COVID-19 Is An Opportunity To Change The Culture Of Death

The doom, gloom, and uncertainty surrounding the ongoing COVID-19 pandemic can be overwhelming, even for an emergency department physician such as myself. The heaviness of the situation largely stems from the deadly nature of the virus, our relatively minimal understanding of how it works, and our seeming inability to control the rapidly changing nature of our day-to-day lives.

TIME Ideas published an excellent piece by Drs. Jessica Gold and Shoshana Ungerleider that confronts the issue of death and uncertainty in the time of COVID-19 from the perspective of palliative care. Specifically, they highlight how decision-making in the context of end-of-life planning can offer some sense of control in these chaotic times. Although we may not be able to control all aspects of how we live during this pandemic, we can control how we die.

What needs to be expanded upon here further, however, is our willingness as a society to speak about “the d-word” at all. Simply talking about COVID-19 itself — from which most people seem to recover — provokes significant anxiety. While countless memes and humorous quarantine videos have provided much needed comedic relief, in order to successfully alleviate our collective consciousness from the emotional and cognitive distress associated with the ongoing pandemic, we need to confront the elephant in the room: our fear of death.

“In this world, nothing can be said to be certain,” goes the proverbial Benjamin Franklin quote, “except death and taxes.” Taxes are clearly a common topic in modern social discourse.

Death, however, makes a less frequent appearance in our daily conversations. As a society, we celebrate birthdays, marriages, graduations, and retirements. All these milestones receive so much of our attention, but the final milestone — death — has been actively avoided, and for some obvious reasons.

It is inherently depressing to think about the end of anything that has been a remotely positive or important experience. The end of all experience is thus a particularly upsetting prospect.

Nonetheless, another side of the coin does exist.

Tuesdays With Morrie, published in 1997, offered a popular heart-warming look into how death can actually be a celebration of life. After all, immortality, although depicted as a much sought-after prize in many stories, would ultimately rob our lives of their meaning. The fact that each one of us will one day cease to exist allows every second that we are alive to carry special significance. By embracing this perspective, we can find value in paying attention to our inevitable end. Death need not have a negative connotation. It can foster joy as an opportunity to honor our own existence.

By bringing more attention to our own mortality, COVID-19 has created a platform upon which we may develop and shift our national conversation on death. The conversation has already started: Atul Gawande’s Being Mortal, numerous death-with-dignity laws, and the Academy Award-nominated short documentary film End Game are just a few examples of how end-of-life has become a more accessible topic for exploration. But why (aside from its undeniable and ever-present nature) does death deserve more of our consideration? Why not focus more on life and its inherently joyful aspects?

Working in the emergency department, death would, in fact, seem to be the enemy. I fight to save people from heart attacks, raging bacterial infections, and traumatic injuries that could end their lives. Some of these people are young and healthy; infinite potential fills their futures. Others are already struggling with chronic heart failure, advanced metastatic cancer, chronic obstructive pulmonary disease, or severe life-long physical and intellectual disabilities.

Of these individuals, some may find daily life painful and nearly absent of joy. Limited mobility, difficulty communicating, constant shortness of breath, frequent vomiting, and uncontrollable diarrhea are just a few of the debilitating symptoms they may encounter. To prolong their day-to-day experiences by fighting death — whether it comes in the form of pneumonia or a stroke – may result in increased suffering.

Even when my work in the ER manages to stave off death in the here and now, it can fail to provide any meaningful increase in life. My patients admitted to the ICU sometimes linger on a ventilator unable to communicate with loved ones while numerous catheters and probes violate their bodies; on occasion, families then face the difficult decision of whether or not to continue such treatment.

Other times, while I may have prevented death in the ER, it still comes in the ICU with rib-cracking chest compressions unable to reverse the inevitable. Devastatingly high medical bills have accumulated in the meantime, leaving loved ones with new challenges. Furthermore, despite the sometimes perfect implementation of care by medical teams, the pain that loved ones suffer pushes them to seek legal action. Something horrible happened, and someone has to be held accountable. Rather than accepting death as natural and human life as fragile, we seek to establish blame. All of this leaves the health care industry between a rock and a hard place.

Most physicians want to provide the best care possible to everyone, but increasing costs associated with medical liability and a disproportionate focus on acute care in the setting of already limited resources (we only have so many EKG machines, CT scanners, medications, nurses, technicians, etc.) means that a financially unsustainable situation has been a more prominent problem for many community hospitals for a while now.

Enter COVID-19. We can no longer afford to ignore the inevitability of death. You will die one day. And so will I.

It may come unexpectedly or too soon. Or, we may receive some warning signs that provide us with weeks, months, or years to plan ahead. Regardless, it is foolish for us to wait around for the latter scenario because it will happen. If you are reading this right now, you have the opportunity to reflect on your own death and what you want it to look like.

Do you want to go down in a metaphorical “blaze of glory,” with a critical care team pursuing every option possible to keep oxygenated blood pumping through your body? Do you want your awareness to be optimized so that you can interact with family and friends for as long as possible? Do you want to be at home resting quietly with your pets? There is no right or wrong answer.

But these questions must be addressed. We must learn about all the options that are available for end-of-life care. If we can learn to embrace the fragile nature of human existence and find joy and purpose in this fragility, not only do we as individuals stand to benefit, but so does the health care industry as a whole.

Haleh Van Vliet is an emergency physician.

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