Dying alone usually has a negative connotation attached to it. This is probably why movies portray it as sad and heartbreaking. On the flip side, dying while being surrounded by friends and family is often thought of as a good death. The person was loved and made to feel secure as they passed on. They didn’t have to endure the pain of dying alone.
But what happens in the final moments of death is a subject that’s largely still being discovered. No one really knows for sure definite answers to the big questions like “Does your consciousness continue after you stop breathing?” or “Will you have a better death if you have loved ones surrounding your bed?”
Social researcher and death studies scholar Glenys Caswell from Nottingham University noted that, for some people, dying alone is something that they choose of their own accord (via The Conversation). One of Caswell’s studies, which was published in the journal Mortality in 2017, involved interviewing 11 elderly persons who lived by themselves and seven hospice nurses about their thoughts surrounding dying alone. While there was some belief among the hospice nurses that dying alone is not something they’d endorse, Caswell found that for the older people, “dying alone was not seen as something that is automatically bad, and for some of the older people it was to be preferred.” They preferred it to having their freedom curtailed or being confined to a care home.
They might die alone to spare their loved ones pain
“We have those patients who die in the middle of the night. We hear stories about the loved one who just stepped out for five minutes and the patient died. We may have even witnessed a quick death ourselves. I believe this happens by the patient’s choice,” wrote Miles. She added that this happens mostly in instances when the dying person is a parent. “I believe it is a protective factor,” she explained.
Henry Fersko-Weiss, a licensed clinical social worker and executive director of the International End-of-Life Doula Association, feels slightly differently about the topic. While he doesn’t discount the fact that some people might die alone, he shared in a YouTube video that people like feeling connected and safe before they pass away. Fersko-Weiss said that “because of the way we think about death, [we] feel that we’ll be a burden to loved ones” if we let them see us die. Sparing loved ones the pain of it all might be at the heart of the decision but this is something friends and family should have an open conversation about, he added
Having an open dialogue with your loved one can help
No matter how painful those final moments might be, it can be a good idea to equip yourself with the right tools to have open conversations that foster understanding on both sides, say the experts. You might want to lean into what dying people want you to know about how they’d ideally want to go, and also assess your own emotions, cultural biases, and ideas around it. If you’re unable to broach the topic yourselves, enlist the help of hospice care workers or even a therapist.
It is possible that the person who is dying is concerned that the loved ones whom they are leaving behind will carry with them for the rest of their lives the burden of seeing them pass, shared Fersko-Weiss in the video. You could reassure them by saying something like, “Of course, we want to be there. It doesn’t matter how it looks or how it sounds or how emotionally difficult it may be to be present. It is part of our love for you that we would want to be there,” said the death doula.
How you choose to be present when someone you love is dying is a decision both the dying and those being left behind can arrive at together, per the experts. And, in the instance when your loved one chooses to wait and die alone, “openness created through discussion might also help to remove some of the guilt that family members feel when they miss the moment of their relative’s death,” added Caswell
A decade ago, Hadley Vlahos was lost. She was a young single mother, searching for meaning and struggling to make ends meet while she navigated nursing school. After earning her degree, working in immediate care, she made the switch to hospice nursing and changed the path of her life. Vlahos, who is 31, found herself drawn to the uncanny, intense and often unexplainable emotional, physical and intellectual gray zones that come along with caring for those at the end of their lives, areas of uncertainty that she calls “the in-between.” That’s also the title of her first book, which was published this summer. “The In-Between: Unforgettable Encounters During Life’s Final Moments” is structured around her experiences — tragic, graceful, earthy and, at times, apparently supernatural — with 11 of her hospice patients, as well as her mother-in-law, who was also dying. The book has so far spent 13 weeks on the New York Times best-seller list. “It’s all been very surprising,” says Vlahos, who despite her newfound success as an author and her two-million-plus followers on social media, still works as a hospice nurse outside New Orleans. “But I think that people are seeing their loved ones in these stories.”
What should more people know about death? I think they should know what they want. I’ve been in more situations than you could imagine where people just don’t know. Do they want to be in a nursing home at the end or at home? Organ donation? Do you want to be buried or cremated? The issue is a little deeper here: Someone gets diagnosed with a terminal illness, and we have a culture where you have to “fight.” That’s the terminology we use: “Fight against it.” So the family won’t say, “Do you want to be buried or cremated?” because those are not fighting words. I have had situations where someone has had terminal cancer for three years, and they die, and I say: “Do they want to be buried or cremated? Because I’ve told the funeral home I’d call.” And the family goes, “I don’t know what they wanted.” I’m like, We’ve known about this for three years! But no one wants to say: “You are going to die. What do you want us to do?” It’s against that culture of “You’re going to beat this.”
Is it hard to let go of other people’s sadness and grief at the end of a day at work? Yeah. There’s this moment, especially when I’ve taken care of someone for a while, where I’ll walk outside and I’ll go fill up my gas tank and it’s like: Wow, all these other people have no idea that we just lost someone great. The world lost somebody great, and they’re getting a sandwich. It is this strange feeling. I take some time, and mentally I say: “Thank you for allowing me to take care of you. I really enjoyed taking care of you.” Because I think that they can hear me.
The idea in your book of “the in-between” is applied so starkly: It’s the time in a person’s life when they’re alive, but death is right there. But we’re all living in the in-between every single moment of our lives. We are.
So how might people be able to hold on to appreciation for that reality, even if we’re not medically near the end? It’s hard. I think it’s important to remind ourselves of it. It’s like, you read a book and you highlight it, but you have to pick it back up. You have to keep reading it. You have to. Until it really becomes a habit to think about it and acknowledge it.
I was reading these articles recently about how scientists are pursuing breakthroughs that could extend the human life span to one hundred twenty.1
1 Examples of which could include devising drug cocktails that get rid of senescent cells and filtering old blood to remove molecules that inhibit healing.
There’s some part of people that thinks they can cheat death — and, of course, you can’t. But what do you think about the prospect of extending the human life span? I don’t want to live to be 120. I have spent enough time around people who are close to 100, over 100, to know that once you start burying your children, you’re ready. Personally, I’ve never met someone 100 or older who still wants to be alive. I have this analogy that I did a TikTok2
2 Vlahos has 1.7 million followers on TikTok, where she posts about her experience as a hospice nurse and often responds to questions about death and dying.
on. This is from having a conversation with someone over 100, and her feeling is that you start with your Earth room when you’re born: You have your parents, your grandparents, your siblings. As you get older, your Earth room starts to have more people: You start making friends and college roommates and relationships. Then you start having kids. And at some point, people start exiting and going to the next room: the afterlife. From what she told me, it’s like you get to a point when you’re older that you start looking at what that other room would be, the afterlife room,3
3 According to a 2021 Pew Research survey, 73 percent of American adults say they believe in heaven.
and being like, I miss those people. It’s not because you don’t love the people on Earth, but the people you built your life with are no longer here. I have been around so many people who are that age, and a majority of them — they’re ready to go see those people again.
“The In-Between” also has to do with the experience of being in between uncertainty and knowing. But how much uncertainty is there for you? Because in the book you write about things that you can’t explain, like people who are close to death telling you that they’re seeing their dead loved ones again. But then you write, “I do believe that our loved ones come to get us when we pass.”4
4 From Vlahos’s book: “I don’t think that we can explain everything that happens here on Earth, much less whatever comes after we physically leave our bodies. I do believe that our loved ones come to get us when we pass, and I don’t believe that’s the result of a chemical reaction in our brain in those final hours.”
So where is the uncertainty? The uncertainty I have is what after this life looks like. People ask me for those answers, and I don’t have them. No one does. I feel like there is something beyond, but I don’t know what it is. When people are having these in-between experiences of seeing deceased loved ones, sometimes it is OK to ask what they’re seeing. I find that they’ll say, “Oh, I’m going on a trip,” or they can’t seem to find the words to explain it. So the conclusion I’ve come to is whatever is next cannot be explained with the language and the knowledge that we have here on Earth.
An image from Hadley Vlahos’s TikTok account, where she often posts role-playing scenes and video tutorials. She has more than two million followers across social media.
Do these experiences feel religious to you? No, and that was one of the most convincing things for me. It does not matter what their background is — if they believe in nothing, if they are the most religious person, if they grew up in a different country, rich or poor. They all tell me the same things. And it’s not like a dream, which is what I think a lot of people think it is. Like, Oh, I went to sleep, and I had a dream. What it is instead is this overwhelming sense of peace. People feel this peace, and they will talk to me, just like you and I are talking, and then they will also talk to their deceased loved ones. I see that over and over again: They are not confused; there’s no change in their medications. Other hospice nurses, people who have been doing this longer than me, or physicians, we all believe in this.
Do you have a sense of whether emergency-room nurses5
5 Who, because of the nature of their jobs, are more likely than hospice nurses to see violent, painful deaths.
report similar things? I interned in the E.R., and the nurse I was shadowing said that no one who works in the E.R. believes in an afterlife. I asked myself: Well, how do I know who’s correct? How am I supposed to know? Are the people in the church that I was raised with6
6 Vlahos was raised in an Episcopalian family. She now refers to herself, as so many do, as spiritual rather than religious
more correct than all these people? How are you supposed to know what’s right and what’s not?
But you’ve made a choice about what you believe. So what makes you believe it? I totally get it: People are like, I don’t know what you’re talking about. So, OK, medically someone’s at the end of their life. Many times — not all the time — there will be up to a minute between breaths. That can go on for hours. A lot of times there will be family there, and you’re pretty much just staring at someone being like, When is the last breath going to come? It’s stressful. What is so interesting to me is that almost everyone will know exactly when it is someone’s last breath. That moment. Not one minute later. We are somehow aware that a certain energy is not there. I’ve looked for different explanations, and a lot of the explanations do not match my experiences.
That reminds me of how people say someone just gives off a bad vibe. Oh, I totally believe in bad vibes.
But I think there must be subconscious cues that we’re picking up that we don’t know how to measure scientifically. That’s different from saying it’s supernatural. We might not know why, but there’s nothing magic going on. You don’t have any kind of doubts?
None. Really? That’s so interesting. You know, I read your article with the atheist.7
7 “How to Live a Happy Life, From a Leading Atheist,” an interview with the philosopher Daniel C. Dennett, published in August.
I feel like you pushed back on him.
There areso many things in our lives, both on the small and the big scale, that we don’t understand. But I don’t think that means they’re beyond understanding. OK, you know what you would like? Because I know that you’re like, “I believe this,” but you seem to me very interested; you’re not just set in your ways. Have you ever heard that little story about two twins in a womb?8
8 Known as the parable of the twins, this story was popularized by the self-help author Dr. Wayne W. Dyer in his 1995 book “Your Sacred Self: Making the Decision to Be Free.”
I’m going to totally butcher it, but essentially it’s two twins who can talk in the womb. One twin is like, “I don’t think that there is any life after birth.” And the other is like, “I don’t know; I believe that there is something after we’re born.” “Well, no one’s ever come back after birth to tell us that there is.” “I think that there’s going to be a world where we can live without the umbilical cord and there’s light.” “What are you talking about? You’re crazy.” I think about it a lot. Do we just not have enough perspective here to see what could come next? I think you’ll like that story.
For the dying people who don’t experience what you describe — and especially their loved ones — is your book maybe setting them up to think, like: Did I do something wrong? Was my faith not strong enough? When I’m in the home, I will always prepare people for the worst-case scenario, which is that sometimes it looks like people might be close to going into a coma, and they haven’t seen anyone, and the family is extremely religious. I will talk to them and say, “In my own experience, only 30 percent of people can even communicate to us that they are seeing people.” So I try to be with my families and really prepare them for the worst-case scenario. But that is something I had to learn over time.
Have you thought about what a good death would be for you? I want to be at home. I want to have my immediate family come and go as they want, and I want a living funeral. I don’t want people to say, “This is my favorite memory of her,” when I’m gone. Come when I’m dying, and let’s talk about those memories together. There have been times when patients have shared with me that they just don’t think anyone cares about them. Then I’ll go to their funeral and listen to the most beautiful eulogies. I believe they can still hear it and are aware of it, but I’m also like, Gosh, I wish that before they died, they heard you say these things. That’s what I want.
You know, I have a really hard time with the supernatural aspects, but I think the work that you do isnoble and valuable. There’s so much stuff we spend time thinking about and talking about that is less meaningful than what it means for those close to us to die. I have had so many people reach out to me who are just like you: “I don’t believe in the supernatural, but my grandfather went through this, and I appreciate getting more of an understanding. I feel like I’m not alone.” Even if they’re also like, “This is crazy,” people being able to feel not alone is valuable.
This interview has been edited and condensed for clarity from two conversations.
A cemetery plot designated for green burial in Cherokee Township Cemetery near North San Juan, Calif.
By Paul Thornton
To get a sense of how progressive ideals don’t always reflect actual practice, try burying a dead relative in Southern California. You’ll find that even in this land where people talk about sustainability, saying farewell in an environmentally responsible manner is, for most people, nearly impossible.
I came to grips with that reality in August, when my mother died from an unexpected illness. Making the final arrangements was my job, and I valued the experience as much as one can while gripped by grief.
My mother, a nurse and devout Lutheran, spent her life caring for the world around her and the people whom Jesus called “the least of these brothers and sisters.” I felt strongly that her remains should be handled in a way that reflected her values and, to some extent, mine.
As funeral director and poet Thomas Lynch wrote, “By getting the dead where they need to go, the living get where they need to be.”
And where are the living? On a planet in serious peril, where resource- and land-intensive burial practices reflect the overconsumption that put us in this mess. So, in the days just before my mom’s death, and with the clock ticking fast, I explored “green burial” options in Southern California that minimize environmental impacts.
That involved ditching the local (and very expensive) mortuary giant Forest Lawn — where seemingly everyone in Glendale, my mom’s hometown, goes to spend eternity — and calling smaller funeral homes that advertise eco-friendly options.
I settled on a small business in Hollywood that partners with a natural burial cemetery — where the land is minimally disturbed and traditional embalming isn’t allowed — and even offers an intriguing “human composting” option. Crucially, prices for the most common services are listed prominently on the funeral home’s website (note to other mortuaries: Please do this).
But the eco-friendly options had serious drawbacks. The natural burial cemetery is near Joshua Tree (gorgeous, but 120 miles away), and human composting — a process that accelerates decomposition and, within a month, turns a body into nutrient-dense soil — isn’t yet legal in California and would have required shipping my dead mother to Washington state.
Burial options that require two-hour flights or three-hour car drives don’t strike me as green. Even in this era of heightened environmental consciousness, the most accessible disposal options are not the sustainable ones. Our final choice: local cremation.
Still, the future for handling the dead in an environmentally sound way isn’t totally dim. Last year, California passed a law to allow human composting starting in 2027. And, although there are only two fully natural burial grounds certified by the Green Burial Council in all of California (none of them near Los Angeles), more “traditional” cemeteries are offering some environmentally friendly options.
Sarah Chavez, executive director of the L.A.-based advocacy group the Order of the Good Death, told me these cemeteries and California lawmakers are responding to an increasing demand for burials that not only conserve resources, but are also more meaningful to the people seeking them.
She said the $20-billion U.S. funeral industry has commodified death in a way that has made people scared of their dead loved ones, convinced that only trained, very expensive professionals must take over the moment a relative dies.
I told Chavez my family resisted this routine, even if we didn’t get a green burial. The funeral home accommodated our request to sit with my mom for several hours before it sent workers to pick her up. In that time, the few of us there had a mini-funeral.
We alternated between tears, laughter and prayers, all while my mom was there with us. Her body was not hazardous waste to be swiftly disposed of.
Chavez said our experience reflects a grassroots change in death services. Her group supports families taking a more active role in burials. She said many people entering the funeral industry now are women who recognize the need for change, which I noticed in making my arrangements as well.
From this desire for more control, we’ll get more green burial options in the future. Just not in time for my mom.
A “green” funeral home in Colorado has found itself in trouble this week after 189 decaying human bodies were found on the premises.
The corpses, which were emitting an “abhorrent smell”, had initially been thought to number 115 when the Return to Nature Funeral Home storage facility in Penrose, Colorado, was first investigated by authorities two weeks ago.
Now, as of Tuesday, 189 bodies have been removed from the site, but authorities have said that numbers could change once again as the process of identifying the bodies continues.
Return to Nature Funeral Home is a so-called “green” funeral home, which holds burial services without the use of embalming fluids to preserve the bodies. There have been no arrests or charges so far, and Newsweek has contacted Return to Nature for comment via Instagram.
The bodies left to decay are now being identified by an FBI team usually deployed for mass casualties such as plane crashes. Around 120 families are worried that their relatives could be among the remains, but it will be weeks until identification of the bodies is completed, using fingerprints, dental records, and DNA testing.
It is perfectly legal not to embalm a body in Colorado and most other states, but the cadaver must be refrigerated. Colorado law specifically states: “A funeral establishment shall embalm, refrigerate, cremate, bury, or entomb human remains within twenty-four hours after taking custody of the remains.”
“Embalming is not required in any state, except in very limited circumstances,” Tanya D. Marsh, a professor of law at Wake Forest University and a licensed funeral director, told Newsweek. “The Colorado funeral home was required to either dispose of the bodies within 24 hours or refrigerate or embalm them. Violation of this is a class 1 misdemeanor in Colorado, which carries a maximum penalty of 364 days imprisonment, not more than a $1,000 fine, or both.
“In addition to criminal liability, this funeral home also faces tort liability from the families of the deceased for ‘interference with the right of sepulcher’,” Marsh said.
Additionally, Colorado has fairly lax rules regarding funeral homes, with operators requiring no routine inspections or qualifications.
The reasons why this funeral home did not manage to refrigerate its bodies is still unclear. However, the owners of the Return to Nature Funeral Home had reportedly missed tax payments in recent months, and were being sued for unpaid bills. They had also been recently evicted from one of their properties.
“We’ll find out more facts as the case unfolds, but my guess in Colorado is that the funeral home either lost its contract with a crematory, or there was some other problem. They started to get a backlog of cases, and it just got out of hand,” Marsh said. “It is really indefensible, but unfortunately not the first time it has happened.
“For example, in the Tri-State Crematory case in 2002, a crematory in Georgia was found to have more than 300 bodies that it had failed to cremate and that were kept on the property in various states of decay. There were also a number of cases of funeral homes with an excess of remains during the worst of the COVID-19 crisis in New York City, and some of those funeral homes did not properly store those bodies,” Marsh added.
The reason for this tragedy is not because of the funeral home’s “green” practices, but instead due to the mishandling of the bodies.
“To be clear, the reason this happened is not because this was a green funeral home. I really think it is important to emphasize this. It is because it was a funeral home that did not follow the most basic rules of care for human remains,” Marsh said.
Green funerals don’t embalm the bodies to avoid transferring harsh preservative chemicals into the ground, and bury people inside more-biodegradable caskets.
“Green funeral companies seek to reduce the amount of chemicals that are put in the soil by using coffins made from untreated materials; wicker is popular in the U.K. They do not embalm as this avoids the embalming chemicals such as formaldehyde and so on. As a result, decomposition occurs more naturally and is quicker and more complete,” Stephen Hughes, a senior lecturer in medicine at the Anglia Ruskin University School of Medicine in the U.K., told Newsweek.
Usually, in place of embalming, a body must be refrigerated to prevent decay. However, it appears that the bodies at Return to Nature Funeral Home were improperly stored. Without being kept cool, a body rapidly starts to break down.
“The decomposition process begins immediately after death,” Mark T. Evely, director of the Mortuary Science Program at Wayne State University, Michigan, told Newsweek. “The rate of decomposition depends on environmental conditions such as temperature, humidity, the setting in which the remains are located, and the physical conditions of the deceased prior to death.”
Other experts worry that this may mar the reputation of mortuary services and green funerals alike, sparking distrust of the practice.
“A great amount of trust is placed in funeral homes by families to care for their loved ones. When that trust is violated, it casts suspicion on the entire funeral profession,” Evely said. “I don’t know the reasons why there would be remains found in the way they were at the funeral home in Colorado. What I can say is that someone failed the families of these loved ones and failed to comply with the legal requirements of the state and the ethical duties demanded by the funeral service profession.”
This case raises the need for contingency plans for funerary providers in the event they are no longer financially viable, or that something goes wrong, Kate Woodthorpe, director of the U.K. Centre for Death and Society, told Newsweek.
“We have the same issue in the U.K. with regard to protecting the buried dead: When cemeteries are no longer income generating or financially viable, what happens? As an island running out of space, this is a critical question that no one has really answered in terms of who is responsible for their maintenance and long-term upkeep,” Woodthorpe said. “It also raises questions about the need for oversight and regulation of ‘green’ above-ground disposal methods. Unlike cremation (over quickly) or burial (contained underground), this third method needs greater surveillance, given the consequences in the event of a company going bust, or a generator failing and so on.”
As the remains continue to be identified, the bereaved families will have to wait for the dreaded news that one of their relatives’ bodies was included in the tragedy.
“In this situation, they may feel guilty that they have made such a disastrous choice of funeral home,” Dr. John Wilson, director of bereavement services counseling at York St John University, northern England, told Newsweek. “Guilt is a complicator of grief, and these relatives may need professional counseling to overcome this. On top of that, they may be traumatized by press reports, and by imagining the scene at the care home, adding to the sense of having let down their lost loved one.
“Anger is a natural feature of grief, so there will be many relatives who are angry to the point of it being potentially unhealthy,” Wilson added. “Given that the number of close mourners for every death averages between five and 10 people, that is going to be a lot of people who could need counseling.”
Since it was first introduced by the economists Anne Case and Angus Deaton in 2015, the phrase “deaths of despair” has become a sort of spiritual skeleton key that promised to unlock the whole tragic story of a new American underclass.
Beginning around the turn of the millennium, Case and Deaton showed, deaths from suicide, opioid overdose and alcohol-related liver disease among less educated, white, middle-aged people began to grow in a pattern that seemed to demonstrate how the country’s white working class was being — or at least feeling — left behind. Last month, the economists presented their updated data with a new paper showing a growing divergence in life expectancy between those with college degrees and those without.
But over the past few years, the “deaths of despair” story has come to seem thinner to many of those reading the literature most closely. And in response to the new findings, pointed critiques were published by Dylan Matthews in Vox and by Matthew Yglesias in Slow Boring, arguing that the deaths of despair narrative had been overhyped, creating a just-so story about postindustrial decline that had seemed too good to scrutinize.
Eight years on, the central claim from Case and Deaton holds up relatively well: Deaths by suicide, overdose and liver disease have been on the rise among the white working class and the middle class. But so have gun deaths across the country, deaths among the young and suicides, which puts the data on white middle-aged men and women in a different light. Among other questions about that data, it turns out that deaths of despair increased pretty uniformly across all demographic groups and that the rise in such deaths among white middle-aged people was, while real and concerning, not all that exceptional.
What does that imply, though? In their critiques, both Yglesias and Matthews argue that the data tells a narrower story than Case and Deaton do — and that rather than invoking national malaise we should focus on the role of opioids among the country’s worst off in the first case, or high school dropouts and heart disease in the second.
But it seems to me that the opposite is true: The American mortality crisis is much larger than deaths of despair, in fact too broad and diffuse to be stuffed into one demographic box or characterized as a failure of one policy area. You can see it almost anywhere you care to look and any way you slice the data.
Unless they’re in the top 1 percent, Americans are dying at higher rates than their British counterparts, and if you’re part of the bottom half of income earners, simply being American can cut as much as five years off your life expectancy. At every age below 80, Americans are dying more often than people in their peer nations: Infant mortality is up to three times as high as it is in comparison countries; one in 25 kindergartners can’t expect to see 40, a rate nearly four times as high as in other countries; and Americans between 15 and 24 are twice as likely to die as those in France, Germany, Japan and other wealthy nations. For every ethnic group but Asian Americans, prepandemic mortality rates in the United States were higher than those of economic peer countries: In 2019, Black Americans were 3.8 times as likely to die as the residents of other wealthy countries, white Americans were 2.5 times as likely to die, and Hispanic Americans 1.8 times as likely to die. Americans with college degrees do substantially better than those without, but that second group represents almost two-thirds of the country. And while mortality rates show a clear geographic divergence, with life expectancy gaps as large as 20 years between the country’s richest and poorest places, just a fraction of American counties even reach the European Union average.
When looking at American trend lines alone, anomalies like overdose spikes or mortality increases among high-school dropouts can jump out, and the divergence between, say, those with bachelor’s degrees and those without is quite striking. But in comparing the overall health of Americans to those in other wealthy countries, almost everyone looks to be suffering, and even those remarkable anomalies turn out to be quite small, contributing only somewhat trivially to the widening gap between how many Americans are dying each year and how many of our peers elsewhere are.
Overdose deaths involving synthetic opioids, for instance, have grown from less than 10,000 in 2015 to 70,000 in 2021. Add heroin and other overdoses and the total grows to more than 100,000 — a public health horror story, and a much graver problem than in any of our peer countries. But that barely explains a fraction of the exceptional American mortality pattern identified by the researchers Jacob Bor and Andrew Stokes, who found that a million more Americans died each year than would have if the country’s overall mortality rates matched those of peer countries in Europe.
Those million extra deaths exceed even the nearly 700,000 who die each year from cardiovascular disease, the country’s biggest killer. But of course many residents of other rich countries die from it, too. And though, as Matthews emphasizes, American progress against heart disease has stalled in recent years, the gap between our cardiovascular mortality and those of our peers turns out to be relatively small, accounting for just another fraction of Bor and Stokes’s “missing Americans.” Which tells you something about how large that number of extra deaths really is: If American mortality rates simply matched those of peers overall, the country’s total number of deaths would have fallen 22 percent on the eve of the pandemic in 2019. In 2021, the researchers found, extra mortality accounted for nearly one in every three American deaths.
“The United States is failing at a fundamental mission — keeping people alive,” The Washington Post recently concluded, in a remarkable series on the country’s mortality crisis. “This erosion in life spans is deeper and broader than widely recognized, afflicting a far-reaching swath of the United States.” In a quarter of American counties, The Post found, death rates among working-age adults are not just failing to improve but are also higher than they were 40 years ago. “The trail of death is so prevalent that a person could go from Virginia to Louisiana, and then up to Kansas, by traveling entirely within counties where death rates are higher than they were when Jimmy Carter was president.” If death rates just among the country’s 55-to-69-year-olds improved to match the rates of peer countries, The Post calculated, 200,000 fewer of them would have died in 2019. That is more than the number of them who died of Covid in 2020.
There are a few things that Americans do as well or better than other countries (cancer treatment, where outcomes have been steadily improving now for decades, and keeping old people alive), so chances that a 75-year-old makes it to 90 or 100 are about the same as in other wealthy countries — though that stat is somewhat distorted by the fact that many fewer Americans make it to 60 in the first place, with those who do likelier in better health.
But by almost every other measure the United States is lagging its peers, often catastrophically. The rate of homicides involving a firearm are 22 times higher in the United States as in the European Union, for instance, a worsening trend that has given rise to research suggesting that the country’s mortality crisis is primarily about gun violence. Another set of researchers emphasize exceptional mortality rates among the young, with rates of death among American children growing more than 15 percent between just 2019 and 2021, with little of that increase attributable to Covid. Americans also die much more often in car crashes, workplace accidents and fires. Our maternal mortality rate is more than three times as high as that of other wealthy countries, and our newborns have the highest infant mortality rate in the rich world. We are almost twice as likely to suffer from obesity as are our counterparts in countries of the Organization for Economic Cooperation and Development, and the downstream consequences — from hypertension to heart disease and stroke — mean that obesity could explain more than 40 percent of the U.S. life expectancy shortfall for women, and over 60 percent for men. The life expectancy among America’s poorest men may be 20 years shorter than that of their counterparts in the Netherlands and Sweden. Overall, among 18 high-income countries, America’s life expectancy ranks dead last.
It’s not quite right to call all this simply “despair,” even if social anomie plays a role. Doing so places too much weight on the suffering of individuals and not enough on what epidemiologists call the social and environmental determinants of health: community support, education and, perhaps most important, health care access. (Since 2015, Case and Deaton have acknowledged these factors; their 2020 book on the subject emphasizes health care inequalities, and Deaton’s new book “Economics in America” focuses squarely on inequality.)
But the bigger problem seems to me to be that talking narrowly about despair localizes the American mortality dysfunction in a small demographic, when almost the entire country is dying at alarming rates. The burden does not fall equally, and the disparities matter. But looking globally, our mortality crisis appears, effectively, national.
Movies, books, and even personal accounts record how, sometimes, people who are in the last stages of life hold on until something they dearly wished for gets resolved. It could look like reconciling with a loved one, spending time with someone they haven’t seen in years, or getting the blessing of a priest.
Given that there’s a lot we don’t know about what people see and hear before they die, is there any truth to the fact that we can choose when we die? Can we willfully resist death until we’re ready to let go? Science tells us that dying is a process: The person’s breathing slows down; their skin color and temperature change; they might experience difficulty breathing; they could sleep a lot more than usual; and their thinking and other senses may dwindle, per Health Direct. However, according to several hospice and palliative care workers, there is some truth to the thinking that people can hold on till they’re ready to let go.
Dr. Toby Campbell, a thoracic medical oncologist in the Division of Hematology, Medical Oncology and Palliative Care at the University of Wisconsin School of Medicine and Public Health, told STAT News, “People in end-of-life care wouldn’t bat an eye if you asked if they think people can, to a certain degree, control those final moments. We’d all say, ‘Well, yeah. Sure.’ But it’s inexplicable.” Science might not have studied this phenomenon extensively nor arrived at one possible explanation, but there are some theories.
It could be related to a hormonal stimulus
What allows someone in the last stages of dying to prolong their life until some unfinished business is completed? Dr. Campbell thinks it could have something to do with a hormonal stimulus (via STAT News). People in the final stages of death “probably have some kind of hormonal stimulus that’s just a driver to keep them going. Then, when whatever event they were waiting for happens, the stimulus goes away, and there must be some kind of relaxing into it that then allows them to die.”
Charles F. von Gunten, a pioneer in the field of hospice and palliative medicine, agreed. “What people will do for one another in the name of love is extraordinary. I think of it as a gift when it happens,” he told The Washington Post.
However, there might be something else that happens that gives dying people a chance to enjoy what time they have left with loved ones before they die. Healthcare professionals call this “rallying” or “the surge,” as explained by licensed hospice nurse, Julie McFadden, who goes by the name Hospice Nurse Julie on YouTube. “A patient will look like they are actively dying or getting very close to death … And then suddenly, they perk up and they start acting like their old selves again. They may be hungry, eat, talk, laugh, joke around, be a little sassy with their family … They frequently do this and then pass away usually the next day.” Again, this isn’t understood well by healthcare workers but it does give loved ones a chance to say goodbye.
How to let go when death is near
Regardless of whether your loved one is holding on so they can spend more time with you or they are experiencing a surge in life just before dying, death is often something we aren’t prepared for. Some people may even experience what is known as “anticipatory grief” — feelings of loss even before their loved one has actually died.
What dying people want you to know, on the other hand, might change depending on their particular life situation; but there is a big possibility that there might be regrets, most of which might have to do with relationships.
The author of the book “Dying Well: Peace and Possibilities at the End of Life,” Dr. Ira Byock, seems to think that we can choose how we die. Byock, who’s a physician and advocate for palliative care, shared in his book that people who are about to die should take the time to say goodbye (via Help Guide). Sentiments like “I love you,” “I forgive you,” “Forgive me,” and “Thank you” are not overrated and should be prioritized between loved ones and the person who’s dying. For loved ones who are letting go, it might also be important to let your dying family member know that it’s alright for them to go and that you will be okay. It could offer immense relief to them when they need it most.
The human mind and body are intricately connected. The relationship between the two is so profound that it can significantly impact our well-being. Whether thinking about death increases the risk of death delves deep into this complex relationship. The age-old saying “mind over matter” suggests that our thoughts have the power to shape our physical reality, and scientific research supports this notion.
Psychoneuroimmunology studies how emotions, thoughts, and beliefs affect the immune and nervous systems (via Reference Module in Neuroscience and Biobehavioral Psychology 2017). A 2017 study in Physiological Reviews shows that the brain communicates directly with the immune system, releasing chemicals and hormones that can profoundly impact how your body functions. Stress hormones like cortisol, released when we experience psychological stress, can lead to health problems like cardiovascular issues and weakened immune responses (per the Mayo Clinic).
The placebo and nocebo effects illustrate this even further. Believing that a treatment will work can trigger remarkable healing responses, while negative expectations can have detrimental consequences.
Ultimately, it’s clear that our thoughts and physical well-being are intricately connected. By exploring the science behind psychosomatic illnesses and how the fear of death influences health, we can better understand how our thoughts shape our bodies’ realities.
Psychosomatic illnesses and their impact
Psychosomatic illnesses are physical conditions stemming from psychological factors like stress, anxiety, or emotional distress. Studies have consistently shown how psychological distress can trigger or worsen various physical health issues (per Healthline). For instance, 2014 research published in the World Journal of Gastroenterology highlighted that patients with IBS often exhibit high levels of anxiety and stress, which can worsen their symptoms.
Additionally, psychosomatic illnesses can affect our hearts. According to 2021 research published in Circulation, negative psychological factors — such as stress, anxiety, and depression — can increase our risk of developing cardiovascular disease (CVD). In contrast, positive psychological factors — such as optimism, resilience, and social support — can reduce our risk of developing the disease.
Similarly, psychological factors also play a significant role in chronic pain conditions. For example, a 2017 report in Neural Plasticity demonstrated a link between depression and chronic pain.
These examples provide compelling evidence of the profound connection between the mind and body.
The positive aspects of mortality awareness
The idea of mortality is a complicated issue that encourages us to explore the depths of our human experience. Realizing that your time on this planet is limited can bring about many emotions, such as fear, anxiety, and despair. However, this realization can also provide you with an opportunity for personal growth and positive change. It urges you to reflect on your life, evaluate your priorities, and cherish every moment.
Embracing life’s impermanence can be a powerful catalyst for personal growth as well as developing and changing habits. It can help motivate you to live a more authentic, meaningful, and purposeful life. By accepting that life is fleeting, you can be inspired to wake up each day with a sense of purpose and gratitude for the world around you. By facing your fears with resilience and courage, you’ll learn to appreciate life’s uncertainties and make the most of the time you have.
What to do if thinking about dying causes anxiety
While it’s important to recognize that death is a natural part of life, it’s also vital to avoid fixating on it and letting it cause undue stress or anxiety. The good news is that there are plenty of constructive steps we can take to address our concerns and maintain a positive outlook on life. A study published in 2022 in Current Psychology has shown that people who find meaning in their lives and can effectively manage stress are less likely to experience death anxiety. This means growing and cultivating resilience in the face of existential fears is possible.
If you worry about death frequently or feel like these fears are starting to impact your daily life, seeking mental health support is a great way to be proactive and get the help you need. Mental health therapists and psychologists can offer guidance, coping strategies, and emotional support to help you navigate your fears and feel more resilient. By embracing the challenges of mortality and seeking support when needed, you can lead a more balanced, fulfilling life and face life’s uncertainties with greater confidence.
