The Best Disease From Which To Die

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We can’t, of course, plan the way we’re going to die (with the obvious exception of suicide). We can, however, live in such a way that reduces the likelihood of our dying from certain diseases. Which is why it’s now almost universally accepted that we should exercise regularly, not smoke, drink only in moderation (if at all), avoid too much fat in our diet (and now probably too much carbohydrate), and not gain too much weight as we age.

Even a quick perusal of this admittedly incomplete list of healthy behaviors reveals that most of the actions within our control aim at reducing our risk of death from heart disease. Certainly, we’re lucky that we have so many ways to reduce this risk as heart disease remains the number one cause of death worldwide. But here’s a strange paradox: as we’ve gotten better at preventing death from heart disease, we’ve increased our exposure to the risk of death from other diseases that kill far less quickly and that arguably end up causing far more suffering. The older we get, the more likely we are to become ill with diseases like cancer, dementia, and stroke, to name just three of the most common illnesses that preferentially affect the elderly.

True, we’ve also become better at treating these diseases, too. And even when we can’t cure them, we can help people to live longer with them. But is this necessarily a good thing? Certainly, longer life in general is. But what kind of quality of life are the elderly now able to anticipate? We’re not nearly as good at measuring quality as we are quantity, but the data we do have paints a surprising picture: there has developed what scientists call a “lengthening of morbidity” among the elderly—meaning we’re spending more years living with chronic diseases and poor health. Though one study reports that exercising in middle age seems to increase the number of years we live into old age without developing chronic illness, we’re now more likely than ever to reach old age and thus experience suffering at the hands of disease at the end of our lives.

When I’ve had the courage to ask some of my elderly patients who suffer from chronic, debilitating diseases about the quality of their lives, I rarely hear them tell me it’s good. “I’m getting by,” some say. “I’m okay,” say others. Some, however, just shrug, as if to say, “This is the life I’ve been given. What can I do but endure it?”

Because the answer to that last question is almost always “nothing other than what you’ve been doing,” I don’t typically pursue the conversation any further. But lately I’ve been wondering if we aren’t all caught in a peculiar moment in our history, one in which we’ve made great strides in delaying and even preventing the number one cause of death but in which we’ve not yet made equally impressive advances in delaying and preventing the other diseases that we’re all now at greater risk for getting because we’re less likely to die of heart disease earlier in our lives.

Having watched so many patients die unpleasant and lingering deaths, I have little doubt that death from heart disease is better than death from many other maladies. Yet an early death from heart disease seems equally undesirable. Which has led to another uncomfortable paradox: all the work we’re encouraged to do to minimize our risk of death from heart disease actually increases our risk of having an unpleasant death. Though ideally we’d all live to a great old age and drop dead from a heart attack, to delay such an end through healthy behaviors is likely to prevent such an end in the first place. Eventually, science will offer better treatments for the other diseases that living longer makes us all more likely to contract, but for now, we all have to live with the truth that decreasing the risk of dying from one disease has increased our risk from dying from other, arguably more horrible ones. And though realizing this hasn’t diminished my enthusiasm for helping patients to decrease their risk of dying from heart disease, it does refocus me on the quality of life that such interventions are trying to buy them. What, then, is the best disease from which to die? Unfortunately, the one we’re the best at preventing.

Next Week: Preventing Compassion Fatigue

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  • A lengthening of morbidity and especially a lengthening of the dying process itself is an unintended result of medical advances. I have wondered about developing an end-of-life equivalent of the APGAR as an aid in helping patients, families and doctors decide what interventions are appropriate and kind. I have seen the loss of dignity, comfort and sanity in the pursuit of prolonging heartbeat and air exchange. Everyone involved suffers longer than is necessary. Hospice is a better approach for this final journey.

    I wish no person had to face an existence which seemed interminable, where every day was painful, purposeless, helpless and lonely. Does our aging population need a new branch of medicine/psychology/sociology/public health to address where prolonging quality of life ends and prolonging morbidity begins and … I don’t know what.

  • How interesting! I’ve had a chronic illness for 10 years. It’s been a great time to grow in many ways. I didn’t see it as an illness that would cause death, though I do think about death since relatives and friends have died recently or on their way.

    The woman who brings me eggs from her farm said yesterday that her husband is scared about being alone—and has only a few more months to live. She told him that “next time, find me sooner.” And smiled.

    I do think about what I’ll do as I age and my memory gets worse, or if I fall. Lately I’ve noticed having age-related physical challenges.

  • To live longer or better? What feels like an age-old problem, yet we hear so little about it! A post on the more hopeless side than usual, Alex, but a balance is a healthy thing occasionally, I think. A topic that deserves so much more discussion than it gets.

    It points to a western fear of death that we consider length of life over quality so often. I am a third year medical student and these exact questions make me think end-of-life care might be a very exciting field to enter (more spiritual than others potentially).

    Spiritually, morally and emotionally provocative. Bravo, Alex.

  • The Oglala Sioux had a cultural practice called throwing oneself away. Elders who could not keep up with the moves from winter to summer hunting grounds or from summer to winter hunting grounds walked away into the woods the morning of the tribe’s departure. The elder’s judgment was respected. The elder did not wish to be a burden, to have someone have to drag them on a sledge.

    I imagine a final assignment as I age: that I will define “quality of life” for myself, and prepare an advance-directives document that gives priority consideration to quality of life.
    If my quality of life is poor (by my own definition), my directive will be to withhold treatment, nutrition, hydration, etc. so that I can throw myself away with dignity.

    There are fates worse than death. Wandering around in this world as a lost soul without purpose, without usefulness, without people to be close to are fates worse than death—for me.

  • Not everything we do to lengthen life does only that one thing. Most of the recommendations for sensible living both lengthen life and improve the quality of life for the duration. I understand that diseases of old age can be very unpleasant and thus trash our quality of life, but healthy eating, lots of healthy exercise, enough sleep, and a genuinely positive outlook don’t just make us live longer in misery. I’m 70 and none of the age-related problems I’m developing has made me unhealthy enough to cause unhappiness. I have increasing aches and pains, and my mind is not as sharp, but my deep appreciation for the good things of life has only increased over the past few years. As my body and mind do their slow decline, my (figurative) heart finds more joy in every experience.

  • My favorite choice to die is the massive hemorrhagic stroke. In the Circle of Willis. Did I say massive?

  • I believe that the nuclear family has isolated our elder population. To be needed, asked advice of, respected, admired, loved and included in daily activities can help ward off loneliness, dementia, depression and even chronic pain.

    Laughter and conversation will help too. However abuse of our bodies by over-eating, alcohol abuse, smoking and an inactive lifestyle comes under the heading we reap what we sow. You simply can not fix 60, 70, 85 years of self abuse. Genetics play a huge part too.

    I believe aging with health starts at birth. Below is a link to what I would do (if i had the courage):–toronto-man-ends-his-life-to-avert-horrors-of-huntington-s-disease

  • Yes, probably this issue is one of the most interesting thing that we found in our daily practice. I am nurse who works with terminal patients in their homes. For me it is very important to ask families of such patients what their relatives thought or said about the end-of-life instructions, supposing we can´t talk with the patient; and mainly their answer is quality of life.

  • I’m scared of dying, but much more scared of aging, and the loss of independence, dignity and enjoyment that often go with it. It might seem a crass comparison, but we euthanize cats and dogs when they no longer seem to be enjoying life. Legislating for euthanasia is a minefield, but I would much rather go peacefully from a massive dose of morphine than hang around miserably for years waiting to die.

  • Alex, I was discussing this very issue with a colleague this morning. My 80-year-old mother is in hospital again, from yet another fall, and all I hear from her mouth is “Why am I still alive?” Among her worries are of course the pain, but the loss of independence and the concern that she is a burden. I don’t think it’s death that our aged and frail fear; I think it’s the prolonged suffering to themselves and their loved ones. It is certainly very challenging to watch it all unfold…

  • Another excellent column, providing much needed food for thought. Two scenarios from own family:

    —I watched my father die at 77 after an unsuccessful attempt to repair a badly diseased aortic valve. Aside from a couple of years of angina and mild (though progressive) shortness of breath, he didn’t suffer tremendously, and continued to work every day before his operation.

    —Ten years later I watched my mother die from a decade-long descent into Alzheimer’s. Five years were spent living by herself—confused, increasingly afraid, and progressively suspicious of persecution by all around her. After falling and breaking a number of bones, her final five years were spent in a nursing home sinking slowly-but-steadily into total dementia. I’m not sure whether she knew who I was most of this time. Even with the medications and the terrific care from the nursing home staff, she lived in constant terror that devolved into a kind of catatonic state. I wish more people were aware of the truly devastating span of this disease. Alzheimer’s is not merely being blissfully forgetful, the way our popular culture mysteriously portrays it. It’s hell on earth.

    My point ought to be obvious—I’m agreeing with your assessment, and adding my anecdotal confirmation. Also, I guess, I’m encouraging Elliot to follow that path toward providing end-of-life care. The consistently great medical providers I encountered during my mother’s illness were, in fact, mainly spiritually-attuned people, working daily with the tough questions while providing essential palliative care and comfort where (IMO) it’s still sorely needed.

    Sorry for the lengthy message. Again, thanks for a fine column.

  • @ George: Bravo!

    Yours is the most Buddhist response, George! It is quietly accepting, full of gratitude. I understand about being able to grasp the big picture, finally, in our older years. It is a peaceful place to be.

  • @chris: Thanks! BTW, my advance directive was prepared and filed many years ago, and I review it and, if necessary, update it every few years. Sometimes, I’ll hear a friend or family member say, “Just shoot me!” (only half-joking), which sums up their dread of a long, slow decline.

  • This was a really interesting post, thank you for sharing it. I too wish to avoid a long painful decline and hope that when my time comes that society will have evolved sufficiently to provide the ability to end my life peacefully with the help of my physician.

  • My husband’s family is fortunate and has good health practices, also. They live long (as in into their late 80s and mid 90s) and die quickly. Usually in a matter of days from pneumonia following a cold, a minor fall, or just that thing the medical community doesn’t like to admit—old age. They don’t have dementia, and they don’t become excessively frail. Some do have heart disease, but that’s not what kills them.

    Healthy eating, exercise, not smoking, and moderation regarding alcohol also help us to avoid other diseases, including dementia and cancer. So, even though my family is prone to cancer, I follow good health practices. I would like to enjoy a physically active life without too many life-style related disabilities, for as long as I can. We have no guarantees in life, but while we are alive, why not be healthy?

    And why not quit worrying every single day? After all, once we adopt healthy practices, our main thought should be “I am alive today.” It is often a glorious day.

  • So should I start smoking?

    Allen: No.


  • Very interesting post, thought-provoking. I come from a family of long-lived folk who were generally pretty feisty until the last few years. Dying prematurely of heart failure is so very sad, and common in Scotland still, my home country. Dying in my 80’s or 90’s of it suddenly appealing… but hard to plan. Start smoking again at 80??

  • Too much exercise amuses me. I have relative who brags of averaging 45 miles a day on a bike and I wonder if he thinks if he eats right and exercises to extremes he will be the first guy to live forever. At least he is trying. But I see it as fear and not having really thought about life and accepting what happens to us all. If his feet are moving all is well. What we really need to do is sit quietly sometimes and think about dying and accept it. Learn to live with it? Plan for it? I ride a horse and jokingly plan to fall off a cliff or some such and do it my way.

  • What did that “Wisest man in all Japan,” say? Even one day of life…

  • I think we will become better at aging as we live longer. Since I’ve had chronic illness most of my life, and chronic pain for over 10 years, I have learned to live well within the perimeters of my limits. I have friends in their 70s and 80s dealing very well with aging and accompanying maladies. Life long learning and continuing to feel loved seem to be key. There’s a certain feeling of gratitude and adaptability that keeps them from despair. A dear 89-year-old friend just this year beat uterine cancer and is extremely happy about every day above ground, even though her pace is slow, she lives better than many half her age.

  • Dearest Alex:

    This article had great meaning for me, since I am now a “young” 76 year old person…..still healthy and still good looking!!

    I work at a Senior Center in New Milford and have the opportunity to extend great compassion, kindness and good feelings to all of these many elderly and sick people.

    I am so grateful to Dr. Ikeda for all his wonderful guidance about life and how we should clean ourselves from the inside out. Every day I have the opportunity to really be a good Buddhist. I am the meeter and the greeter in this wonderful place.

    I am so grateful for Dr. Ikeda’s wonderful guidance about life. I try to put it to use every day.

    Thanks for your wonderful “Happiness In This World.”


  • That´s exactly why I have been a member of the Right-To-Die society of the country where I have citizenship from the start of it. But the legal fights are far from finished. The number of MDs who have stopped to force their patients to die according to Xtianity is still too small (albeit growing), therefore:

    Thank you, Alex!!!