She’d been preoccupied with death for several years now; but one aspect had never before crossed her mind: dying, you don’t get to see how it all turns out. Questions you have asked will go unanswered forever. Will this one of my children settle down? Will that one learn to be happier? Will I ever discover what was meant by such-and-such? … She had also supposed that there would be some turning point, a flash of light in which she’d finally wake up wiser and more contented and accepting. But it hadn’t happened. Now it never would. She’d supposed that on her deathbed … deathbed! Why, that was this everyday, ordinary Posturepedic, not the ornate brass affair that she had always envisioned.

— Anne Tyler, Dinner at The Homesick Restaurant

How do our expectations of what happens after death affect our dying? For example, if we expect to face a harsh judgment on our lives and potential punishment, would we not fear death and seek to avoid it in any way possible? If we expect to be reunited with deceased loved ones, would we not look forward to death? If we expect to be reincarnated as a new soul or resurrected in spirit, would that take some of the fear away from death? And, if we are agnostic, not sure about our own or anybody else’s ability to say or predict anything intelligible about death, wouldn’t that affect our dying?

Death is part of the natural order. It would be difficult to think of anything, animate or inanimate, that doesn’t have a natural lifespan. The elucidation of apoptosis, or programmed cell death, shows how the development of the proper functioning of organs depends, in part, on cell death. “Under normal physiological circumstances, damaged or senescent cells sacrifice themselves for the greater good of the whole organism through a genetically programmed type of cell death called apoptosis.“¹ Natural selection, the basic paradigm of biology, reveals that “death inevitably occurs at that point in the individual life when it serves the viability of the … species… Like cells sloughed off by a human body and constantly renewed, individuals within a species also are sloughed off and renewed in order to sustain the viability of the species as a whole.”²

But is the end of one thing always the beginning of something else, a transformation, or is the end simply the end?

We are born in the middle and die in the middle. The world existed before we got here and it will continue to exist after we are gone. We all know that, but have difficulty at times not to think of reality as that which we have experienced in our lifetime.

I remember the death of my first patient as a medical student doing my internal medicine clerkship. This woman, who we worked on for days, died in the Intensive Care Unit, after a futile, all out-resuscitation effort. I was moved by the drama and solemnity of her death, and the noble and heroic attempts to resuscitate her in which I played a small role. But I was even more awed by the fact that we just went from there to lunch, like nothing had happened. The radio at the nurse’s station never stopped playing its rock and roll tunes during this whole time. What may have been eternity for someone else was not even registered on the radar screen of the ICU for more than a moment, let alone in the world at large. Life goes on; it always has and it always will.

We share this little span of time with others of our generation, and this can bring with it a special bond with them. My father and his World War II army friends shared something that I never could. I visited the Vietnam Memorial in Washington, DC., a few years ago while doing college visits with my oldest son. I had not been in Washington since the last war protest march in the 1970’s and so was very emotional. However, the Vietnam Memorial overwhelmed me: all those names of those of my generation who never made it into middle age, who never made it to the 1980’s or the 1990’s, and suddenly I was crying, thinking about what they missed. Time had not moved for them since the 1960’s or 70’s, nor will it ever move again. But won’t that happen to each of us? While visiting the grave of someone you loved, we all wish we could tell him or her about all the things are going on. Recently I started to read Marie-Louise von Franz’s book called On Dreams and Death – A Jungian Interpretation. I realize what a long history such questions have had and, indeed, how they have been at the foundation of whole civilizations. This dream by the writer J. B. Priestly is an inspiring vision:

I was standing at the top of a very high tower, alone, looking down upon myriads of birds flying in one direction; every kind of bird was there, all the birds in the world. It was a noble sight, this vast aerial river of birds. But now in some mysterious fashion the gear was changed, and time speeded up, so that I saw generations of birds, watched them break their shells, flutter into life, mate, weaken, falter, and die. Wings grew only to crumble; bodies were sleek and then, in a flash, bled and shriveled; and death struck everywhere at every second. What was the use of this entire blind struggle towards life, this eager trying of winds, this hurried mating, this flight and surge, all this gigantic meaningless biological effort? As I stared down, seeming to see every creature’s ignoble little history almost at a glance, I felt sick at heart. It would be better if not one of them, if not one of us all, had been born, if the struggle ceased forever. I stood on my tower, still alone, desperately unhappy. But now the gear was changed again, and time went faster still, and it was rushing by at such a rate, that the birds could not show any movement, but were like an enormous plain sown with feathers. But along this plain, flickering through the bodies themselves, there now passed a sort of white flame, trembling, dancing, then hurrying on; and as soon as I saw it I knew that this white flame was life itself, the very quintessence of being; and then it came to me, in a rocket burst of ecstasy, that nothing mattered, nothing could ever matter, because nothing else was real but this quivering and hurrying lambency of beings. Birds, men, or creatures not yet shaped and coloured, all were of no account except so far as this flame of life traveled through them. It left nothing to mourn over behind it; what I had thought as tragedy was mere emptiness or a shadow show; for now, all real feeling was caught and purified and danced on ecstatically with the white flame of life. I had never felt before such deep happiness as I knew at the end of my dream of the tower and the birds.³

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1. Hetts, S. “To die or not to die. An overview of apoptosis and its role in disease.” JAMA. 1998; 279:300-307.
2. Jonas, Doris F. “Life, death, awareness, and concern: a progression,” in Life After Death, ed, Arnold Toynbee. Londone: Weidenfeld & Nicolson. 1976.
3. Piestly J .B., Man and Time, as quoted by Marie-Louise von Franz, On Dreams & Death. New York: Open Court. 1999.