On the inevitability of death.
It was one of those weeks when it was impossible to deny the inevitability of death. Like many of us who work in palliative care, I find it necessary to protect myself from time to time by denying death, in subtle ways, so as not to be overwhelmed by death and what many of us refer to as death anxiety or death terror. But this past week was just too overwhelming. The constancy and rapidity of a series of confrontations with death shared with patients combined with a series of deaths of close friends and family forced me to look away. I could not “stare at the sun,” as Yalom (2008) wrote about the impossibility of confronting and contemplating death for too prolonged and sustained a period of time. It had been brewing for some time, but last week was the tipping point. My ability to grapple with my own death anxiety, while working day in and day out with patients who were in despair about their mortality and the “nearness” and “reality” of their deaths from cancer, was being challenged on a regular basis. Age milestones, family milestones, and work milestones all conspired to penetrate any defenses I might have employed to deal with aging and the much-too-rapid passage of time. Even the deaths of celebrities who made up the cultural context of my life shook me: Robin Williams, Garry Shandling, and Mary Tyler Moore. How could they have died? I remember turning, one day recently, to my son and half-jokingly saying out loud, “If Don Rickles [a famous American comedian] can die, that means ANYBODY can die!” That revelation included an evaluation of the reality of my own fate and the stark inescapable reality of my own mortality. I also can’t underestimate the effect of the very recent death of one of my heroes and a pioneer in death-and-dying studies. Avery Weisman, a leading Harvard psychiatrist and director of the Omega Project with Bill Worden in the 1960s, died at the age of 103. Avery taught us about “middle knowledge,” a concept related to coping with death anxiety (Weisman, 1972). The concept of middle knowledge explicates the fact that denial of death is complex and often involves two simultaneously and opposite views of the inevitability of death. We can deny death and minimize the bleakness of one’s prognosis with a terminal illness while simultaneously making plans for that death by completing a will, arranging burial plots, and planning a funeral service. This concept of middle knowledge was important for several reasons: it suggested the benefits of denial in preventing us from being overwhelmed by death terror, thus allowing us to assimilate and even accommodate the reality of our deaths at a manageable pace, and it suggested that human nature and biology utilize denial in complex ways that are not uniformly detrimental to the process of dying.