Ars Moriendi — The lost art of dying

By Dr Patrick Kee
03 April 2010

The topic of death and dying is taboo to many of us. Some feel it is bad luck to talk about dying. Others are just very fearful about the subject of death. We prefer to focus our attention on the gifts of longevity and healing. Medical advances in the treatment of diseases have blinded us to the reality that death is our common and final destiny. No matter how young or old, how rich or poor, we will all die one day — sooner or later! [1]

There is also much confusion between euthanasia, physician assisted suicide and the advance medical directive. Terms like active and passive euthanasia further confuse the difference between euthanasia and end of life care that is based on common sense and compassion.

The objective of the advance medical directive is NOT euthanasia but to ensure that doctors will not carry out FUTILE medical interventions against the wishes of the patients who are at the end of life as well as to protect doctors from families who insist on futile treatments.

Euthanasia or physician assisted suicide is the ACTIVE termination of a life in a patient who is NOT at the end of life on the pretext of ending suffering. It is in fact an act of assisted suicide which is no different from the suicide of a person suffering from depression. However, discontinuation of futile medical treatment is NOT passive euthanasia — it is common sense and compassionate end of life care.

Ars Moriendi – The Art Of Dying

To live well, we need to learn to face death and to see death as a part of life. We need to “befriend” death so that our deaths will bear the fruit of love, joy and peace in the lives of those we leave behind. But this is a far cry from choosing death as a way out of our suffering and problems in life through euthanasia or suicide which saddles loved ones left behind with the burden of guilt, anger and resentment.

Caring for the elderly and the dying have taught me many lessons about death and dying. So often, it is in our dying that we find true life. To find meaning in suffering and to face the reality of death we need to change our mindsets towards suffering and life. We have lost the art of dying in our modern society. We do not know how to prepare for death. Many have been seduced by the proponents of euthanasia that a quick and easy death is a good death. The psychosociospiritual dimensions of dying are often neglected. Dying is ultimately a spiritual event — a movement from the dusk of the physical process of dying through the dark night of death to the dawn of a new life in the spiritual realm. [2]

The real question before our death, according to Henri Nouwen, is not, “How much can I still accomplish, or how much influence can I still exert?” but “How can I live so that I can continue to be fruitful when I am no longer here among my family and friends?” [3]

We are all born to die but human beings, unlike the other animals, have a sense of eternity in their hearts. Deep within us we know that there is something beyond the grave. We are spiritual beings and not mere robots programmed by a bag of genes. If we want to die well, we need to live every day as if it is our last day — one day we will be right and we will be ready. More importantly, when we live each day as our last, we will find each day worth living as we do something special for ourselves and for others. When we do so each day and every day, we will add life to our days instead trying to add years to our lives.

Euthanasia – A Symptom Not A Solution

Euthanasia is more of a symptom, a cry for help, rather than the solution to suffering. From my experience in caring for the dying, it is important to understand the three different messages we hear from those who are asking for euthanasia:

  1. Let me die
  2. I want to die
  3. Kill me

Let me die:

The elderly sick often request that they be allowed to die. Such requests are not requests for euthanasia but a healthy acceptance of death and a communication to their loved ones that they are on the last mile of their life. Their decisions against any active medical interventions that cause distress should be respected and acceded to. Surely common sense should dictate that the dying should not be subjected to unnecessary and futile interventions such as NG tube feeding, IV drips, ventilators, etc.

An old lady with cancer expressed her wish for an early death. I told her that she was in fact dying and that her time would not be long. She thanked me for giving what many assume is “bad news” but which was good news to her! Her primary concern was that she would be a burden to the family. She asked if I could give her an injection to end her life. However she did not have much physical pain. I assured her that we would not do anything to prolong her dying but we would do all we could to help her live each day as well as she could without pain. She was comforted by this assurance and by the fact that her days were numbered.

I want to die:

Another group of patients may tell us that they want to die. Again, such requests are not really requests for euthanasia but expressions of the suffering that they are going through. What they need urgently is the relief of their physical and emotional suffering rather than assisted suicide. With all the modern drugs and our modern technology, physical pain and even physical disability need not be a reason for suicide.

A man suffering from metastatic cancer of the prostate was physically well when he was told that there is no more treatment available for his cancer. He struggled with this “death sentence” but found support in a hospice day care centre. Unfortunately, he developed a urinary obstruction a couple of months later and had to use an indwelling urinary catheter and he had to stop going to the centre.

The cancer spread and caused an intestinal obstruction and he had to have a colostomy a few months later. In spite of all the above complications, he was able to live an independent life at home. He was understandably demoralized and depressed by his condition but we encouraged him to live one day at a time.

One morning as he was walking to his favourite hawker stall he was knocked down by a car and suffered a fracture of his right hip. But he was able to walk after his hip operation and died at home after another 3 months.

It was not an easy time for him and his family and he expressed a wish to die a couple of times. If euthanasia had been permitted by law, he could have found someone to assist him in ending his life. But choosing euthanasia would have deprived him and his family the last few months of his life which gave them an opportunity to resolve issues and the opportunity to share their love with one another.

Kill Me:

Only a few patients make the request, “Please kill me.” They are often depressed and are afraid of becoming a “living dead” without any control of the decision making with regard to their medical treatment. Such requests are born out of fear, ignorance and a sense of hopelessness. They are no different from the suicide attempts of those who are physically well but depressed and have lost all hope for their lives.

There was a middle aged man with cancer who made a strong request for euthanasia. He was single and had caring brothers who were struggling to come to terms with his impending death. Their concern and attempts to get him to eat and to get well were very stressful to the patient. I could not accede to the patient’s request for euthanasia. I explained to him that he needed to give his brothers time to prepare for his death.

At the same time, I advised the brothers to face the truth of the patient’s terminal condition and to respect his wish not to have tube feeding, etc. I shared with them the fact that those who are in their last days of life will often just stop eating and drinking. This is the natural and comfortable way of dying. We relieved his pain and he passed away peacefully at home a few weeks later with the family at peace as well.

The evil of euthanasia is that it is a symptom of a materialistic society that measures life only in terms of wealth and health. Such a society is one that is without hope and spiritually poor for it deprives the people from showing compassion and love as they care for the dying.
The primary problem is not whether we should legalise euthanasia but how we can provide better end of life care and to humanise the practice of medicine.

Suffering is a call for compassion and not a license to kill. We always have the choice to choose life or to choose death. However it would be wrong to insist that doctors must assist their patients who choose suicide as a way out of their suffering. It is also foolhardy to confuse the doctor’s role as a healer with that of an executioner. A healer is not just one who cures but one who creates a healing space for the patient in the midst of suffering and pain.

Hospice Care

The alternative to euthanasia is hospice care. Hospice care is not a place for the dying but a philosophy of care that focuses on the total care of the whole person. The hospice movement was founded on the belief that we need to do all we can to help the dying to live as well as they can up to the time of death. It seeks to humanize the process of dying which is becoming dehumanized by modern medicine. [4]

The answer to suffering is not to end life but to see it as a challenge to love and to care more. Dying has become medicalised to the extent that it is practically impossible to die naturally once a patient is admitted to hospital. Modern medicine often prolongs the dying process at the expense of the quality of life. It is foolish to put our faith in doctors only to cure our diseases instead of seeing them as our fellow and fallible human beings who can use their medical skills to relieve our physical suffering and disabilities so that we can live our final days with meaning, dignity and grace.

Euthanasia is not the best way to die well — the simplest and easiest way for the terminally ill to die naturally is to provide hospice home support for them and their families so that they can remain at home and not be admitted to hospital. Do we really need laws for the dying to die a natural death or just common sense? Competent and compassionate end of life care at home will help the dying and their families have a meaningful closure. There are five important tasks to be fulfilled at the end of life — to express love, to forgive, to seek forgiveness, to express gratitude and to say goodbye,

When one is at the end of life, the most important thing to do is to stop all treatment that does not relieve suffering so that the process of dying is not unnecessarily prolonged. For example, when the body is shutting down at the end of life, not eating or drinking is normal and does not cause suffering. At this stage, artificial feeding is futile and may in fact cause more suffering.

Competent and compassionate end of life care will help us to learn the art of dying. To say no to euthanasia is not just because it is wrong but because the most loving thing is to help another to choose life rather than death and to affirm that our lives matter right up to the time we die. For even though we die, we live on in the hearts of those we love. And so we need to pass on hope, faith and love not only through our lives but in our deaths.



[1] Kee, Patrick: Living Well In The Autumn Of Life, page 126
[2] Ibid, page 128
[3] Ibid, page 129
[4] Ibid, page 137-139