This article is part of a longitudinal series on humanities.
Death, be not proud, though some have called thee
Mighty and dreadful, for thou art not so;
For those whom thou think’st thou dost overthrow
Die not, poor Death, nor yet canst thou kill me.
From rest and sleep, which but thy pictures be,
Much pleasure; then from thee much more must flow,
And soonest our best men with thee do go,
Rest of their bones, and soul’s delivery.
Thou art slave to fate, chance, kings, and desperate men,
And dost with poison, war, and sickness dwell,
And poppy or charms can make us sleep as well
And better than thy stroke; why swell’st thou then?
One short sleep past, we wake eternally
And death shall be no more; Death, thou shalt die.1
– John Donne, 1633
Although Donne’s account of death was written in the 17th century, it continues to resonate our fears, thoughts and attitudes towards death and feelings of dying. Death is feared, death is repulsive and death deprives. The fear of pain, fear of indignity and fear of abandonment have been previously explored in dying patients.2 Donne’s poignant reflection echoes humanity’s trepidations of death and questions death’s unbridled arrogance. He belittles death by self-assurance of an afterlife and, paradoxically, commands death to die, but one is left unbeknownst whether Donne himself is truly convinced of this hypothesis or whether he is, indeed, frustrated by ambiguity of the unknown.
Medical professionals are constantly faced with the predicament of sickness and death as it consumes our patients, our families and sometimes, sadly, even our colleagues under tragic circumstances. Advances in medical treatment can prolong life eternally, where a patient can be kept alive indefinitely, but cannot thrive. For some patients with terminal illness or others with severe depression, death can provide the ultimate reprieve from the shackles of incessant suffering. Death and dying are therefore profound paradigms, treacherous for some and liberating for others.
In general practice, more so than in other specialities, we take great pride in providing holistic, patient-centred care, where a patient is valued as a whole person beyond their pathology. In medicine, we are trained to preserve life and relieve suffering, and receive little to no training about death or caring for the dying. Because death is ironically one of life’s only certainties,3 as ‘specialists in life’ it is imperative for general practitioners (GPs) to appreciate the multifaceted nature of death. The present narrative explores some physical, metaphysical and spiritual discourses of death to enable GPs to provide better care for patients throughout their journey of life, including dying.
The biomedical definition of death necessitates specific criteria, including the irreversible cessation of all function of the brain of the person; or irreversible cessation of circulation of blood in the body of the person.4 Physical changes include the absence of brain stem reflexes and postmortem rigidity, otherwise known as rigor mortis, caused by the depletion of adenosine triphosphate (ATP) from the muscles.5 Postmortem hypostasis can cause accumulation of blood, causing skin hyperpigmentation.6 It has been proposed that in such a biomedical definition of death, ‘organism death is equated with the death of the being’ and reduces the value and essence of human life.7 Furthermore, Jakušovaitė et al assert that the predominance of clinical criteria for determination of death in practice leads to medicalisation of death and limits the holistic reflection of an individual’s death,7 echoed in an exquisite literary analysis on the subject by Haider.8
Bioethicists claim that the legal death criteria are not inclusive of the biopsychosocial context of the patient without any regard for metaphysical or spiritual entities. In the metaphysical discourse of death, two main questions about what human death is and how to determine the fact of death clearly separate the ontological and epistemological aspects of death.7 Ontology relates to what exists, therefore necessitating the need to define death objectively, whereas epistemology focuses on the justification of human knowledge, therefore drawing on the circumstances of death, as well as specific clinical measures to assess how death was established to understand reality.9 It maybe argued that the rational process of certifying death in biomedicine incorporates these metaphysical considerations to a certain extent. Philosophers have also discussed the complex conundrum of whether the biological death of an individual means that they cease to exist as a person; in other words, whether an individual’s identity is lost when they are biologically classified as dead. The renowned French philosopher, Rene Descartes, also proposed in the 17th century that death has to be grounded in natural philosophy. As a corollary, the death of a body can then be seen as the destruction of its identity by virtue of loss of consciousness.10
Spiritual concepts surrounding death also require deep consideration for GPs because the sociocultural context of death is embedded into the human psyche. Sheikh describes death and dying from the point of view of the Islamic faith, where he reaffirms that to a Muslim, death is not seen as the end, but rather as a passage into the eternal life.11 Many Eastern religions believe in the concept of the perpetuation of the soul and find comfort knowing that their loved one will be reborn into a new life. Enduring physical suffering is believed to yield spiritual growth and a more fortunate rebirth.12 In traditional Aboriginal Australian spirituality, each person is thought to receive a special sign from their own animal spirit connected to Country, to indicate their closeness to dying. Returning to their ‘Death Country’ allows the spirit to re-enter the dreamtime, where it will return through rebirth.13 Taken together, and as previously explored by medical anthropologists Koenig and Gates-Williams,14 a medical practitioner must incorporate cultural sensitivity when approaching difficult topics such as death and dying.
Humanity has long been regarded as ‘death averse’, which extends to the notion of death in biomedicine.2 The intolerance of death may indeed reflect our own feelings of inadequacy, failure to rescue, failure to heal and failure to relieve suffering because death is beyond the realms of biomedicine.15–19 With technological advances on the rise, GPs face greater pressures to balance intervention with the natural processes of ageing and dying.2 The loss of a loved one is tragic, no doubt; however, the meaning attributed to death is subjective, being a catastrophe for some and a triumph for others. By integrating clinical knowledge with an understanding of metaphysical and spiritual facets of death, a GP will be best placed to have difficult yet meaningful discussions about the dilemma that is death.19 Donne’s synthesis, written almost 400 years ago, continues to reflect the quest to comprehend the phenomenon of death. Death indeed conquered Donne, but the power of his words forever remain.