When Do We Begin To Die?

Death has a definite and precise meaning. For example, clinical death is the cessation of blood circulation and breathing. Biological death includes the irreversible termination of both cardiopulmonary and brain function. Dying, on the other hand, has no clear meaning. The criteria that define its parameters are debatable, and the word can even be used in unpredictable ways. ‘I’m dying’ - a terminally ill cancer patient with six months left says to their family. Meanwhile, an unprepared medical student would also say this same phrase before their exam. 

 

The Cambridge Dictionary defines dying as the following: very ill and likely to die soon. The ambiguous adverb, ‘soon’, has no quantitative distinction concerning the span of time. In the case of patients with metastatic cancer, for instance, such a definition fails to delineate whether the patient is already ‘dying’ when their cancer has become apparent, or only when the effects of organ failure begin to set in. Or maybe it would be correct to say that the patient has been dying since the emergence of their first cancer cells. Who could have known, that medical oncology has tied itself up with our existential ontology. Even cancer confuses us about when exactly we begin to die.

 

Undoubtedly, the basic functions of life have already begun deteriorating since birth. During cell replication, peripheral ends of DNA sequences are lost due to replication-associated functions. Telomeres in the chromosome termini serve to buffer the DNA loss and protect genetic information, but the culmination of a lifetime’s worth of DNA replication leads to an increasingly shortened telomere. When the buffer is exhausted, the result is apoptosis, senescence, and oncogenic catastrophe. [1] In other words, we begin to die when we are born.

 

'It will happen to all of us’ as Christopher Hitchens once said, ‘that one day you'll be tapped on the shoulder and told the party's going on - and you have to leave.' [2] 

 

In life, there is living, a process that begins with birth and ends with death. Then there is dying, the same process that begins with birth and ends with death. The lens we choose to look through colors how we view the same journey of life. For sure, it is a preposterous notion to say we have been dying all our lives because ‘dying’ will just become a meaningless concept. Not to mention, the devil is in the details of how broad ‘soon’ means, and the scope of what ‘illness’ includes. Yet if we accept that living and dying are not antithetical concepts, but are two subjective verbs of the same story, then we can shift away from the spoiled fantasy that dying is not a problem for most of us and liberate the topic for everyone to participate in. Because not enough people are willing to talk about dying. 

 

Most people do not have an end-of-life plan, nor are they aware of how their family members would want to be treated if an accident or disease rendered them unconscious. [3] Even for terminally ill and elderly patients, discussions about dying and end-of-life care often start too late, if they even had one. Major studies on the quality of death and end-of-life care in Hong Kong repeatedly find a substantial gap between patients’ preferred way to die and how they end up dying. [4] This communal blunder is brought on by a variety of reasons. Patients refuse to ‘give up’, doctors believe in the cure-oriented power of medicine, cultural taboos repudiate conversations about death, funding for palliative care consistently remains negligible, and the public social agenda is urged to address other more pressing issues. [5] [6] [7]

 

The academic literature is clear on what people want in their final moments: being surrounded by loved ones and being free from pain. [6] But we need dialectical social conversations about dying in the private and public spheres to know what we ourselves and healthcare systems can do better when we are dying. 

 

The failure to heed the topic of dying into patient-doctor consultations and public discourse is a costly price paid with human suffering. It is now far too common to hear stories of ill patients dying in gruesome and unnecessarily cruel ways. Elderlies are rushed to the A&E for another round of exhausting resuscitation; the frail are hooked onto austere life in the bright-lit and clamorous ICU. The faulty management between A&E and other extended-care facilities regarding patients who prefer end-of-life care will more often than not result in doctors fighting to prolong additional time which many patients do not value, undermining everything that a good death strives to be. [6] 

 

Knowing when we begin to die comes with accepting mortality as a constant of human life. With mortality ever in the present, we should also realize it has an important place in our current conversations. We need space for an honest dialogue about how we want to go, not a stifling culture that will devastate it all together. As individuals and as a society, all the tools we need to avoid these terrible endings are at our fingertips: open discussions and public policies. It will certainly be a difficult time confronting our own mortality - but death offers no second chances, so we will need to try.

 

References 

 

1. Shammas, Masood A. “Telomeres, lifestyle, cancer, and aging.” Current opinion in clinical nutrition and metabolic care vol. 14,1 (2011): 28-34. doi:10.1097/MCO.0b013e32834121b1

2. Hitchens, Christopher. “‘It Will Happen to All of Us That One Day You'll Be Tapped on the Shoulder and Told -- Not Just That the Party's over -- but Slightly Worse: The Party's Going on, and You Have to Leave. That's the Reflection, I Think, That Most Upsets People about Their Demise." Pic.twitter.com/xbigcwszv0.” Twitter, Twitter, 10 Aug. 2019, https://twitter.com/Hitch_Slapping/status/1160277069860954112. 

3. Shalowitz, David I et al. “The accuracy of surrogate decision makers: a systematic review.” Archives of internal medicine vol. 166,5 (2006): 493-7. doi:10.1001/archinte.166.5.493

4. Wong, Eliza Lai-Yi et al. “Quality of Palliative and End-Of-Life Care in Hong Kong: Perspectives of Healthcare Providers.” International journal of environmental research and public health vol. 17,14 5130. 16 Jul. 2020, doi:10.3390/ijerph17145130

5. Chan, Timothy H Y et al. “Death preparation and anxiety: a survey in Hong Kong.” Omega vol. 54,1 (2006): 67-78. doi:10.2190/6478-6572-v704-1545

6. Chung, Roger Yat-Nork et al. “Knowledge, Attitudes, and Preferences of Advance Decisions, End-of-Life Care, and Place of Care and Death in Hong Kong. A Population-Based Telephone Survey of 1067 Adults.” Journal of the American Medical Directors Association vol. 18,4 (2017): 367.e19-367.e27. doi:10.1016/j.jamda.2016.12.066

7. Chan, Helen Y L et al. “Diagnosing Gaps in the Development of Palliative and End-of-Life Care: A Qualitative Exploratory Study.” International journal of environmental research and public health vol. 17,1 151. 24 Dec. 2019, doi:10.3390/ijerph17010151