Death – The Ultimate Reality
Life asked death, “Why do people love me, but hate you?”
Death responded, “Because you are a beautiful lie and I am the unpleasant truth.”
As I read the above lines a long time ago, I wondered if death was the most misunderstood reality. Even doctors, who see deaths very closely, often have misgivings about this. These apprehensions are partly due to the recent spurt in violent reactions by the public in response to negative clinical outcomes.
What is Death?
It is not easy to define death. There have been various definitions, and the concept of death in the Bhagavad Gita is probably the most ancient. Hence, no discussion about life and death can be complete (or even commence) without quoting from the Bhagavad Gita.
Here is a shloka from Chapter 2 Verse 20 of the Bhagavad Gita:
न जायते म्रियते वा कदाचि न्यायं भूत्वा भविता वा न भूय: |
अजो नित्य: शाश्वतोऽयं पुराणो न हन्यते हन्यमाने शरीरे || 20||
The soul is neither born, nor does it ever die; nor having once existed, does it ever cease to be. The soul is without birth, eternal, immortal, and ageless. The soul is not destroyed when the body is destroyed.
Dutifully, the first edition of Encyclopedia Britannica in 1768 described, “Death is generally considered as the separation of the soul and body; in which sense it stands opposed to life, which consists in the union thereof.”
The “modern” definition of death for medical and legal purposes is more clinical and less spiritual. Death is the cessation of life; permanent cessation of all vital bodily functions.
For legal and medical purposes, the following definition of death has been proposed – the irreversible cessation of all of the following: (i) total cerebral function (the brain), (ii) spontaneous function of the respiratory system (the lungs), and (iii) spontaneous function of the circulatory system (the heart).
Brain death is irreversible brain damage as manifested by complete unresponsiveness to all stimuli, the absence of all spontaneous muscle activity, including respiration, shivering, etc., and an isoelectric (flat) electroencephalogram (EEG) for 30 minutes, all in the absence of hypothermia or intoxication by central nervous system depressants. This definition is legally useful for determining the feasibility of organ donation.
While doctors learn the definition of death and its diagnosis, the conventional medical curriculum stops there. We are not trained in how to handle death, but every doctor deals with this experience. Elaborate discussion about a death-situation may have been considered a taboo, as doctors are supposedly trained to “prevent” deaths. Probably, this notion is contagious, and even the public is of the same opinion, and occasionally does not accept the death of a patient who is under medical care.
Societies attribute different meanings of death too. While traditional societies like ours in India considered death as a natural part of the life cycle, the modern (Western) world brought the idea of medical failure. While traditional societies considered “end of rebirths” as the ultimate goal (moksha), the modern world played around with the idea of “end of death” itself.
What is a “good death”? Generally, an ideal or good death is one in which a person dies a relatively pain-free death, on their own terms and in a dignified situation. Most adults would choose one of these three – (i) sudden death in sleep, (ii) dying at home, or (iii) dying while engaged in meaningful activity. No wonder many patients wish to have their last breath at home, instead of the hospital.
The concept of good death is so closely embedded in the Indian culture that there is a prayer, to be recited when sitting in a temple, imploring the Almighty to grant one a good death!
अनायासेन मरणं विनादैन्येन जीवनं | देहांते तवसायुज्यं देहिमे मधुसूदना ||
Hey Almighty, Please grant me three boons: an easy (good) death, a life without begging, and your proximity after my bodily death.
The realization of the certainty of death brings a sense of calm and humility too.
Death in Hospitals
Doctors, paramedical staff, and hospital support staff are allegedly not judicious enough while dealing with death, especially those frequently dealing with death. Clinical personnel are uncomfortable with declaring death and dealing with the ensuing emotions and questions. Some doctors avoid meeting the relatives and leave the hospital in these situations. However, it is a fact that the kin will have their own emotions including anguish, fears, grief and guilt; they need closure too.
Too much confusion exists in the management of those brought dead. Handling that situation sensitively, while still being legally correct is a challenging task for all doctors. While relatives are mourning an unexpected and untimely loss of life, we have to talk about police intimation and autopsy. Unfortunately, we do not have a choice in most cases and have to follow the law of the land.
Reactions to Death
I encounter death often in my clinical practice. Most often, close relatives want to know if they could have done something to prevent or delay what happened, “Should we have brought my father a bit sooner?”
Sometimes, there may be a feeling of guilt about either having done or not done something to the person who died, “I should have avoided giving feeds when my mother was not responding.”
If these questions aren’t dealt with sensitively, this guilt may linger on and trouble them for the rest of their life. I frequently have relatives who return after a couple of weeks of death to try to understand the reason for what happened. They want to know and reach closure.
Occasionally, a demise is a relief too. It is difficult to take care of family members who have untreatable diseases resulting in pain and suffering. The passing away of a suffering loved one is a relief, an anticipated end of suffering.
Few other times, the reactions may be quite the opposite, “Your negligence and delay are responsible for this.” Such reactions result in a complicated situation, justifying a death. It takes a great deal of self-control to explain the situation to an accusing but mourning family member.
Imagine life without death. That would be terrible; without sufficient resources to cater for everyone forever, we would all die anyway!
Death is not the opposite of life, but a part of it. Death is an inevitable destiny.
Ralph Waldo Emerson said aptly, “Of all the ways to lose a person, death is the kindest.”
- “Death.” In Encyclopaedia Britannica, 1st edition. Vol. 2. Edinburgh: A. B. & C. Macfarquhar, 1768. In Encyclopaedia Britannica, 15th edition. Vol. 5. Chicago: Encyclopaedia Britannica, 1973.
Dr Shashikiran Umakanth (MD, FRCP Edin.) is Professor & Head of Internal Medicine at MMMC, Manipal Academy of Higher Education, and has clinical responsibilities at the Department of Medicine, Dr TMA Pai Hospital, Udupi, Karnataka, India.