Emily Dickinson wrote about the “bustle in a house the morning after death” being the “solemnest of industries/Enacted upon earth,“ and I suppose that’s correct, especially for her time. Today, however, with the advent of new and continuing research in medicine, perhaps the new solemn industry should focus on setting goals for end-of-life care.
It seems that although we are mortals, we are reluctant to talk about dying. Today, however, everyone needs to plan for which among the various options available is suitable for them. For it is the process of dying that is of concern here and not death itself.
In an earlier time in America, most people died at home and had the death confirmed by a physician who signed the death certificate. Today’s world is vastly different. A dying person quite likely is to be no longer in the care of family and friends at home. A dying person more likely is to be cared for in a hospital or a nursing home because these institutions are now looked upon as places of refuge, of care and of cure.
The physical circumstances, language, and cultural and social aspects of death have all changed as a result of advances in modern medicine. Medicine is able to prolong life by many means. These modernities require professional, medical, technical and nursing staffs, expensive equipment and controlled environments.
When exactly does death occur? A “patient etherized upon a table” (as T.S. Eliot described one) isn’t exactly dead if the brain is partially functioning and the circulatory and respiratory systems are functioning — even artificially. Language seems to be inadequate here, and complications multiply as research in medicine continues to yield therapies and treatments heretofore dreamed of only in Greek myths of immortality and transformation, or in the imagination of poets.
Further, some people have prepared medical powers of attorney or advanced directives. Even then, sometimes families quarrel among themselves or with the physician whose best judgments about care differ from their own. These differences make decisions about care extremely difficult. Sometimes questions of competency arise, especially for elderly patients with dementia or Alzheimer’s. Occasionally, if a patient has not kept legal papers up to date, the patient’s designated agent may be no longer competent to decide or has died.
Almost certainly the patient, the designated agent and the family are afraid, overwrought emotionally, anxious about making choices whether moral, legal, financial, spiritual, emotional or ethical. Few people seem to make these difficult choices in advance. However, an actively dying person needs to be better prepared for dying by considering the questions and preparing in advance of the time needed their own personally selected goals of care.
When individuals fail to arrange for their own dying, and leave critical decisions to others, they often stir up arguments among family members that wind up in the courts. When family members and medical personnel disagree about a course of treatment, or Medicare-Medicaid denies treatment for reasons of expense or futility, all entities involved feel threatened, become defensive, argue and wind up in legal entanglements. When enough court cases ensue, legislators tend to want to make laws about what should happen in these situations.
We could avoid all of these potential problems if we were to perform our solemn industry and prepare for our own end-of-life care while we are still in charge of our mental faculties. Many of us will have written wills, making sure that our coveted possessions are distributed according to our wishes after we die. Few of us have made plans for our own end-of-life goals of care before death. We need to talk about end-of-life care with our families, our physicians, our lawyers, our financial planners, our spiritual advisers and anyone else who can help us to plan for what happens to us as we lay dying.
These issues are difficult to discuss. For some of it we don’t have satisfactory language to help us start the conversation. We need to find some.
One possibility is for us to go online to our favorite search engine and type in “poems about dying.” A treasury of language and ideas await us. We should read them, reread them, learn them, digest them and invite our friends to share with us the insights we gain from them. We can learn for ourselves whether we understand death to be a lover, or friend or deliverance; or, suffocating darkness. When we know the answer to that question, planning for death might be an easier task.
Emily Dickinson was right in pointing out the “solemn industries” of death. Before death, however, as we move somewhere toward the end of life, we need to enact the solemn industries of dying. We must remember that we are mortal and therefore we will die; we should be prepared.
Esther Rauch is a retired vice president of Bangor Theological Seminary. This column is derived from a talk she gave at Ethics Grand Rounds at Eastern Maine Medical Center as part of a panel on the topic of dying and death.