C. 1993. The Interpretation of Cultures . London: Hutchinson.

Gellner, E. 1992 . Postmodernism Reason and Religion. London and New York: Routledge.

Harari, N. Y, 2017. Homo Deus: A Short History of Tomorrow . London: Vintage.

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Heidegger, M. 1967. Being and Time. Oxford: Basil Blackwell.

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Hilgervoord, J, and Uffing, J. 2016. The Uncertainty Principle. Stanford Encyclopaedia of Philosophy (Winter 2018 edition) Edward Zalta (ed.) https://plato.stanford.edu/archives/win2016/entries/qt-uncertainty

Huffman, C. 2018. Pythagoras. Stanford Encyclopedia of Philosophy (winter 2018 edition) Edward Zalta (ed.). https://plato.stanford.edu/entries/pythagoras/ .

Isherwood, D. 2016. Science at last explains our soul: exploring the human condition with clues from science. https://www.zmescience.com/science/science-explains-our-soul/ .

King, R. 2001. Aristotle on Life and Death. London: Duckworth.

Kokosalakis, N. 2001. Symbolism (religious)) and Icon. International Encyclopedia of Social and Behavioural Science . Amsterdam: Elsevier.

Kokosalakis, N. 2020. Symbolism and Power in David Martin’s Sociology of Religion. Society. vol. 57, pp. 173–179. https://doi.org/10.1007/s12115-020-00462-x .

Kraut, R. 2017. Plato. The Stanford Encyclopaedia of Philosophy (Fall 2017 edition) Edward N. Zaltman (ed.) https://plato.stanford.edu/archives/fall2017/entries/plato/ .

Levinas, E. 1969. Totality and Infinity: An Essay on Exteriority . (Trans. A. Lingis). Pittsburgh: Duquesne University Press.

Levinas, E, 1991 . Otherwise than Being or Beyond Essence . (trans. A. Lingis). Dordrecht: Kluwer Academic.

Levinas, E. 1998. Of God Who Comes to Mind . (trans, Betina Bergo). Stanford CA: Stanford University Press.

Levinas, E. 2000. God, Death and Time . (tr. Betina Bergo) Stanford Calif: Stanford University Press.

Lorenz, H. 2009. Ancient Theories of the Soul. The Stanford Encyclopaedia of Philosophy . (Summer 2009 edition), Edward N. Zalta (ed.) https://plato.stanford.edu/archives/sum2009/entries/ancient-soul/ . Accessed 22 Apr 2009.

Martin, D. 1978. A General Theory of Secularization . Oxford: Basil Blackwell.

Martin, D. 1980. The Breaking of the Image. Oxford: Basil Blackwell

Sartre, Jean-Paul. 1969. Being and Nothingness: An Essay on Phenomenological Ontology. London: Methuen.

Shagufta, B. and M. Hamad. 2018. Concept of immortality in Platos’s Phaedo. Al-Hikmat , Vol. 36, pp. 1–12.

Shakespeare, W. 1890, Charles Knight (ed.) The Works of William Shakespeare. London: Routledge. Vol V, p. 132.

Shields, C. 2015. De Anima. (tr. with an introduction and commentary). Oxford: Oxford University Press.

Shields, C. 2016. Aristotle. The Stanford Encyclopaedia of Philosophy (winter 2016 edition) Edward N. Zalta (ed.). https://plato.stanford.edu/entries/aristotle/ . Accessed 29 Jul 2015.

Steadman, G. 2015. Plato’s Phaedo , 1 edition. https://geoffreysteadman.files.wordpress.com.....PDF. Accessed 15 Jun 2015.

Taylor, C. 1992. The Malaise of Modernity . Cambridge MA: Harvard University Press.

Taylor, C. 2007. A Secular Age . Cambridge MA Harvard University Press.

Turner, V. 1969. The Ritual Process. London; Penguin.

Van Gennep, A. 1960 [1909]. The Rites of Passage . (tr. From the French),

Vereker, C. 1967. Eighteenth Century Optimism. Liverpool: Liverpool University Press.

Weber, Max, 1968. The Protestant Ethic and the Spirit of Capitalism . London: Unwin University Books (9nth Impression).

Wilson, B. 1969. Religion in Secular Society. London: Penguin Books.

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Kokosalakis, N. Reflections on Death in Philosophical/Existential Context. Soc 57 , 402–409 (2020). https://doi.org/10.1007/s12115-020-00503-5

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Published : 27 July 2020

Issue Date : August 2020

DOI : https://doi.org/10.1007/s12115-020-00503-5

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In a short paper—even a research paper—you don’t need to provide an exhaustive summary as part of your conclusion. But you do need to make some kind of transition between your final body paragraph and your concluding paragraph. This may come in the form of a few sentences of summary. Or it may come in the form of a sentence that brings your readers back to your thesis or main idea and reminds your readers where you began and how far you have traveled.

So, for example, in a paper about the relationship between ADHD and rejection sensitivity, Vanessa Roser begins by introducing readers to the fact that researchers have studied the relationship between the two conditions and then provides her explanation of that relationship. Here’s her thesis: “While socialization may indeed be an important factor in RS, I argue that individuals with ADHD may also possess a neurological predisposition to RS that is exacerbated by the differing executive and emotional regulation characteristic of ADHD.”

In her final paragraph, Roser reminds us of where she started by echoing her thesis: “This literature demonstrates that, as with many other conditions, ADHD and RS share a delicately intertwined pattern of neurological similarities that is rooted in the innate biology of an individual’s mind, a connection that cannot be explained in full by the behavioral mediation hypothesis.”  

Highlight the “so what”  

At the beginning of your paper, you explain to your readers what’s at stake—why they should care about the argument you’re making. In your conclusion, you can bring readers back to those stakes by reminding them why your argument is important in the first place. You can also draft a few sentences that put those stakes into a new or broader context.

In the conclusion to her paper about ADHD and RS, Roser echoes the stakes she established in her introduction—that research into connections between ADHD and RS has led to contradictory results, raising questions about the “behavioral mediation hypothesis.”

She writes, “as with many other conditions, ADHD and RS share a delicately intertwined pattern of neurological similarities that is rooted in the innate biology of an individual’s mind, a connection that cannot be explained in full by the behavioral mediation hypothesis.”  

Leave your readers with the “now what”  

After the “what” and the “so what,” you should leave your reader with some final thoughts. If you have written a strong introduction, your readers will know why you have been arguing what you have been arguing—and why they should care. And if you’ve made a good case for your thesis, then your readers should be in a position to see things in a new way, understand new questions, or be ready for something that they weren’t ready for before they read your paper.

In her conclusion, Roser offers two “now what” statements. First, she explains that it is important to recognize that the flawed behavioral mediation hypothesis “seems to place a degree of fault on the individual. It implies that individuals with ADHD must have elicited such frequent or intense rejection by virtue of their inadequate social skills, erasing the possibility that they may simply possess a natural sensitivity to emotion.” She then highlights the broader implications for treatment of people with ADHD, noting that recognizing the actual connection between rejection sensitivity and ADHD “has profound implications for understanding how individuals with ADHD might best be treated in educational settings, by counselors, family, peers, or even society as a whole.”

To find your own “now what” for your essay’s conclusion, try asking yourself these questions:

• What can my readers now understand, see in a new light, or grapple with that they would not have understood in the same way before reading my paper? Are we a step closer to understanding a larger phenomenon or to understanding why what was at stake is so important?  
• What questions can I now raise that would not have made sense at the beginning of my paper? Questions for further research? Other ways that this topic could be approached?  
• Are there other applications for my research? Could my questions be asked about different data in a different context? Could I use my methods to answer a different question?  
• What action should be taken in light of this argument? What action do I predict will be taken or could lead to a solution?  
• What larger context might my argument be a part of?  

What to avoid in your conclusion  

• a complete restatement of all that you have said in your paper.  
• a substantial counterargument that you do not have space to refute; you should introduce counterarguments before your conclusion.  
• an apology for what you have not said. If you need to explain the scope of your paper, you should do this sooner—but don’t apologize for what you have not discussed in your paper.  
• fake transitions like “in conclusion” that are followed by sentences that aren’t actually conclusions. (“In conclusion, I have now demonstrated that my thesis is correct.”)
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Final thoughts

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How death shapes life

As global COVID toll hits 5 million, Harvard philosopher ponders the intimate, universal experience of knowing the end will come but not knowing when

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Does the understanding that our final breath could come tomorrow affect the way we choose to live? And how do we make sense of a life cut short by a random accident, or a collective existence in which the loss of 5 million lives to a pandemic often seems eclipsed by other headlines? For answers, the Gazette turned to Susanna Siegel, Harvard’s Edgar Pierce Professor of Philosophy. Interview has been edited for length and clarity.

Susanna Siegel

GAZETTE: How do we get through the day with death all around us?

SIEGEL: This question arises because we can be made to feel uneasy, distracted, or derailed by death in any form: mass death, or the prospect of our own; deaths of people unknown to us that we only hear or read about; or deaths of people who tear the fabric of our lives when they go. Both in politics and in everyday life, one of the worst things we could do is get used to death, treat it as unremarkable or as anything other than a loss. This fact has profound consequences for every facet of life: politics and governance, interpersonal relationships, and all forms of human consciousness.

When things go well, death stays in the background, and from there, covertly, it shapes our awareness of everything else. Even when we get through the day with ease, the prospect of death is still in some way all around us.

GAZETTE:   Can philosophy help illuminate how death impacts consciousness?

SIEGEL: The philosophers Soren Kierkegaard and Martin Heidegger each discuss death, in their own ways, as a horizon that implicitly shapes our consciousness. It’s what gives future times the pressure they exert on us. A horizon is the kind of thing that is normally in the background — something that limits, partly defines, and sets the stage for what you focus on. These two philosophers help us see the ways that death occupies the background of consciousness — and that the background is where it belongs.

“Both in politics and in everyday life, one of the worst things we could do is get used to death, treat it as unremarkable or as anything other than a loss,” says Susanna Siegel, Harvard’s Edgar Pierce Professor of Philosophy.

Stephanie Mitchell/Harvard Staff Photographer

These philosophical insights are vivid in Rainer Marie Rilke’s short and stunning poem “Der Tod” (“Death”). As Burton Pike translates it from German, the poem begins: “There stands death, a bluish concoction/in a cup without a saucer.” This opening gets me every time. Death is standing. It’s standing in the way liquid stands still in a container. Sometimes cooking instructions tell you to boil a mixture and then let it stand, while you complete another part of the recipe. That’s the way death is in the poem: standing, waiting for you to get farther along with whatever you are doing. It will be there while you’re working, it will be there when you’re done, and in some way, it is a background part of those other tasks.

A few lines later, it’s suggested in the poem that someone long ago, “at a distant breakfast,” saw a dusty, cracked cup — that cup with the bluish concoction standing in it — and this person read the word “hope” written in faded letters on the side of mug. Hope is a future-directed feeling, and in the poem, the word is written on a surface that contains death underneath. As it stands, death shapes the horizon of life.

GAZETTE: What are the ethical consequences of these philosophical views?

SIEGEL: We’re familiar with the ways that making the prospect of death salient can unnerve, paralyze, or derail a person. An extreme example is shown by people with Cotard syndrome , who report feeling that they have already died. It is considered a “monothematic” delusion, because this odd reaction is circumscribed by the sufferers’ other beliefs. They freely acknowledge how strange it is to be both dead and yet still there to report on it. They are typically deeply depressed, burdened with a feeling that all possibilities of action have simply been shut down, closed off, made unavailable. Robbed of a feeling of futurity, seemingly without affordances for action, it feels natural to people in this state to describe it as the state of being already dead.

Cotard syndrome is an extreme case that illustrates how bringing death into the foreground of consciousness can feel utterly disempowering. This observation has political consequences, which are evident in a culture that treats any kind of lethal violence as something we have to expect and plan for. A glaring example would be gun violence, with its lockdown drills for children, its steady stream of the same types of events, over and over — as if these deaths could only be met with a shrug and a sigh, because they are simply part of the cost of other people exercising their freedom.

It isn’t just depressing to bring death into the foreground of consciousness by creating an atmosphere of violence — it’s also dangerous. Any political arrangement that lets masses of people die thematizes death, by making lethal violence perceptible, frequent, salient, talked-about, and tolerated. Raising death to salience in this way can create and then leverage feelings of existential precarity, which in turn emotionally equip people on a mass, nationwide scale to tolerate violence as a tool to gain political power. It’s now a regular occurrence to ram into protestors with vehicles, intimidate voters and poll workers, and prepare to attack government buildings and the people inside. This atmosphere disparages life, and then promises violence as defense against such cheapening, and a means of control.

GAZETTE: When we read about an accidental death in the newspaper, it can be truly unnerving, even though the victim is a stranger. And we’ve been hearing about a steady stream of deaths from COVID-19 for almost two years, to the point where the death count is just part of the daily news. Why is the process of thinking about these losses important?

SIEGEL: It might not seem directly related to politics, but when you react to a life cut short by thinking, “If this terrible thing could happen to them, then it could happen to me,” that reaction is a basic form of civic regard. It’s fragile, and highly sensitive to how deaths are reported and rendered in public. The passing moment of concern may seem insignificant, but it gets supplanted by something much worse when deaths are rendered in ways likely to prompt such questions as “What did they do to get in trouble?” or such suspicions as “They probably had it coming,” or such callous resignations as “They were going to die anyway.” We have seen some of those reactions during the pandemic. They are refusals to recognize the terribleness of death.

Deaths can seem even more haunting when they’re not recognized as a real loss, which is why it’s so important how deaths are depicted by governments and in mass communication. The genre of the obituary is there to present deaths as a loss to the public. The movement for Black lives brought into focus for everyone what many people knew and felt all along, which was that when deaths are not rendered as losses to the public, then they are depicted in a way that erodes civic regard.

When anyone dies from COVID, our political representatives should acknowledge it in a way that does justice to the gravity of that death. Recognizing COVID deaths as a public emergency belongs to the kind of governance that aims to keep the blue concoction where it belongs.

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There is one thing I can be sure of: I am going to die. But what am I to make of that fact? This course will examine a number of issues that arise once we begin to reflect on our mortality. The possibility that death may not actually be the end is considered. Are we, in some sense, immortal? Would immortality be desirable? Also a clearer notion of what it is to die is examined. What does it mean to say that a person has died? What kind of fact is that? And, finally, different attitudes to death are evaluated. Is death an evil? How? Why? Is suicide morally permissible? Is it rational? How should the knowledge that I am going to die affect the way I live my life?

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For more information about Professor Kagan’s book Death , click here .

Plato, Phaedo John Perry, A Dialogue on Personal Identity and Immortality Leo Tolstoy, The Death of Ivan Ilych

Course Packet: Barnes, Julian. “The Dream.” In History of the World in 10 ½ Chapters .

Brandt, Richard. “The Morality and Rationality of Suicide.” In Moral Problems . Edited by James Rachels. New York: Harper & Row, 1979.

Edwards, Paul. “Existentialism and Death: A Survey of Some Confusions and Absurdities.” In Philosophy, Science and Method: Essays in Honor of Ernest Nagel . Edited by Sidney Morgenbesser, Patrick Suppes and Morton White. New York: St. Matrin’s Press, 1969. pp. 473-505

Feldman, Fred. “The Enigma of Death.” In Confrontations with the Reaper: A Philosophical Study of Nature and Value of Death . Oxford: Oxford University Press, 1992. pp. 56-71

Hume, David. “On Suicide.” In Essays: Moral, Political, and Literary .

Kaufmann, Walter. “Death.” In The Faith of a Heretic . New York: New American Library, 1959. pp. 353-376

Kaufmann, Walter. “Death Without Dread.” In Existentialism, Religion, and Death: Thirteen Essays . New York: New American Library, 1976. pp. 224-248

Martin, Robert. “The Identity of Animal and People.” In There are Two Errors in the the Title of This Book: A Sourcebook of Philosophical Puzzles, Problems, and Paradoxes . Peterborough, Ontario: Broadview Press, 2002. pp. 223-226

Montaigne, Michel de. “That to Philosophize is to Learn to Die.” In The Complete Essays .

Nagel, Thomas. “Death.” In Mortal Questions . New York: Cambridge University Press, 1979. pp. 1-10

Rosenberg, Jay. “Life After Death: In Search of the Question.” In Thinking Clearly About Death . Englewood Cliffs: Prentice-Hall, 1983. pp. 18-22

Schick, Theodore and Lewis Vaughn. “Near-Death Experiences.” In How to Think About Weird Things . New York: McGraw Hill, 2005. pp 307-323

Swift, Jonathan. Gulliver’s Travels , Part III, chapter 10.

Williams, Bernard. “The Makropulos Case: Reflections on the Tedium of Immortality.” In Language, Metaphysics, and Death . Edited by John Donnelly. New York: Fordham University Press, 1978. pp. 229-242

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Home > Blog > How To Conclude an Essay: Examples and Tips

How To Conclude an Essay: Examples and Tips

• Smodin Editorial Team
• Published: August 12, 2024
• Step-by-Step Instructions for Writing

Every piece of writing, especially essays, benefits greatly from a well-crafted conclusion. It’s not just about signaling the end of your essay; it’s about providing a satisfying closure that reinforces your argument.

Concluding an essay is a crucial part of writing. It’s your last chance to make an impression on your reader. An effective conclusion paragraph should tie your ideas together and remind readers of your main point. It’s also a good idea to try and leave them with something to think about.

Keep reading if you want to find out how to conclude an essay for college or school, along with some tips on how to structure your conclusion and what to avoid.

How To Conclude an Essay: 3 Factors To Consider

A conclusion paragraph serves several important purposes in an essay. It’s the final section that ties everything together, reinforcing the main points of your essay.

Let’s break down the key purposes a conclusion serves to help you improve your essay-writing skills when it comes to your closing argument.

1. Summarize the Thesis and Main Points

One of the primary functions of a conclusion is to restate the thesis and summarize the main points of your essay. This doesn’t mean you should simply repeat what has already been said. Instead, you should synthesize the information, bringing it all together to reinforce your main argument. This ensures that the reader is reminded of the core message of your essay.

Example: If your essay discusses the impact of climate change on marine life, your conclusion should restate the various points you’ve made. Think of points such as rising ocean temperatures, acidification, and pollution.

2. Show the Broader Implications

Beyond just summarizing, a strong conclusion should highlight the broader implications of your argument. This means discussing the significance of your findings and how they relate to a larger context. By doing this, you help readers understand why your essay matters in the bigger picture. Additionally, you inform how it contributes to the ongoing conversation about the topic.

Example: In an essay about social media’s impact on youth, the broader implications might include considerations for parents, educators, and policymakers. This step helps your reader see the importance of your argument beyond the scope of your essay.

3. Leave a Lasting Impression

Finally, your conclusion is essentially your last word, so it should aim to leave a lasting impression on the reader. This can be achieved through a thought-provoking statement or a poignant quote that resonates with your main points. The goal is to ensure that your readers walk away with a thoughtful reflection on your essay. It can be useful to conclude your essay on a positive note.

Example: In an essay advocating for renewable energy, you might end with a call to action urging readers to support sustainable practices. This wraps up your essay and motivates your readers to think and act on the information you’ve presented.

How To Conclude a College Essay

When you are writing a college essay, you must follow a similar outline to the one we mentioned above. You must ensure that your conclusion is clear and you are not repeating information word for word. Moreover, you must sound articulate and present your thoughts logically.

Depending on the type of essay, you can offer your own opinion as well based on what you have written. Do not forget to have a good flow in your writing to ensure your readers understand your closing statements, even your last sentence, well.

Keep reading, as below we go into more detail into how to conclude a college essay and generally all essays for that matter.

How To Conclude an Essay: Example

Take a look at our top tips for how to conclude an essay through our example below.

Example of Restating a Thesis

“In conclusion, reading offers numerous benefits, from enhancing cognitive abilities to reducing stress.”

This restatement of the thesis encapsulates the core argument of the essay, reminding the reader of the fundamental points discussed.

Example of Reviewing the Main Points

“By improving focus, expanding knowledge, and fostering empathy, reading is a powerful tool for personal growth.”

This brief summary reiterates the key points made in the essay, highlighting how reading contributes to individual development. It synthesizes the main arguments, showing how each benefit connects to the overall thesis.

Example of Showing the Broader Implications

“Encouraging a culture of reading can lead to more informed, empathetic, and engaged communities.”

This final statement underscores the larger significance of promoting reading. It suggests that the benefits of reading extend beyond the individual, potentially transforming society by fostering greater understanding and civic engagement.

By combining these elements, the conclusion reinforces the essay’s main points and emphasizes the broader impact of the argument. This will leave the reader with a compelling reason to value and promote reading.

Now that we have looked into a “how to conclude an essay” example, let’s take a look at some general writing tips when wanting to write a solid conclusion.

Writing Tips for a Strong Conclusion

Take a look at our top three tips for writing a good conclusion that will leave a lasting impression:

• Keep it concise: A few sentences should be enough to wrap up your essay without introducing new ideas. Conciseness helps maintain the reader’s attention and reinforces the clarity of your argument.
• Use simple language: Clear, straightforward language can have a powerful impact on a conclusion. Avoid complex vocabulary or jargon that might confuse the reader at this critical point.
• Avoid clichés: Phrases like “in conclusion” or “to sum up” are unnecessary and can weaken your writing. Instead, aim for a natural transition that seamlessly leads into your concluding thoughts.

Common Mistakes Made When Writing a Conclusion

If you write a good essay at school, this can increase your chances of getting into college by 10 times . Hence, it is essential not to make mistakes. However, many writers fall into the same mistakes when writing a conclusion for an essay. Here are some points to avoid when writing your next conclusion.

1. Introducing New Arguments

Your conclusion should wrap up your essay, not present new points or evidence. Introducing new arguments can confuse the reader and dilute the impact of your original thesis. The purpose of a conclusion is to provide closure and synthesis. Do not introduce fresh information that hasn’t been discussed in the body of the essay.

Any new points should have been addressed earlier in your writing. Keeping your conclusion focused ensures that your reader leaves with a clear understanding of your argument.

2. Repeating the Introduction

While it’s good to revisit your thesis, avoid repeating your introduction verbatim. Instead, rephrase and expand on it to reflect the development of your ideas. Your conclusion should show how your thoughts and arguments have evolved throughout the essay. This demonstrates growth and provides a more nuanced understanding of your thesis.

By avoiding repetition, you keep your writing engaging and your argument compelling, ensuring that your conclusion adds value rather than redundancy.

3. Using Apologetic Language

Don’t undermine your argument by suggesting there might be better approaches. Confidence in your conclusion reinforces the strength of your overall essay. Using apologetic language can make your argument seem weak or uncertain.

Stand by your points and present them with assurance. A strong, confident conclusion leaves a lasting impression on your reader and validates the effort and thought you put into your writing. Avoid phrases that might suggest hesitation or doubt, and instead, affirm the importance and validity of your conclusions.

Frequently Asked Questions

How long should a conclusion be.

A conclusion should be concise, typically around five to seven sentences, depending on the length of your essay. This length allows you to effectively summarize and reflect without dragging on.

Can I introduce new information in the conclusion?

No, introducing new information can confuse your reader. The conclusion should only summarize and reflect on what has already been discussed. Introducing new ideas at this stage can undermine the clarity of your essay.

How can I make my essay conclusion more impactful?

End with a strong, closing sentence that leaves your reader thinking about your argument and its implications. Consider using a quotation, rhetorical question, or call to action to leave a lasting impression.

Perfect Your Conclusion With Smodin.io

By following the steps and tips in our guide, you can master the art of writing a conclusion that ties your essay together. A strong conclusion wraps up your essay effectively and reinforces your thesis statement. Remember, your conclusion is your final opportunity to influence your reader, so make it count. Summarize your key points succinctly, highlight the broader implications of your argument, and end with a thought-provoking statement.

Ready to perfect your essay conclusion? Enhance your writing skills with Smodin’s AI writing tool. Create compelling essays effortlessly at Smodin.io and take your writing to the next level. Smodin’s intuitive platform provides guidance on structuring your conclusion, ensuring that each essay you write ends on a high note.

Try Smodin.io now to improve your conclusion-writing skills and gain confidence in your ability to leave a lasting impression.

Confronting the Reality of Death and Dying

Part ii: ways to make the end of life a bit easier on you and your loved ones..

Posted June 29, 2021 | Reviewed by Chloe Williams

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• When facing the end of life or the loss of a loved one, the first step is to recognize one's own feelings about death.
• Taking the time to grieve is also important, as is connecting with and communicating with others. Isolation can make things more difficult.
• Finding meaning in what is happening and taking care of oneself by getting enough sleep and maintaining a reasonable diet can also help.

In my last post , I talked about the death of my close friend David and the way he and his family and I confronted and dealt with his death. If you review that post, you will see that there are a number of things that you and those closest to you can do to make the ending easier. The first step in all of this is to recognize your own feelings about death. Avoiding our feelings does not work in our best interest or the interest of those around us. Being honest about our fears and anxieties is important.

We need to connect with and communicate with others. Isolating and going it alone usually only makes things more difficult for all concerned. Talk about how you feel. Express your feelings. Crying is a good thing and something that we should do in the grieving process. Take time to grieve. If we don't, we will usually later regret it.

I remember a young man I worked with a number of years ago who lost his mother suddenly. He threw himself into work and other activities to distract himself and never really grieved the loss. Six months later, he was feeling very depressed and wondered why. There were a number of factors, but the main one was that he had never really taken the time or the focus to grieve the loss of his mother, someone he loved dearly.

And don't engage in denial or wishful thinking. This is not helpful to you if you are the person who is going to die or to those around you. Honesty, in general, is the best policy. Being honest is one of the ways that you can take care of yourself and those around you.

Taking care of others is also a way of taking care of yourself. But be sure to take care of yourself in other ways. Caregivers often neglect their own health. They don't get enough sleep or maintain a reasonable diet . If you're going to be there for others, you have to be there for yourself first. Not doing this is one of the reasons that caregivers sometimes die before the person they are providing care for.

Try to find meaning and purpose in what is happening. As I mentioned with David, one of the benefits, if you want to call it that, of his death was that it brought his family back together. Seek support from others and from the people and things you value. David and his family found this through their religious faith.

Be willing to use humor in a positive way. As I mentioned in my previous post, my friend Bill and I enjoyed some of the last times we had together with David reminiscing about the things we had done and remembering the stories that David used to love to tell. Things don't always work out the way you think they will. Sometimes this is tragic and sometimes it is humorous. If you recall the movie Little Big Man, when the old chief goes out to lie down and die, it begins to rain. His friend tells him, "Well Chief, this is not a good day to die." The old chief then decides he will postpone his demise to another day.

The last thing I would say is to take care of your affairs and do some planning. Don't put off doing a living will or legal will. Taking care of these things in advance will be very helpful to those around you.

I hope the things that I've reviewed in this post will be helpful to you since all of us will confront at some point the death of someone close to us that we care deeply about. And we will all certainly at some point confront our own death.

Ron Breazeale, Ph.D. , is the author of Duct Tape Isn’t Enough: Survival Skills for the 21st Century as well as the novel Reaching Home .

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Seven Keys to a Good Death

Some years ago, I helped tend to a friend of mine who was dying of cancer. Near the end of his life, he had reached a place of equanimity around dying.

But instead of honoring his wishes for a peaceful death, his doctors ordered aggressive chemotherapy treatment, which did nothing to halt his cancer. The treatments caused him immense suffering, rendering him unable to sleep, eat, or converse with family and friends as he was dying.

Unfortunately, deaths like my friend’s are not that rare. Though more than 70 percent of Americans surveyed say they want to die in their own home without unnecessary procedures to extend their lives, 50 percent of all deaths occurs in facilities away from home. Of those, 40 percent occur in ICU’s, where physicians are charged with doing everything they can to keep a person alive, regardless of the outcome.

Sometimes, the quest to avoid death can seem extreme, like in the much-publicized cases of Terry Shiavo and Marlise Munoz, where unnecessary life-extending procedures created exorbitant medical bills and emotionally burdened their loved ones.

But, if Shiavo and Munoz are examples of a bad death, is there any better way? Is a “good death” just an oxymoron? Or can the experience of death be far more positive—an opportunity for growth and meaning?

Listening to the dying

These are questions that I first began to consider when I was a young psychologist at the oncology unit at UCSF in the mid-1970’s. At that time, I was the first and only mental health worker on the staff on a 40-bed unit. Modern palliative care was not widely understood or employed yet, and hospice care was not as readily accessible as it is now. My job was to help these patients with whatever emerged psychologically around their deaths.

And, there was a lot going on psychologically which wasn’t being attended to. The physicians and nurses in our unit were talented, skilled, well-intentioned people. But they focused on staving off death at all costs.  Their training gave no guidance on how to provide their patients with the conditions for a good death—one that allowed patients to come to terms with their life and find peace and wellbeing at the end.

Since then, I’ve worked with hundreds of dying people. To help combat the lack of trained support staff, I founded Shanti —a peer counseling program that provides compassionate, trained listeners to help patients and their families through serious illness and the transition of dying. Shanti volunteers have supported many people facing death to do so with grace through their presence and compassion.

What I’ve learned through my experience is that what people most need on their deathbed is to be heard—to have their wishes considered and, whenever possible, fulfilled. But even with Shanti’s success, and the proliferation of palliative care programs and hospices around the nation, there are still many dying Americans who don’t get that chance. Here are seven ways to help create the conditions for a good death.

How to die well

1. experience as little pain as possible..

When I talk of being pain-free, I mean physically, psycho-socially, and spiritually pain-free. Nowadays, there are medications that can manage most people’s physical pain and make them far more comfortable, and these should not be denied to any patient. Spiritual pain can occur, too. In fact, I have sat with several clergy who had crises of faith on their deathbeds. Sometimes, easing spiritual pain can be accomplished by the presence of a person of faith or readings from sacred texts; other times, it’s better to have someone who can engage in spiritual questioning. Either way, spiritual issues are common at the end of life, and they need attention.

2. Recognize and resolve interpersonal conflicts.

We must also recognize psycho-social pain, the residue of life’s unresolved conflicts with other people. There are almost always interpersonal issues within families, and sometimes between close friends, when one is dying—people who’ve become estranged, “I love you”’s that were never expressed, and more. Ira Byock, a palliative care doctor, wrote in his book, The Four Things That Matter Most , that there are four basic messages a person needs to communicate at the end of life:

I love you. Thank you. I forgive you. Please forgive me.

These, I think, are a good start. A good death creates a space for people to say those words.

3. Satisfy any remaining wishes that are consistent with their present condition.

Some people want to live long enough to go to a grandson’s graduation, to see a book published, to see a cousin they were close to who lives 3000 miles away. But, be careful that these are the wishes of the patient and not just the patient’s significant others. There’s a difference between a good death and an appropriated death—one that’s stolen from the dying person by other forces, including the agenda of close family members.

4. Review their life to find meaning.

There are two main ways that people on their deathbeds find meaning: in the recognition of all of the people they have loved and who have loved them, and in the work that they’ve done that has contributed to the greater good. In some cases, contributory work will be obvious; in others, it may be less so. But, helping the dying to articulate what brought meaning to their lives will help them feel more at peace with their death.

5. Hand over control to a trusted person, someone committed to helping them have the kind of death they desire.

The whole issue of deathbed conversations—asking a person what he needs or wants—is very important. What does the dying person want? How can they get that? Is it reasonable? Sometimes it’s not reasonable: A friend’s dying mother wanted help in ending her own life; well, that wasn’t going to happen. Sometimes you can have the conversation without acting on it, and any conflicts or issues can be addressed.

6. Be protected from needless procedures that serve to only dehumanize and demean without much or any benefit.

Emergency rooms, ICU’s, and 911 are set up to preserve life and are not typically supportive of the conditions for a good death. If a person is suffering tremendously, there may be cause to get emergency help; but for most situations, when you throw a person into the larger healthcare system, the prevention of death becomes the imperative, and that can serve to increase suffering for the dying person. One has to be very persistent and clear to avoid procedures that are unwanted—to insist on palliative or hospice care, instead. It can help to have an advanced directive or a “physician-orders for life sustaining treatment” in writing and communicated to loved ones; but often a person also needs a vocal advocate—a family member, friend, or volunteer caregiver.

7. Decide how social and how alert they want to be.

Sometimes a dying person wants solitude; sometimes they want friends and family around. Whatever the case, the dying person should decide. And, though trickier, dying people should be allowed to decide how much consciousness they want. Some people want to sleep all of the time; others want to be alert as much as possible. Once these wishes are known, an advocate can help make that happen.

A good death is possible

People who are dying should be treated as living human beings. They will have good and bad days. The important thing for caregivers is to be mindfully present . The poet John Milton wrote, “They also serve who only stand and wait.” We are so addicted to action that it may feel like we’re doing nothing if we just sit by someone’s deathbed. But it’s often very important to bear witness and listen or hold a hand.

The potential for growth through dying is definitely there. It doesn’t mean it will automatically happen, though. Death can bring out our goodness—our capacity to transcend, love, and grow—or it can bring out our capacity to hate, create enemies, and deteriorate psychologically. To help promote the former, we should create sacred spaces for those who are dying so that they can benefit most from the experience. If we know the conditions for a good death, we are more apt to prepare ourselves and the ones we love to die with dignity and the sense of a life well-lived, rather than treating death as a calamity requiring a trip to the hospital.

A good death is no oxymoron. It’s within everyone’s realm of possibility. We need only realize its potential and prepare ourselves to meet it mindfully, with compassion and courage.

About the Author

Charles garfield.

Dr. Charles Garfield serves as Clinical Professor of Psychology in the Department of Psychiatry at the University of California School of Medicine at San Francisco (UCSF). A Fellow of the American Psychological Association, he is currently a Visiting Scholar at the Graduate Theological Union in Berkeley. He has been recognized internationally as the founder of Shanti, which has been at the forefront of a growing national movement to enhance the quality of life for persons living with life-threatening or chronic illnesses by providing volunteer-based emotional and practical support. His ten books include Sometimes My Heart Goes Numb: Love and Caregiving in a Time of AIDS and Stress and Survival: The Emotional Realities of Life Threatening Illness . He is a member of the Greater Good Science Center's editorial board.

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How Americans' refusal to talk about death hurts the elderly

by Sarah Kliff

In my family, we don't really talk about death. But, every now and then, we joke about it.

For some reason, there is a running joke among my immediate family about how my parents will die. Specifically, my brother and I will come home for Thanksgiving one year and find them decomposing on the couch.

Yes, this is a bizarre thing to crack jokes about. But it's also, in its own, ghoulish way, a bit of a fantasy — an affront to the way that Americans tend to die in the 21st century, with ticking machines and tubes and round-the-clock care. In this joke, my parents' death is a simple, quiet, and uncomplicated death at home.

I joke about death because I am as terrified of having serious end-of-life conversations as the next person. Usually I don't have to think much about dying: my job as a health-care reporter means writing about the massive part of our country devoted to saving lives — how the hospitals, doctors, and drugs that consume 18 percent of our economy all work together, every day, to patch up millions of bodies.

More on dying

9 lessons Atul Gawande taught me about dying

The art of dying well

The science of human decay: inside the world's largest body farm

But recently, the most interesting stories in health care have been about death: the situations where all the hospitals, doctors, and drugs in the world cannot halt the inevitable.

In September, Ezekiel Emanuel — an oncologist, bioethicist, and health-policy expert — wrote a powerful essay for The Atlantic about why he will no longer seek medical treatment after he's 75. "Living too long is also a loss. It renders many of us, if not disabled, then faltering and declining, a state that may not be worse than death but is nonetheless deprived," he wrote. At 75, Emanuel says, he will become a conscientious objector to the health-care system's life-extending work. "I will need a good reason to even visit the doctor and take any medical test or treatment, no matter how routine and painless. And that good reason is not 'It will prolong your life.' I will stop getting any regular preventive tests, screenings, or interventions. I will accept only palliative — not curative — treatments if I am suffering pain or other disability."

The following month, Atul Gawande, a surgeon, published his new book, Being Mortal: Medicine and What Matters In the End . He argues that his profession has done wonders for the living, but is failing the dying. "Scientific advances have turned the processes of aging and dying into medical experiences," he writes. "And we in the medical world have proved alarmingly unprepared for it."

After months of watching this debate unfold, I've realized something that feels, to me at least, like a revelation. This conversation isn't about death at all. "Death" is the word that confuses the conversation, that makes people too afraid, and too angry, and too frantic to keep talking. This conversation is really about autonomy. It is about what makes life worth living, and if, in keeping people alive for so long, we are consigning them to a fate worse than death.

When death came quick and fast, there was no fight to remain autonomous. Two graphs near the beginning of Gawande's book help make clear how recently this tension developed. There is this first graph, which shows what life used to be like a century ago: moving along, steadily, until some horrific event happened. Maybe it was a disease, maybe it was a car accident (or, even earlier, a horse and buggy accident). Whatever the event, death happened quickly.

(Metropolitan Books)

Modern medicine has done incredible things. A woman born in the United States in 1885 had an average life expectancy of just over 44 years. I was born in 1985 and, thanks to advances in technology and sanitation, my life expectancy is 82. But these improvements have also changed, and extended, how we die. "The curve of life becomes a long, slow fade," Gawande writes.

That slow, long fade means we get to live longer, but often at the cost of our autonomy, and, in the view of some, at the cost of our most essential self. Autonomy — the freedom to see the people we want, partake in the activities we enjoy, and wake up each morning to our own agenda — is a value that arguably all of us hold dear. Even as physical independence disappears, it is possible (albeit more challenging) for autonomy to remain and for the elderly to retain control of how they spend their days.

But aging makes the facilities, both mental and physical, that we need to maintain our autonomy, weaker. The activities we enjoy and the ones we find core to our identity become more difficult to pursue.

As we get older, we lose the mastery we once had over the world around us, the admiration we once inspired in those we loved. Simple tasks — driving to a family member's home, grocery shopping, preparing meals — become harder. The things we want to do aren't always things we can still decide to do. Emanuel writes about the plight of his father, who had a heart attack followed with a bypass surgery at age 77. It was more difficult to do the things that defined his existence:

Once the prototype of a hyperactive Emanuel, suddenly his walking, his talking, his humor got slower. Today he can swim, read the newspaper, needle his kids on the phone, and still live with my mother in their own house. But everything seems sluggish. Although he didn’t die from the heart attack, no one would say he is living a vibrant life.

Emanuel doesn't see this as unique to his father. He thinks this is the norm — that we have fooled ourselves into believing we have prolonged life, when instead we have prolonged the process of death. He writes that half of people 80 and older have functional limitations, and a third of people 85 and older have Alzheimer’s. And as for the remainder, they, too, slow and stumble, in mind as well as body.

"Even if we aren’t demented, our mental functioning deteriorates as we grow older," he says. "Age-associated declines in mental-processing speed, working and long-term memory, and problem-solving are well established. Conversely, distractibility increases. We cannot focus and stay with a project as well as we could when we were young. As we move slower with age, we also think slower." We become necessarily capable of making the decisions that we used to. Our bodies and brains simply won't allow it. This isn't to say autonomy disappears, but that it takes more support and conscious effort to plan.

Emanuel's argument is fundamentally pessimistic about the future that we all face: it suggests that, even as we learn more about extending life, we won't be able to improve the quality of life that precedes death.

Gawande's book acknowledges that the body will break down, too. The second chapter, "Things Fall Apart," is devoted to the ways that our body — from the color in our hair to the joints of our thumbs — diminishes at the end of life.

There are sections from this chapter that haunt my nights. The brain shrinks an astonishing amount in the course of a normal lifetime, with the frontal sections that control memory and planning diminishing the fastest. "At the age of 30, the brain is a three-pound organ that barely fits inside the skull," Gawande writes. "By our seventies, gray-matter loss leaves almost an inch of spare room." This explains, by the way, why falls can be so damaging for the elderly: their brain has a spare inch of space to get jostled around.

"Living too long is also a loss," he writes. "It renders many of us, if not disabled, then faltering and declining, a state that may not be worse than death but is nonetheless deprived."

Most of us look at nursing homes — with their scheduled meals, constant supervision, adult diapers, wheelchair-bound residents, and depressing bingo nights and we think: I do not want that. I do not want to give up control over my own life, my ability to see the people I want to see and do the things I want to do. I do not want to live a life where I can't dress myself, where I'm not allowed to feed myself, where I'm barred from living any semblance of the life that I live right now.

( Shutterstock )

As Gawande points out, assisted living and nursing facilities sometimes rob residents of the autonomy they'd have elsewhere. A patient who is bedridden, for example, likely ends up eating on a schedule to fit into the nurse's rounds — not whenever they feel like having a snack. Getting dressed can be handed over to staff because they can do it more efficiently.

"Unless supporting people’s capabilities is made a priority, the staff ends up dressing people like they’re rag dolls," he writes. "Gradually, that’s how everything begins to go. The tasks come to matter more than the people."

But somehow, millions of Americans end up with life: there are 1.5 million nursing-home residents in America right now. On average, those nursing-home residents live in these facilities for two years, three months, and 15 days.

Here, however, Gawande identifies an unexpected culprit: the young, not the old.

At one point in the book, Gawande speaks with Keren Wilson, the woman who opened the country's first assisted-living facility. And she gave him one of those quotes that every reporter dreams of — a single sentence where, after hearing it, you can't ever look at the issue in the same way again. "We want autonomy for ourselves and safety for those we love," she says.

One reason that nursing homes are so soulless is that it's often not the residents who made the decision about where they would live. Instead, it's their caretakers — often adult children — who chose the home, and their end-of-life priorities are frequently different from their parents'. Namely, where their parents value autonomy, children value safety. Wilson continues:

Many of the things that we want for those we care about are the things that we would adamantly oppose for ourselves because they would infringe upon our sense of self. It's the rare child who is able to think, "Is this place what Mom would want or like or need?" It's more like they're seeing it through their own lens. The child asks, "Is this a place I would be comfortable leaving Mom?"

Gawande argues that what's wrong with how we die now is that the patient — the person facing the end of life — is not the decision-maker. The locus of power shifted away from the people who will actually experience living in a nursing home and into the hands of their full-grown children, who often pay much of the bill.

Gawande and Wilson don't argue that children are acting maliciously, trying to thwart the life that their parents wish to lead. It's just that grown children and their elderly parents often have conflicting views of what matters at the end of life. Children often want every precaution taken to prevent injuries and falls. The elderly often want to live as autonomous a life as they can, even if it entails more risk. There's one 89-year-old woman Gawande talks to who makes this point especially clearly, echoing what the dozens of other elderly interviewees told him:

"I want to be helpful, play a role," she said. She used to make her own jewelry, volunteer at the library. Now, her main activities were bingo, DVD movies, and other forms of passive group entertainment. The things she missed most, she told me, were her friendships, privacy, and a purpose to her days ... it seems we’ve succumbed to a belief that, once you lose your physical independence, a life of worth and freedom is simply not possible.

One of the more depressing anecdotes in Gawande's book details how food has become a battleground in nursing homes; the "Hundred Years War," as he describes it. The battles — with a diabetic who hoards cookies, the Alzheimer patient who wants to eat at non-standard meal times — exemplify the tensions between safety and autonomy that pervade the modern nursing-home experience.

"We make these choices all the time in our home and taking those away from people takes away really fundamental things about who they are, what makes a life worth living," Gawande told me in an interview. "The biggest complaints about patients in nursing homes — by the way you can get a report filed against you in a nursing home — are about violating food rules. So you'll see Alzheimer's patients hoarding cookies. Give them the damn cookie. They might choke on it, but what are we trying to keep them alive for? Let's allow some risk, even in the Alzheimer's patient."

Section 1233 begins on page 425 of the House's final draft of the Affordable Care Act . It's a relatively tiny portion of the law, taking up nine of the bill's 1,017 pages. It didn't have much of anything to do with Obamacare's main goals of expanding coverage or reducing health-care costs.

But Section 1233 became the most politically toxic section of a law rife with contested projects and programs. Section 1233 is where Sarah Palin initially found the so-called "death panels" that would be among the most memorable, and ugly, skirmishes in the Obamacare debate.

Patients, Palin wrote in an August 2009 Facebook post coining the term, "will have to stand in front of Obama's 'death panel' so his bureaucrats can decide ... whether they are worthy of health care." When asked where she found these death panels in the law, Palin's spokesperson pointed to Section 1233.

But Section 1233 did nothing of the sort (PolitiFact ultimately named "death panels" its lie of the year in 2009 ). The provision simply allowed Medicare to reimburse doctors when they provided patients an explanation of "the continuum of end-of-life services ... including palliative care and hospice." This wasn't a death panel. It was an end-of-life care consultation — a conversation where a doctor would tell a patient about his or her options. They could discuss important issues like would the patient prefer to die in the hospital or at home? If there is no treatment left, would they consider hospice care? What are the things they value at the end of life and how can those be achieved? The doctor would not make the decisions for the patient — the patient and family would make up their own minds about how to proceed.

The "death panel" rhetoric quickly became a popular cudgel conservatives used to bash the law. The Independent Payment Advisory Board , for instance, which would have unilateral power to cut Medicare reimbursement rates, became a "death panel." (The board, meanwhile, has no power to change the type of benefits Medicare provides or which patients get them — it only has authority over what Medicare pays).

The 2009 Sarah Palin Facebook post that coined the term "death panel" ( Facebook )

Death panels signs and slogans popped up at town-hall protests across the country; news stories mentioned the term 6,000 times in August and September , Politifact later found. By October, it still came up at least 150 times per week — and Section 1233 was doomed. Legislators saw the backlash and quickly relented. They left the end-of-life planning provision on the cutting-room floor.

The explosive death-panel debate, touched off by the smallest, weakest attempt to talk about the inevitable, shows just how impossible it is for America and the people we send to Washington to have this particular discussion.

Dying in America is expensive. The six percent of Medicare patients who die each year typically account for 27 to 30 percent of the program's annual health-care spending. During the last six months of life, the Dartmouth Atlas has found that the average Medicare patient spends 9.9 days in the hospital and 3.9 days in intensive care. Forty-two percent see 10 or more doctors.

In Washington, something so costly typically forces constant conversations about cutbacks and trade-offs and balancing priorities. But with end-of-life care, the opposite tends to be true: we can't talk about the cost of dying because it sounds like a discussion about rationing. Taking cost into account feels callous and inappropriate in the context of death.

But that's left, in its place, not a thoughtful approach towards end-of-life care, but a dumb default that pushes everyone — doctors, patients, and families — toward more tests, surgeries, and treatments, no matter the cost in pain and disability to the patient.

The fear at the heart of the death-panel debate was a fear about the loss of autonomy: that a group of anonymous bureaucrats would make the decisions that ought to be reserved for the terminally ill.

That's a terrible system. No Democrat, Republican, nor any health-policy expert I've talked to sees that as the right approach for America.

But they also point out that our haphazard approach to death isn't especially good at respecting the rights of the dying, either. We don't like to think about death — and so we don't. The death-panel debate affirmed that legislating end-of-life issues is terrible politics, so politicians simply avoid it. The result isn't a more compassionate policy, but a vacuum of policy.

The dearth of debate and discussion doesn't eliminate the difficult, heart-wrenching decisions that patients, doctors, and their families must make at the end of life. It arguably exacerbates them: not paying doctors to discuss end-of-life issues with Medicare patients, for example, likely means they know less about what patients want at the end of life. By the time the issue simply can't be ignored, it's often too late — the patient is already incapacitated or too delirious to articulate his or her priorities.

Much like nursing homes get to decide who eats what, and when, unarticulated end-of-life decisions get outsourced to family members and doctors who make their best guess at what a loved one would have wanted. Patients, in a way, end up living the exact scenario that the death-panel rhetoric made so fearsome: giving over decisions about their last moments of life to another party.

There's a beautiful story that Gawande tells in his book, about a man named Jack Block. At 74, he had to decide whether to undergo a surgery to remove a mass growing on his neck. The procedure ran a 20 percent chance of paralyzing him from the neck down — but without it, the growth would definitely leave him unable to move his legs or arms.

This is the moment, Gawande argues, that there has to be a discussion about what makes life worth living. Gawande interviews his daughter, Susan, who is a palliative-care specialist. And even though this is her line of work, she tells him that the conversation about this surgery was "really uncomfortable:"

We had this quite agonizing conversation where he said — and this totally shocked me — ‘Well, if I’m able to eat chocolate ice cream and watch football on TV, then I’m willing to stay alive. I’m willing to go through a lot of pain if I have a shot at that.’

Susan says this wasn't the answer she expected; she didn't even remember her father watching football. But just hearing what mattered — knowing what Jack would consider a life worth living — ended up guiding all further decisions. When Susan's father developed spinal bleeding, she asked the surgeons: will he be able to watch football and eat ice cream? The answer was yes. They kept going with treatment, until the answer was no.

"Few people have these conversations, and there is good reason for anyone to dread them," Gawande writes. "They can unleash difficult emotions. People can become angry or overwhelmed. Handled poorly, the conversations can cost a person’s trust. Handled well, they can take real time."

But these conversations could be the starting point for a health-care system that cares just as well for patients who will heal as those who will not. They're the place where autonomy gets defined for each patient: whether a life worth living means one where they are able to see friends, or drive their car, or eat chocolate ice cream, or the millions of other things they may hold dear. Those conversations don't happen now. And as long as that's the case, all of our autonomy, as we inevitably grow old and become more dependent, is at risk.

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Knowing how doctors die can change end-of-life discussions.

Stephanie O'Neill

Nora Zamichow says if she and her husband, Mark Saylor, had known how doctors die, they might have made different treatment decisions for him toward the end of his life. Maya Sugarman/KPCC hide caption

Nora Zamichow says if she and her husband, Mark Saylor, had known how doctors die, they might have made different treatment decisions for him toward the end of his life.

Dr. Kendra Fleagle Gorlitsky recalls the anguish she felt performing CPR on elderly, terminally ill patients.

It looks nothing like what we see on TV. In real life, ribs often break and few survive the ordeal.

"I felt like I was beating up people at the end of their life," she says. "I would be doing the CPR with tears coming down sometimes, and saying, 'I'm sorry, I'm sorry, goodbye.' Because I knew that it very likely not going to be successful. It just seemed a terrible way to end someone's life."

Gorlitsky now teaches medicine at the University of Southern California and says these early clinical experiences have stayed with her.

Shots - Health News

Pain and suffering at life's end are getting worse, not better.

Gorlitsky wants something different for herself and for her loved ones. And most other doctors do too: A Stanford University study shows almost 90 percent of doctors would forgo resuscitation and aggressive treatment if facing a terminal illness.

It was about 10 years ago, after a colleague had died swiftly and peacefully, that Dr. Ken Murray first noticed doctors die differently than the rest of us.

Videos On End-Of-Life Choices Ease Tough Conversation

"He had died at home, and it occurred to me that I couldn't remember any of our colleagues who had actually died in the hospital," Murray says. "That struck me as quite odd, because I know that most people do die in hospitals."

Murray then began talking about it with other doctors.

"And I said, 'Have you noticed this phenomenon?' They thought about it, and they said, 'You know? You're right.' "

In 2011, Murray, a retired family practice physician, shared his observations in an online article that quickly went viral. The essay, " How Doctors Die ," told the world that doctors are more likely to die at home with less aggressive care than most people get at the end of their lives. That's Murray's plan, too.

"I fit with the vast majority of physicians that want to have a gentle death and don't want extraordinary measures taken when they have no meaning," Murray says.

A majority of seniors report feeling the same way. Yet, they often die while hooked up to life support. And only about 1 in 10 doctors report having conversations with their patients about death.

A family portrait of Nora Zamichow, husband Mark Saylor and their daughter, Zia Saylor. Maya Sugarman/KPCC hide caption

A family portrait of Nora Zamichow, husband Mark Saylor and their daughter, Zia Saylor.

One reason for the disconnect, says Dr. Babak Goldman , is that too few doctors are trained to talk about death with patients. "We're trained to prolong life," he says.

Goldman is a palliative care specialist at Providence Saint Joseph's Medical Center in Burbank, Calif., and he says that having the tough talk may feel like a doctor is letting a family down. "I think it's sometimes easier to give hope than to give reality," Goldman says.

Goldman, now 35, read Murray's essay as part of his residency. He says that he, too, would prefer to die without heroic measures, and he believes that knowing how doctors die is important information for patients.

"If they know that this is what we'd want for ourselves and for our own families, that goes a long way," he says.

In addition, Medicare does not pay doctors for end-of-life planning meetings with patients.

Hello, May I Help You Plan Your Final Months?

Nora Zamichow wishes she had read Murray's essay sooner. The Los Angeles-based freelance writer says she and her husband, Mark Saylor, likely would have made different treatment decisions about his brain tumor if they had.

Zamichow says that an arduous regimen of chemo and radiation left her 58-year-old husband unable to walk, and ultimately bedridden in his final weeks. "And at no point did any doctor say to us, 'You know, what about not treating?' "

Zamichow realized after reading Murray's essay that doing less might have offered her husband more peace in his final days.

"What Ken's article spelled out for me was, 'Wait a minute, you know, we did not get the full range of options,' " she says.

But knowing how much medical intervention at the end of life is most appropriate for a particular person requires wide-ranging conversations about death .

Murray says he hopes his essay will spur more physicians to initiate these difficult discussions with patients and families facing end-of-life choices.

This story is part of a reporting partnership with NPR, KPCC and Kaiser Health News .

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Euthanasia and assisted dying: the illusion of autonomy—an essay by Ole Hartling

Read our coverage of the assisted dying debate.

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• Danish Council of Ethics, Denmark
• hartling{at}dadlnet.dk

As a medical doctor I have, with some worry, followed the assisted dying debate that regularly hits headlines in many parts of the world. The main arguments for legalisation are respecting self-determination and alleviating suffering. Since those arguments appear self-evident, my book Euthanasia and the Ethics of a Doctor’s Decisions—An Argument Against Assisted Dying 1 aimed to contribute to the international debate on this matter.

I found it worthwhile to look into the arguments for legalisation more closely, with the hope of sowing a little doubt in the minds of those who exhibit absolute certainty in the matter. This essay focuses on one point: the concept of “autonomy.”

(While there are several definitions of voluntary, involuntary, and non-voluntary euthanasia as well as assisted dying, assisted suicide, and physician assisted suicide, for the purposes of brevity in this essay, I use “assisted dying” throughout.)

Currently, in richer countries, arguments for legalising assisted dying frequently refer to the right to self-determination—or autonomy and free will. Our ability to self-determine seems to be unlimited and our right to it inviolable. The public’s response to opinion poll questions on voluntary euthanasia show that people can scarcely imagine not being able to make up their own minds, nor can they imagine not having the choice. Moreover, a healthy person answering a poll may have difficulty imagining being in a predicament where they simply would not wish to be given the choice.

I question whether self-determination is genuinely possible when choosing your own death. In my book, I explain that the choice will always be made in the context of a non-autonomous assessment of your quality of life—that is, an assessment outside your control. 1

All essential decisions that we make are made in relation to other people. Our decisions are affected by other people, and …

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Approaching Death: Improving Care at the End of Life (1997)

Chapter: 10 conclusions and recommendations, 10 conclusions and recommendations.

Our lives are time travel, moving in one direction only. We accompany one another as long as we can; as long as time grants us.

Joyce Carol Oates, A Letter to My Mother , 1996

We go toward something that is not yet.

Paul Tillich, The Eternal Now , 1959

Dying is at once a fact of life and a profound mystery. Death comes to all, yet each person experiences it in ways that are only partly accessible to the family member or physician, the researcher or philosopher. In principle, humane and skillful care for the dying is a social obligation as well as a personal offering from those directly involved. In reality, both society and individuals fall short of what is reasonably, if not simply, achievable.

Evidence and experience both indicate that much dying is far harder than it should be. Like the mythic king Tantalus, who reached for fruit and water just beyond his grasp, the dying person has too often been destined to seek but not find a pain-free and peaceful death. Such a fate need not be; better deaths are possible now.

This is not to claim that dying and death can be made easy, although certain illnesses tend to bring less-difficult deaths than others; nor is it to suggest that caring well for those approaching death can be made an exact science or flawless art. Caring well involves a frequently stressful, imperfect effort to balance science with sentiment, honesty with hope, patterns of care with room for exceptions.

This report has identified ways in which clinicians, educators, and communities do not care adequately for those approaching death. It has pointed to steps that can improve care at the end of life and sustain improvements through difficult times. It has also highlighted the reasons for believing that professionals, policymakers, and the public are ready to support such steps. These reasons range from the examples of well-known men and women facing death with grace to the focus on deficiencies in care

stimulated by the debate over assisted suicide. In sum, the timing appears right to press for a vigorous societal commitment to improve care for the dying. Such a commitment would motivate and sustain local and national efforts to strengthen and apply the existing knowledge base, reform procedures and policies that impede good care for the dying, and stress the caring functions of health delivery systems.

Today and Tomorrow

The preceding chapters have profiled important aspects of dying in America. They have noted that three-fourths of those who die are elderly and that most people who die are covered by Medicare or other federal, state, or local programs for older, disabled, or impoverished people. Compared to earlier times, death now comes more often in old age from a chronic or progressive disease. Most deaths occur in institutions, mainly hospitals and, to a lesser extent, nursing homes. The proportion of people who die at home is, however, increasing. Only a minority of all deaths involve people cared for by formal hospice programs, and the majority of these involve cancer diagnoses. All patients can potentially benefit from good palliative care, but hospice programs as organized and financed in the United States are most applicable to those with relatively predictable prognoses.

Although specifics may vary according to the nature of a person's disease and his or her personal circumstances, care for dying people and those close to them has several broad dimensions: physical, psychological, spiritual, and practical. Each of these dimensions is intertwined in the key processes of care, which include determining and communicating diagnosis and prognosis, establishing goals and plans, and fitting palliative and other care to these goals. The way care is organized, financed, monitored, and regulated affects how these processes are carried out in different settings for different kinds of patients.

The twenty-first century will bring new realities as well as continuing problems and opportunities in care at the end of life. It will undoubtedly deliver improvements in what medical science can do to prevent and relieve distress for those approaching death, but demographic, economic, and other trends will strain systems that already find it difficult to deliver what clinical knowledge currently allows—and what compassion should grant.

The committee focused primarily on trends and expectations relevant to care for dying patients during the next 10 to 20 years. One of these expectations is that policymakers and others will need to prepare during this period for the final demographic consequences of the post-World War II baby boom. The oldest members of the baby boom generation will reach age 65 in the year 2011, and the youngest members will do so nearly 20

years later. Barring dramatic unexpected developments, older adults will constitute a larger proportion of the population than today, and the absolute numbers of dying patients will be much larger. In the face of an ever-increasing population with chronic conditions, the current system, with its emphasis on acute curative care, will fail to provide needed long-term chronic care and palliative and support services. Although health care and social service providers have a long lead time compared with the educators and communities who had to scramble to provide schooling for the baby boom generation, the difficulties that policymakers are having with Social Security and Medicare do not bode well for the nation's ability to cope with an aging population.

In addition, continuing increases in longevity will mean that the proportion of those dying past age 75 will increase. The impact on the health care system and society on larger numbers of people dying in older old age will depend in part on their health status in the years before death. The "compression of morbidity hypothesis," for which the evidence is ambiguous, posits that an increase in healthier life styles means that people will experience disabling conditions for a smaller proportion of the years before death than today. Even if this does occur, the overall impact of the larger proportion of older people and their longer life span will still pose enormous challenges for social and health care systems.

Demographic politics are likely to be complex in coming years. On the one hand, the so-called senior lobby should be strengthened by the "baby boom" cohort. The "baby boomers," throughout their childhood, youth, and early middle age, have drawn public attention to their needs and concerns. On the other hand, the burden on the smaller working-age population of supporting its elders raises the specter of a generational backlash (even though younger people could also be burdened if the social support available to their aging parents is reduced). Such a backlash could take many forms, including means-testing Social Security benefits or less sympathy for supportive services for frail elderly people, those with serious disabilities, and people who are dying.

Cultural trends add further complexity to demographic politics. Immigrants, who tend to be young and have more children than native-born Americans, have been a major source of growth in the total U.S. population (NRC, 1997). Nonhispanic Caucasians—now a majority—are a decreasing proportion of the U.S. population. Thus, the large elderly population in the first decades of the next century will be dependent on a smaller and more culturally diverse population of younger people.

As described in preceding chapters, health care in the United States is undergoing major changes. The use of hospital services has dropped significantly, and further declines are likely, particularly in those areas with continued relatively high rates of use. Hospital care will likely be less available

to dying patients, potentially including some who could benefit from such care as well as many who will do better with alternatives.

Despite indications that health care spending increases have moderated from years past, the pressure to cut health care costs does not appear to be abating. In particular, given the bleak financial picture for Medicare and the significant portion of spending accounted for by beneficiaries in their last year of life, these constraints may be manifested in some degree of age-based rationing. That is, older people could be denied services simply because of their age, without regard to their life expectancies, function, or expected benefit from care. Decreased access to advanced technologies intended to prolong life could be a highly visible issue, although it is relatively unimportant for the great majority of those dying at an advanced age.

If successful, increased efforts to shift Medicare beneficiaries into various forms of managed care will test these entities, whose enrollment now is overwhelmingly concentrated in younger, healthier age groups. Potential problem areas include payment, contracting, and utilization review mechanisms that limit access to clinicians and care teams experienced in palliative care, patient scheduling norms that limit time for careful clinician-patient communication, marketing strategies intended to discourage enrollment or encourage disenrollment by seriously ill people, drug formularies that exclude or restrict important medications, and bureaucratic hurdles that discourage people from seeking care or preclude them from receiving requested services. One characteristic of many managed care organizations is an emphasis on moving more responsibility for diagnosis and patient management to primary care clinicians, including nurse practitioners, nurses, and other nonphysicians. How well this will work for seriously ill and elderly patients is not yet clear. A major role for nurses and other health care professionals is, however, already well tested in hospice, social health maintenance organizations, and other settings that care for patients dying of advanced progressive diseases, particularly cancer, and for frail elderly people.

As well as focusing attention on competing ethical and policy values, this prospect of constrained resources underscores the need for more valid and reliable tools for assessing health status, measuring outcomes, and linking them to health interventions. Considerable progress is being made in this arena. In addition, improved computer-based information and decision support systems promise several benefits. At the level of the individual, they will help patients, families, and clinicians in making more informed decisions about care at the end of life. At the system or societal level, they will strengthen structures and processes of accountability involving health care providers, purchasers, patient/consumers, and public officials.

Moreover, advanced information and communications technologies may make health care more accessible for some who face geographic or

other barriers to care. Although the potential for practical, effective, and affordable "medicine at a distance" is more promised than proved, telemedicine could help bring palliative and other expertise and services to homes, nursing homes, and other places where they are not very available today (IOM, 1996e). People who have chronic and advanced illnesses but do not qualify for hospital inpatient care could benefit.

Findings and Recommendations

Although the committee found many problems, it also found much that was good and improving in care for those approaching death. It was impressed by the principles, aspirations, and practices being advanced by the field of palliative medicine and being implemented or attempted through interdisciplinary care teams in varied settings, including hospices, hospitals, nursing homes, and private homes. More effort is now being devoted to understanding differences in people's paths toward death and developing programs that are flexible enough to accommodate these differences. In addition to dedicated professionals, many volunteers contribute their time and energy to provide emotional and practical support to dying patients and those close to them. People from a variety of backgrounds have also joined together to direct the attention of policymakers and ordinary citizens to the need to remove barriers to good care created by laws, regulations, organizational practices, and lack of supportive community resources.

Care for the dying should also benefit from ongoing efforts to improve continuity of care, strengthen information systems, prevent health problems, and create accountability for the quality of care. The developing fields of outcomes measurement can make important contributions to the care of the dying by teaching us how to conceptualize and measure quality of life and well-being for those approaching death. Quality improvement strategies are helping to identify and remedy system problems that impede good care. The committee is encouraged by the growing interest in end-of-life issues as recently evidenced by the publication of books and articles for lay and professional audiences, the commitment of foundation resources to support research and education, and the organization of conferences, working groups, and other initiatives sponsored by professional societies and others.

Deficiencies in Care at the End of Life

Notwithstanding these positive features, the committee concluded that very serious problems remain. Indeed, in this committee's view, if physician and hospital performance in infection control were as poor as it is, for

example, in pain management, the ensuing national outcry would create an immediate demand for responses from clinicians, managers, and educators.

The committee identified four broad deficiencies in the current care of people with life-threatening and incurable illnesses. First , too many people suffer needlessly at the end of life both from errors of omission—when caregivers fail to provide palliative and supportive care known to be effective—and from errors of commission—when caregivers do what is known to be ineffective and even harmful. As reported in Chapter 3 , studies have repeatedly indicated that a significant proportion of dying patients and patients with advanced disease experience serious pain, despite research identifying a range of effective pharmacological and other options for relieving most pain. Other symptoms are less well studied, and more research on symptom prevalence and management is needed, but the information available to the committee suggested similar care problems. Deficiencies in the application of existing knowledge to prevent and manage pain and other distressing symptoms stem from an unfortunate mix of ignorance about effective pharmacological and other interventions, misplaced concern about opioid addiction, and inadequate attention to people's quality of life while dying. These problems are reinforced by care systems that are not structured to provide the clinical expertise, reliability, continuity, and emotional support needed by people approaching death. Cultural biases and fears about illness, disability, and death may also contribute to avoidance of dying patients and those close to them.

In perverse counterpoint to the problem of undertreatment, the aggressive use of ineffectual and intrusive interventions may prolong and disfigure the period of dying. Some of this care is knowingly accepted; some is provided counter to patients' wishes; much is probably provided and accepted with little knowledge or consideration of its probable benefits and burdens. Medical culture still tolerates and even rewards the misapplication of life-sustaining technologies while slighting the prevention and relief of suffering.

Second , legal, organizational, and economic obstacles conspire to obstruct reliably excellent care at the end of life. Despite some reforms, outdated and scientifically flawed drug-prescribing laws, regulations, and interpretations by state medical boards still frustrate and intimidate physicians who wish to relieve their patients' pain. Addiction to appropriately prescribed opioids is virtually nonexistent whereas their underprescription for pain is well documented. Organizational structures often interfere with the coordination and continuity of care and impede the further development and application of palliative care strategies in patient care, professional education, and research.

Financial incentives also discourage health care practitioners and providers from rearranging care so that it serves dying patients well. Tradi-

tional financing mechanisms—including arrangements based on discounted fees—provide incentives for the overuse of procedural services and the under-provision of the assessment, evaluation, management, and supportive services so important for people with serious chronic or progressive medical problems. Medicare hospice benefits have helped fill gaps for a small segment of dying patients, but many more have conditions that do not readily fit the current hospice model or requirements. Alternatives to fee-for-service financing in combination with restrictive administrative practices pose different potential hazards that are largely unstudied as they affect seriously and incurably ill people.

Third , the education and training of physicians and other health care professionals fails to provide them with the knowledge, skills, and attitudes required to care well for the dying patient. Many deficiencies in practice stem from fundamental prior failures in professional education. Despite encouraging signs of change, most clinicians-in-training experience and learn too little of the caring that helps people to live well while dying. Undergraduate, graduate, and continuing medical education do not sufficiently prepare health professionals to recognize the final phases of illnesses, construct effective strategies for care, communicate with patients and those close to them, and understand and manage their own emotional reactions to death and dying.

Fourth , current knowledge and understanding are inadequate to guide and support the consistent practice of evidence-based medicine at the end of life. In addition to existing knowledge not being well used, we still know too little about how people die; how they want to die; and how different kinds of physical, emotional, and spiritual care might better serve the dying and those close to them. Biomedical and clinical research have emphasized the development of knowledge that contributes to the prevention, detection, or cure of disease and to the prolongation of life. Research on the end stages of diseases and the physiological bases of symptoms and symptom relief has been less well supported. Epidemiological and health services research has likewise not provided a strong base for understanding the degree to which people suffer symptoms (except, perhaps, cancer pain), experience death alone rather than in the company of those who care, comprehend diagnostic and prognostic information, and achieve a dying that is reasonably consistent with their preferences, community norms, and palliative care principles. Methods development is important to define and measure outcomes other than death (including patient and family perceptions) and to monitor and improve the quality of care for those approaching death.

More generally, it seems that this nation has not yet discovered how to talk realistically but comfortably about the end of life, nor has it learned how to value the period of dying as it is now experienced by most people.

For most of human history, death came fairly quickly in childhood or at adult ages that today seem relatively young. As the twentieth century ends, most people in economically advanced countries live fairly healthy lives into older age but then experience progressive disability for some time before they die. Except what can be inferred from newspaper obituary pages, this reality is largely shunned by the news, information, and entertainment media as distasteful or uninteresting. One result is an unhelpful combination of public fear, misinformation, and oversimplification that views misery as inescapable, pain as unavoidable, and public spending as misdirected for people who are approaching death.

Recommendations and Future Directions

The committee developed seven recommendations directed at different decisionmakers and different deficiencies in care at the end of life. These recommendations and a brief explanation follow. Each applies generally to people approaching death, including those for whom death is imminent and those with serious, eventually fatal illnesses who may live for some time.

RECOMMENDATION 1: People with advanced, potentially fatal illnesses and those close to them should be able to expect and receive reliable, skillful, and supportive care . Educating people about care at the end of life is a critical responsibility of physicians, hospitals, hospices, support groups, public programs, and media. Most patients and families need information not only about diagnosis and prognosis but also about what support and what outcomes they should reasonably be able to anticipate. They should, for example, not be allowed to believe that pain is inevitable or that supportive care is incompatible with continuing efforts to diagnose and treat. They should learn—before their last few days of life—that supportive services are available from hospices and elsewhere in the community and that those involved in their care will help arrange such services. Patient and family expectations and understanding will be aided by advance care planning that considers needs and goals, identifies appropriate surrogate decisionmakers, and avoids narrow preoccupation with written directives. To these ends, health care organizations and other relevant parties should adopt policies regarding information, education, and assistance related to end-of-life decisions and services. For those who seek to build public understanding of dying as a part of life and to generate public demand for reliable and effective supportive services, one model can be found in the perspectives, spirit, and strategies that have guided efforts to promote effective prenatal care and develop mother- and family-oriented arrangements for childbirth.

RECOMMENDATION 2: Physicians, nurses, social workers, and other health professionals must commit themselves to improving care for dying patients and to using existing knowledge effectively to prevent and relieve pain and other symptoms. Most patients depend on health care professionals to prevent and manage the varying physical and psychological symptoms that accompany advanced illness. To meet their obligations to their patients, practitioners must hold themselves and their colleagues responsible for using existing knowledge and available interventions to assess, prevent, and relieve physical and emotional distress. Unrelieved pain and other symptoms are the most evident problems that practitioners can readily avoid for the great majority of patients, but problems with communication, appropriate regard for patient and family wishes, and timely referral to palliative care specialists or teams are other areas in need of improvement. When good practice is hindered by organizational, financial, or legal impediments, health professionals have the responsibility as individuals and members of larger groups to advocate for system change.

RECOMMENDATION 3: Because many deficiencies in care reflect system problems, policymakers, consumer groups, and purchasers of health care should work with health care providers and researchers to

Although individuals must act to improve care at the end of life, systems of care must be changed to support such action. System change requires the involvement of public and private purchasers of care, regulators, and others whose policies and practices may create incentives for inappropriate care and barriers to excellent care.

Better information systems and tools for measuring outcomes and evaluating care are critical to the creation of effective and accountable systems of care and to the effective functioning of both internal and external systems of quality monitoring and improvement. Reliable and valid information about quality of care should be available to patients, purchasers, and ac-

crediting organizations, but organizations also need to audit their structures and processes for problem areas and commit themselves to improving care on an ongoing basis. Problem areas include insufficient numbers and types of properly trained personnel, nonexistent or inadequate protocols for symptom assessment and management, and poor procedures for evaluating the need for patient transfers or referrals and for carrying out such transfers without harm to patients. The committee supports the development of guidelines for clinical practice that assist clinicians in preventing and relieving symptoms and in managing the end stages of specific diseases.

Policymakers and purchasers need to consider both the long-recognized deficiencies of traditional fee-for-service arrangements and the less thoroughly understood strengths and limitations of alternatives, including various kinds of capitated and per case payment methods that apply in diverse ways to individual practitioners, interdisciplinary care teams, specific institutions, networks of providers, or integrated systems of care. Particularly in need of attention are the levels of payment for home and nursing home visits by physicians, the interpretation of evaluation and management codes, the lack of diagnosis- or condition-related adjustments in hospice payments for both home and inpatient care, and other financing incentives that may discourage hospices or health plans from enrolling sicker patients. In addition, reimbursement methods and related incentives should encourage continuity of care that supports patients all the way through death and reduces disconnected and episodic care. Health care professionals and organizations also need to formulate ethical guidelines to guard against possible conflicts of interest in capitated and other care systems.

The problems with laws relating to prescribing practices are twofold. One problem is outdated, scientifically flawed laws and regulations themselves. The other problem is clinician, regulator, and public misunderstanding of the appropriate use of opioids. State medical societies, licensing boards, legislative committees, and other groups should cooperate to review state laws, regulations, board practices, and physician attitudes and practices to identify problem areas and then devise revisions in those statutes and regulations that unduly burden clinical management of pain. Regulatory review and revision should be accompanied by educational efforts to increase scientifically and clinically based knowledge and correct misperceptions about the appropriate medical use of opioids and about the biological mechanisms of opioid dependence, addiction, and pain management. Legal change should help—but cannot be relied upon alone—to correct undertreatment.

RECOMMENDATION 4: Educators and other health professionals should initiate changes in undergraduate, graduate, and continuing education to ensure that practitioners have the relevant attitudes, knowledge, and

skills to care well for dying patients. Dying is too important a part of life to be left to one or two required (but poorly attended) lectures, to be considered only in ethical and not clinical terms, or to be set aside on the grounds that medical educators are already swamped with competing demands for time and resources. Every health professional who deals directly with patients and families needs a basic grounding in competent and compassionate care for seriously ill and dying patients. For clinicians and others to be held truly accountable for their care of the dying, educators must be held accountable for what they teach and what they implicitly and explicitly honor as exemplary practice. Textbooks and other materials likewise need revision to reflect the reality that people die and that dying patients are not people for whom "nothing can be done." As described in Chapter 8 , a number of promising curriculum models exist, and others are being developed and tested.

RECOMMENDATION 5: Palliative care should become, if not a medical specially, at least a defined area of expertise, education, and research. The objective is to create a cadre of palliative care experts whose numbers and talents are sufficient to (a) provide expert consultation and role models for colleagues, students, and other members of the health care team; (b) supply educational leadership and resources for scientifically based and practically useful undergraduate, graduate, and continuing medical education; and (c) organize and conduct biomedical, clinical, behavioral, and health services research. More generally, palliative care must be redefined to include prevention as well as relief of symptoms. Attention to symptoms should begin at earlier points during the trajectory of an illness because early treatment may well contribute to lessening pain at the end of life. The model for palliative care stresses interdisciplinary, comprehensive, and continuing care of patients and those close to them.

RECOMMENDATION 6: The nation's research establishment should define and implement priorities for strengthening the knowledge base for end-of-life care. The research establishment includes the National Institutes of Health, other federal agencies (e.g., the Agency for Health Care Policy and Research, the Health Care Financing Administration, the National Center for Health Statistics), academic centers, researchers in many disciplines, pharmaceutical companies, and foundations supporting health research. Their active support and involvement is necessary to advance basic and clinical research on the physiological mechanisms and treatment of symptoms common during the end of life, including neuropsychiatric problems. To extend understanding of quality-of-life issues in the treatment of advanced disease, those supporting clinical trials should encourage the collection of more information on the quality of life of those who die while

enrolled in such trials. A further step is to support more research on the physiological mechanisms and treatment of symptoms common during the end of life, including neuropsychiatric problems. Pain research appears to supply a good model for this enterprise to follow. In addition, pathways need to be developed to further the dissemination and replication of proven health care interventions and programs. Demonstration projects to test new methods of financing and organizing care should be a priority for the Health Care Financing Administration. To encourage change in the attitudes and understandings of the research establishment, the committee urges the National Institutes of Health and other public agencies to take the lead in organizing a series of workshops, consensus conferences, and agenda-setting projects that focus on what is and is not known about end stage disease and symptom prevention and treatment and that propose an agenda for further research. For the Agency for Health Care Policy and Research, the committee encourages support for the dissemination and replication of proven health care interventions and programs through clinical practice guidelines and other means.

RECOMMENDATION 7: A continuing public discussion is essential to develop a better understanding of the modern experience of dying, the options available to dying patients and families, and the obligations of communities to those approaching death. Individual conversations between practitioners and patients are important but cannot by themselves provide the supportive environment for the attitudes and actions that make it possible for most people to die free from avoidable distress and to find the peace or meaning that is significant to them. Although efforts to reduce the entertainment and news media's emphasis on violent or sensational death and unrealistic medical rescue have not been notably successful, a modicum of balance has recently been provided by thoughtful analyses; public forums; and other coverage of the clinical, emotional, and practical issues involved in end-of-life care. Regardless of how the current, highly publicized policy debate over physician-assisted suicide is resolved, the goal of improving care for those approaching death and overcoming the barriers to achieving that goal should not be allowed to fade from public consciousness. Much of the responsibility for keeping the public discussion going will rest not with the media but with public officials, professional organizations, religious leaders, and community groups.

Finally, the committee agreed that it was not prepared to take a position on the legality or morality of physician-assisted suicide. The issue should not, in any case, take precedence over those reforms to the health care system that would improve care for all dying patients. The goal of those who favor legalizing physician-assisted suicide is to promote patient autonomy, but true autonomy is not possible when significant numbers of

people have the limited choice between suicide or continued suffering. If the laws permitting physician-assisted suicide are implemented at the state level, careful monitoring of their consequences for the quality of care and the public's trust in health care will be very important.

Concluding Thoughts

Improving care at the end of life will require many changes in attitudes, policies, and actions. Such changes will involve a multitude of people and institutions that have a role in making and implementing decisions about patient care or in structuring the environments in which such decisions are reached and realized. Clearly, what patients and their families know, expect, and desire is important. Health care professionals play critical roles in diagnosis, communication, guidance and direction, treatment, negotiation, and advocacy for patients at many levels. Decisions by health plan managers, institutional administrators, and governmental officials shape and often impede the ability of patients, families, and clinicians to construct a care plan that serves the dying person well.

In general, changes in systems of care—not just individual beliefs and actions—are necessary if real gains are to be made in helping people live well despite fatal illness. Such widespread changes depend in part on a stronger social consensus on what constitutes appropriate and supportive care for those approaching death. Widely publicized—albeit not necessarily typical—instances of patient and family powerlessness to stop what they see as futile and painful treatments reflect a lack of such consensus. Paradoxically, this lack of consensus also is evident when patients or families demand treatments that practitioners see as useless, counterproductive, or even inhumane. It similarly reveals itself in a health care delivery and financing system that still rewards life-prolonging interventions (even when they will be ineffectual) and slights palliative and supportive services for those for whom life-extending treatment is neither helpful nor desired.

Freud may have been right that "our unconscious does not believe in its own death; it behaves as if immortal" (Freud, 1915, in Freud, 1959, p. 304). The committee was optimistic, nonetheless, that this society would cultivate the conscious intelligence and spirit to recognize the reality of death and the likelihood that it will bring distress. It likewise was optimistic that people would work together to create humane systems of care that assure the consistent use of existing knowledge to prevent and relieve suffering and that support efforts to provide people the right care at the right time in the right way. The analyses, conclusions, and recommendations presented here are offered with optimism that we can, individually and together, "approach" death constructively and create humane care systems that people can trust to serve them well as they die.

When the end of life makes its inevitable appearance, people should be able to expect reliable, humane, and effective caregiving. Yet too many dying people suffer unnecessarily. While an "overtreated" dying is feared, untreated pain or emotional abandonment are equally frightening.

Approaching Death reflects a wide-ranging effort to understand what we know about care at the end of life, what we have yet to learn, and what we know but do not adequately apply. It seeks to build understanding of what constitutes good care for the dying and offers recommendations to decisionmakers that address specific barriers to achieving good care.

This volume offers a profile of when, where, and how Americans die. It examines the dimensions of caring at the end of life:

• Determining diagnosis and prognosis and communicating these to patient and family.
• Establishing clinical and personal goals.
• Matching physical, psychological, spiritual, and practical care strategies to the patient's values and circumstances.

Approaching Death considers the dying experience in hospitals, nursing homes, and other settings and the role of interdisciplinary teams and managed care. It offers perspectives on quality measurement and improvement, the role of practice guidelines, cost concerns, and legal issues such as assisted suicide. The book proposes how health professionals can become better prepared to care well for those who are dying and to understand that these are not patients for whom "nothing can be done."

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Guest Essay

After My Brother’s Overdose Death, Misinformed People Added to Our Grief

By John Woller

Dr. Woller is an internist in Baltimore.

On a crisp December morning in my small Southern hometown, my mother found my brother unresponsive in his bed. She knew she was too late. His body was cold, stiff and blue. Blood had pooled on one side of his face, causing it to swell. After her initial panic and calls to my father and 911, she was alone with my brother. She instinctively did what any mother would do: She covered him with blankets and lay down with him. She wanted to hold her son one more time.

When law enforcement officers arrived, they performed testing to confirm fentanyl overdose was the cause of death. When the test turned positive, they informed my parents that it was unsafe to enter my brother’s room. They instructed my parents to schedule expensive decontamination cleaning and provided contact information for a “bio cleaning” agency that deals with hazardous substances and environments.

The following day at the funeral home, where my brother’s body awaited cremation, my family and I were told that we would not be allowed to be in the same room with him because of the risk of fentanyl exposure and accidental overdose. It was unsafe for us to breathe the air in the room of someone who died “that way,” we were told. A funeral home employee told stories of family members who had lost consciousness after viewing loved ones who had died from fentanyl overdose, and of one family member who overdosed and died after visiting a deceased relative.

I was intent on seeing my brother. And as a physician who cares for patients who use fentanyl, I knew these claims were incorrect. I informed the employees that their policy was based on false information and incomplete anecdotes, and that they are needlessly depriving families of opportunities to see their loved ones. They relented only when we accepted responsibility for any potential exposure.

Spending time with my brother’s body was painful for all of us, but it was important for our grief process. We said goodbye through tears and held my brother’s hand one last time. Most important, it allowed my mother to see him resting peacefully, providing an alternative final image she can carry.

For the past few years, over 70,000 overdose deaths in the United States have involved synthetic opioids, primarily fentanyl and its analogues. Most families grieving these deaths won’t have a doctor in the family to dispute misconceptions perpetuated by law enforcement, funeral homes and others. How many American families are being unnecessarily deprived of a somber, sacred moment based on stigma and rumors?

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