Thousands of people are currently working on solving the problem of death. Maybe they will succeed, or maybe they will be bored to death and reread this sentence when they are 900 years old and look back fondly on the first century of their lives that they wasted. In the meantime, billions will die. Some from disease, some from freak accidents, and many from what we commonly call “old age.” The latter seems like a relatively pleasant way to end things. A peaceful ending. But what exactly does it look like? What does it actually mean to die of old age? In this week’s Giz Asks, we reached out to several experts to find out.
This article was originally published on August 3, 2020.
Elizabeth Zheng
Assistant Professor of Medicine, University of California, San Francisco
In our society, it is common to say that someone “died of old age.” However, no one actually dies of “old age.” There is always another pre-existing condition or a new condition that causes the death in question. “Old age” is not something that will be written on a death certificate. It is more likely to be something like a heart attack caused by an underlying condition such as an infection, heart attack, or cancer. For example, a blood clot can travel to the lungs, depriving the brain or body of oxygen and causing the heart to stop beating. When someone dies, whether young or old, their body has stopped working due to some disease or disease process.
Disease can manifest itself in different ways in older people. As we age, our bodies wear down normally and do not respond as resiliently to health problems. Young people can and do die from the same things that older people do: heart attacks, blood clots in the lungs, but older people may react differently to these diseases. For example, pneumonia may not show the normal signs of infection. Instead, if you have diabetes, it may show up as high blood sugar, and if you have dementia, it may show up as a change in your mental status. You may become more confused and unable to do the things you used to do. When these things happen as you age, you may not be able to attribute them to an underlying disease process.
People always say they want to “die in their sleep,” but this is not a specific phenomenon. People who die in their sleep may have had cancer or infections that were accidentally discovered while they were asleep, not while they were awake. It is also important to note that people with serious illnesses, such as terminal congestive heart failure or terminal cancer, may choose to “let themselves die naturally.” This means focusing on relieving symptoms and making themselves comfortable, rather than going to the hospital and receiving aggressive treatment.
Jessica Humphries
Assistant Professor of Medicine, University of California, San Francisco, specializing in palliative care
People often say, “I want to die in my sleep when I’m old.” But everyone dies the same way. The heart stops beating. That’s the final stage. When you fill out a death certificate, you have to put in the cause of death. You have to go back to cardiopulmonary arrest, a blood clot in the lungs, a cancer diagnosis, and so on. I train my students to think, “What was the cause before that? What was the cause before that?” and so on.
As a palliative care physician, I care for seriously ill patients. Many of them are dying. My job is to sit down with people and talk about the process of dying, and then help them get through it. To me, the word ‘natural’ means a kind of gentleness. You don’t know what’s happening, you don’t have to think about it.
But the reality is that our death process rarely happens that way. Nowadays, it is very rare for someone who is perfectly healthy and has no medical problems to fall asleep one night and have a heart attack. (And despite the common expression of ‘dying in your sleep’, unless we observe the person, it is very rare to know if they actually died in their sleep. They may have been awake.)
In America, the “natural history” usually goes like this: We find out that someone has a problem, we try to cure them, we try to ease their suffering, we try to prolong their life. And then we start losing the fight. Then we think about how to focus on making their life as good as possible.
Caveat: I have done a lot of work in Uganda and India, and I will tell you that in most of the world, a “natural” death actually involves a lot more pain and a lot more suffering. We don’t have access to opioids in most of the world. In some ways, the most “natural” death is one in excruciating pain. So our goal should be to alleviate suffering as much as possible.
David Cassaret
He is a professor of medicine and director of palliative care at Duke University School of Medicine and author of Shocked: Adventures in Bringing Back the Recent Dead.
Do you want to die of old age? Well… you can’t. It’s a fancy idea, and there’s actually a lot of conventional wisdom about “dying of old age.” Many people want to do it, and many of my patients do. They live like skiers on a slalom course, dodging life-threatening diseases one by one, slogging through heart failure, prostate cancer, pneumonia, and now COVID, all in the hope of dying peacefully of “old age.”
But there is no such thing as dying of old age. As you get older, your heart doesn’t just beat more slowly until, late at night, it stops beating. Aging puts you at risk for a variety of diseases, from cancer to dementia, any of which can end your life. But don’t blame old age.
For example, my grandmother died at the ripe old age of 103. (No one in my family worried about inheriting her china collection; they just hoped they would inherit her longevity genes.) She grew frail, but she was lucid and mentally sound, and she read a book a day, including my novels, one of which she actually finished.
But she didn’t die of old age. Her age and frailty increased her risk of a hip fracture, which she suffered. She then underwent high-risk surgery, which she completed with great success, but was eventually interrupted by a stroke. She died very old. And although she had the level of mental and physical health that most of us can only hope for in her last years, she didn’t die of old age. She died from an avalanche of bad events, and her age made her more vulnerable.
An interesting question arises: What do you want to die of? If you watch your cholesterol closely so you don’t die of a heart attack, eat a lot of raw kale so you don’t die of colon cancer, and avoid smoking so you don’t get emphysema, what will you die of? What will be left? (The first person to ask that question in my mind 20 years ago was my mentor, Dr. Joan Lin. I still don’t know the answer.)
If we could avoid every life-threatening disease the world throws at us, what would be left? Well, my grandmother’s story is one answer to that question. She did everything right, from her healthy lifestyle (don’t laugh) to her easygoing, easygoing disposition that kept her supernaturally calm. She did everything right, but doing everything right can only get you so far. And then life finally makes the final call and intervenes with a fall, a stroke, a heart attack, or pneumonia.
One thing to note. I said there is no such thing as dying of old age, but people certainly do die of old age. And this is a distinction to keep in mind. Many people who live to old age retain most of their mental acuity and physical functions. And many, and probably most, succeed in dying suddenly in their sleep. Of course, you wouldn’t want to die that way in your 20s with no warning or time to prepare. But if you’ve walked the earth for a century and never had a warning or barely survived to say goodbye, dying in your sleep is probably a really good way to go.
And that is probably the biggest difference between those who die very old and the rest of us. Many people who die in their 90s or older have made peace with death. They have done what they needed to do and said what they needed to say. They have probably been preparing for years. So in my experience as a palliative care physician, there is often less struggle and less last-minute rescue attempts in the form of aggressive surgery or long-term chemotherapy. They just make peace and sign up. Whatever “dying old” means, it is a willingness to say goodbye and move on.
Alan Andrade
Assistant Professor, Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
The Centers for Disease Control and Prevention recommends that doctors no longer use the terms “death of old age” or “natural death” because these terms have little value in the medical community. These terms have been widely used in low-income settings when doctors are uncertain about the sequence of events that led to the death recorded on the death certificate, when an unnatural cause of death, such as homicide or suicide, is not suspected, or when a medical examiner cannot conduct an investigation to determine the exact cause of death. However, these terms are still popular with the public because they convey that the death was not an unexpected or traumatic event and help avoid sensitive questions about the cause of death. This is because we all want to stay “young and healthy” for as long as possible and we all want to avoid debilitating, serious illnesses. Like birth, death is a liminal event associated with intense emotion and is a topic that people generally avoid.
Interestingly, most people do not fear death itself, but rather the process of dying. People who die naturally without artificial life support, such as a ventilator, generally experience a similar process of dying. What determines the difference in the process of dying is how quickly the body stops. This process can range from weeks to months, days to weeks, hours to days, or minutes to hours. People who die in the weeks to months period tend to have a steady decline in function and generally spend more time sitting or lying down, relying more on others for personal care. People who die in the days to weeks period have increasingly more difficulty concentrating, less awareness of their surroundings, and less interest in food and water. People who die in the hours to days period are generally less aware of their surroundings, have difficulty swallowing, have difficulty breathing, and appear exhausted, as if they just finished a sprint. People who die in the minutes to hours period are unconscious and have irregular breathing patterns.
In short, death is a natural process and is usually peaceful. Depending on the time and cause contributing to death, people may experience symptoms such as shortness of breath, pain, or delirium. Delirium is a common medical condition associated with poor concentration and confusion, and can be managed to minimize suffering and maximize the person’s comfort and quality of life during the remaining time.
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(Updated with new details on March 4, 2022)