As an event that we will all experience, it is amazing how it remains a great mystery to us. Kubler-Ross is well known for her extensive research on the subject. The five stages of dying that she describes address the psychology of dying but not the mystery of death itself. People with near death experiences have written about the wonder peace and beauty of heaven. There have also been accounts of people who have returned from hell. One of my patients recounted entering a courtroom with an official behind a high podium who directed him to leave and then regained consciousness. But still, for each of us it remains a personal mystery. What will I actually experience? Will I meld with the energy of the universe (cognitive or noncognitive)?  Will I cease to exist? Will I experience the “tunnel”, the white light? Will I be greeted by relatives who preceded me in death? Will I retain my personal identity?

For those of us who are believers (regardless of religion) the expectation is that we will enter some type of heaven (or, for some, hell).  Will there be some recognition of where we are heading at the moment of death?

As a physician, I have observed the death of many patients. The experience has made me more aware of my own death and has led me to many of the questions addressed above. However, I have noted that most patients passed peacefully (Final stage of acceptance?). I have noted that for some it is the anticipated relief from suffering and pain. Some seem to be unaware of what’s happening or are preparing for the next step by excusing themselves from this world. Many are praying or anticipating their meeting with God. Surprisingly, it is not uncommon for patients with mental confusion to suddenly become lucid saying goodbye’s or giving direction to their loved ones. I have not, to my knowledge, observed the death of a truly evil person and wonder if there is anything unique to the manner of death for such a person. I have had one experience that came close. The patient was an elderly lady who had been ill for some time and was now approaching death. She had been a faithful Christian for most of her life and her children and siblings had shared her faithfulness. However, ten years previously her beloved husband died of cancer. She had begged God for a miracle but none came and he passed away. From that moment she became enraged with God and refused to allow Him into her life ever again. As she lay dying she refused to see a pastor or to reconcile with the Lord. Her children and her brother pled with her to make her peace. But as she lay in her bed she became more and more angry and withdrawn. Ultimately, she died. Whether it was real or imagined, her son insisted that he heard her mutter “forgive me” with her last breath.

Most doctors and especially nurses believe that patients have some control over when they die. They hold on till a family member traveling from a distance arrives. Or they hold on until they can talk with someone to accomplish unfinished business. A while back I had a patient who was on a ventilator for three months. He couldn’t seem to make any progress and was very difficult for the staff refusing to cooperate with treatment. One Saturday morning when I was making rounds I stepped into his room. I closed the door and pulled the curtain. Pulling a chair up to his bed, I attempted to elicit more cooperation with his care. I said to him, “John, you’re not making any progress. We need you to help us so you can get better. Otherwise, if you wish to die, that’s ok but you need to make a decision.” I didn’t expect that he would make that decision so quickly and definitively. He died that afternoon. Did he just need for someone to give him permission? Serendipity? I don’t know. But it left me wondering how much control we have over our dying process.

I have often wondered about the funeral ritual. It feels as if the departed is not involved, that the remains are an empty vessel on display. He/she has indeed departed to parts unknown. The ceremony is for the comfort of the living, a display of love or duty. People being different may all react in their own way depending upon the nature and depth of the relationship. For some, there is a need to be left alone with a realization that well-meaning folks don’t understand what you are going through.

I was tired of well-meaning folks, telling me it was time I got over being heartbroke. When somebody tells you that, a little bell ought to ding in your mind. Some people don’t know grief from garlic grits. There’s somethings a body ain’t meant to get over. No I’m not suggesting you wallow in sorrow, or let it drag on; no I am just saying it never really goes away. (A death in the family) is like having a pile of rocks dumped in your front yard. Every day you walk out and see them rocks. They’re sharp and ugly and heavy. You just learn to live around them the best way you can. Some people plant moss or ivy; some leave it be. Some folks take the rocks one by one, and build a wall.”
― Michael Lee WestAmerican Pie

The irreversibility of death needs time to sink in. He/she is absent from the bed at night and again in the morning. The familiar “I’m home!!” no longer echoes at the end of the day. The intimate conversations are gone. Even the squabbles remain absent. The daily call to mom no longer occurs. Time heals but never restores. We compensate in our beliefs that “they’re in a better place”, “they’re with God”. Reminded of our own demise, this comforts us that we too will be in that place someday. What are your thoughts?