Issue 7 / 3 March 2014

PERHAPS it’s my age, but I seem to have been to more than the usual number of funerals lately, and there have been others for relatives and lifetime family friends that were too far away to attend.

Many of the words I heard at the various commemorative ceremonies had the intent of validating the life that had been lived and providing a context within which we might be able to normalise what had happened. It led me to reflect on the ways that we as a community come to grips with the fact that someone in our lives has died.

Each of us has inherited responses and evolved cultural mechanisms to prepare for and deal with the fact that someone we knew is not going to be here any more. We share with other species a variety of common biological reactions to loss, as described some time ago by Konrad Lorenz, a winner of the Nobel Prize for Physiology or Medicine.

Every human community — past and present — seems to integrate discussion of death into day-to-day life and perform some form of ritual that provides comfort for the family after a person has died. Though our beliefs may differ, we are generally content to participate respectfully in a funeral run by any denomination of religion that helps to normalise a death.

What intrigued me as I joined in those funerals was that the social mechanisms that might normalise death for a patient, their family and their friends had barely got started, let alone reached their full stride, until after the person died.

Contemporary health systems and community expectations almost conspire to block us from preparing for death until it is staring us in the face. Has death become an anomaly, not only for those who did not know the person was ill, but even for those who did? It is as though we have been taught to believe death cannot happen. Was this always the case, or is it a recent phenomenon?

From prehistoric hunter-gatherer communities until the end of the 19th century the average life expectancy at birth was seldom more than 40 years, even in the most stable communities. Perhaps a third, or more, of all children died before the age of 10 years, and of those who survived childhood very few lived on into extreme old age.

Death and dying were everyday events and, although not always foreseen, were so common as to be scarcely a surprise. Almost everyone dealt with death from the time they could be aware of it. Then, as now, a funeral, often with a promise of some form of continuity after death, provided consolation and context to the living as they contemplated both the ongoing wellbeing of the deceased and their own future mortality.

Our average life expectancy in the developed world is now about 80 years and our relationship with death has changed dramatically. Today, death in childhood is so rare as to generate the comment that it “is not natural”.

Cure-focused medicine has sold us a new set of expectations for the course of our lives and has generally ignored the inevitability of life’s end. Some patients and their families become almost incredulous when options for treatment run out.

Dealing with a death also reminds us of the shocking reality that we too might die. We may be more unnerved by a death today than previous generations when the risks of dying anytime soon were far higher.

The ascendancy of scientific explanations for disease has diminished the option of ascribing the causes of death to supernatural forces. When there was a general belief in the power of prayer to alter the future we might have felt we had some personal influence on the course of our illnesses. It can be hard to find the solace of meaning when disease is caused by bad habits, bad luck or bad genes.

We have been rendered relatively powerless to believe we can influence our fate, apart from subjugating ourselves to the dictates of technology.

The funerals I went to did as good a job as was possible in the circumstances of retrospectively normalising death. But retrospective validation is a poor substitute for the peace that a person can bring to their own death when they are prepared by realistic expectations.

It is timely to carefully consider the values and goals of modern health care. The challenge as I see it is to work out how to re-establish the prospective acceptance of the normality of death within the practice of modern medicine.

“After all, to the well organised mind, death is but the next great adventure”, as Albus Dumbledore in Harry Potter and the Philosopher’s Stone put it.

Associate Professor Will Cairns is the director of the Townsville Palliative Care Service, Queensland.

3 thoughts on “Will Cairns: Normalising death

  1. Dr Susan McDonald says:

    I agree wholeheartedly with Will Cairns. Many doctors write death certificates but few are present at a ” normal death”. I was recently present at my 91 year old Father’s death. It was a peaceful end as my mother and I held his hand. Mum had never seen a dead body before even though her brother died in an accident in his 30’s and she lived in England during the war. She was pleasantly surprised at how natural it all was. I said a dead body is nothing to be feared. It is just pale and still and the life force has gone. She sort of smiled, that at the age of 90, she had witnessed one of lifes great miracles.

  2. Dr Simon Wamono says:

    This is a great article. Our own future mortality hangs in the balance. Medicalisation of health has let us to believe that we can hang on life for ever with the use of technology. Prevention of disease has been replaced by illusions of Cure of disease. Our denial of impending death blocks us from preparing for it until we face death head-on. Professional errors in treatments called Iatrogenesis causes serious side effects and the public is made docile and reliant on medical professionals to cope with life in their society. The idea of childbirth, aging and dying are defined as medical conditions and illnesses  making individuals and society less able to deal with these natural processes. 

  3. Juhaina Hussain says:

    Great discussion about end-of-life issues.  Ironic quote of the week  – “Dealing with a death also reminds us of the shocking reality that we too might die.”  There’s no “might” about it – the correct verb is “will” and therein exemplifies one of our biggest cultural blocks dealing directly with the event. 

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