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Experts warn of the increasing overmedicalization of death, call for rethink of how society cares for dying people

Health and social systems around the world are failing to give appropriate, compassionate care to people who are dying and their families. According to a new Lancet Commission, today’s current overemphasis on aggressive treatments to prolong life, vast global inequities in palliative care access, and high end-of-life medical costs have lead millions of people to suffer unnecessarily at the end of life.

The Commission calls for public attitudes to and dying to be rebalanced, away from a narrow, medicalised approach towards a compassionate community model, where communities and families work with health and to care for people dying.

Bringing together experts in health and social care, , economics, philosophy, political science, theology, community work, as well as patient and community activists, the Commission has analysed how societies around the world perceive death and care for people dying, providing recommendations to policy makers, governments, civil society, and health and social care systems.

“The COVID-19 pandemic has seen many people die the ultimate medicalised death, often alone but for masked staff in hospitals and intensive care units, unable to communicate with their families, except digitally”, says Dr. Libby Sallnow, palliative medicine consultant and honorary senior clinical lecturer at St Christopher’s Hospice and UCL (UK) and co-Chair of the Commission, “How people die has changed dramatically over the past 60 years, from a family event with occasional medical support, to a medical event with limited family support. A fundamental rethink is needed in how we care for the dying, our expectations around death, and the changes required in society to rebalance our relationship with death.”

The Commission focuses primarily on the time from when a person is diagnosed with a life-limiting illness or injury, to their death and the bereavement affecting the lives of those left behind—it does not cover sudden or , deaths of children, or deaths due to injustice.

Death and dying have become over-medicalised, hidden away and feared

Over the past 60 years, dying has moved from the family and community setting to become primarily the concern of health systems. In the UK for example, only one in five people who require care are at home, while about half are in hospital (table 2).

Global life expectancy has risen steadily from 66.8 years in 2000 to 73.4 years in 2019. But, as people are living longer, they are living more of these additional years in poor health, with years lived with disability increasing from 8.6 years in 2000 to 10 years in 2019.

Prior to the 1950s, deaths were predominantly a result of acute disease or injury, with low involvement from doctors or technology. Today, the majority of deaths are from chronic disease, with a high level of involvement from doctors and technology. The idea that death can be defeated is further fuelled by advances in science and technology, which has also accelerated the over-reliance on medical interventions at the end of life.

And, as healthcare has moved centre stage, families and communities have been increasingly alienated. The language, knowledge, and confidence to support and manage dying have been slowly lost, further fuelling a dependence on health systems. Despite this, rather than being viewed as a professional responsibility for the doctor, and a right for all people and families who wish it, conversations about death and dying can be difficult and uncomfortable and too often happen in times of crisis. Often they don’t happen at all.

“We will all die. Death is not only or, even, always a medical event. Death is always a social, physical, psychological and spiritual event and when we understand it as such we more rightly value each participant in the drama,” adds Commission co-author, Mpho Tutu van Furth, priest, Amstelveen, Netherlands.

Worldwide, too many people are dying a bad death

While palliative care has gained attention as a specialty, over half of all deaths happen without palliative care or pain relief, and health and social inequalities persist in death.

Interventions often continue to the last days with minimal attention to suffering. Medical culture, fear of litigation, and financial incentives also contribute to overtreatment at the end of life, further fuelling institutional deaths and the sense that professionals must manage death.

Dr Libby Sallnow and Dr M.R. Rajagopal call for radical rethink of how society cares for dying people. Today’s current overemphasis on aggressive treatments to prolong life, vast global inequities in palliative care access, and high end-of-life medical costs have lead millions of people to suffer unnecessarily at the end of life. The Lancet Commission on the Value of Death provides recommendations to policy makers, governments, civil society, and health and social care systems. Credit: The Lancet

Untreated suffering, vast inequalities, and aggressive medical treatments have come at a high cost. A disproportionate share of the total annual expenditure in high income countries goes towards treatment for those who die, suggesting that treatments at the end of life are being provided at a much higher threshold than for other treatments.

In high income countries, between 8% and 11.2% of annual health expenditure for the entire population is on the less than 1% who die that year (table 6). Care in the last month of life is costly and, in countries without universal health coverage, can be a cause of families falling into poverty.

“Dying is part of life, but has become invisible, and anxiety about death and dying appears to have increased. Our current systems have increased both undertreatment and overtreatment at the end of life, reduced dignity, increased suffering and enabled a poor use of resources. Healthcare services have become the custodians of death, and a fundamental rebalance in society is needed to re-imagine our relationship with death,” says Dr. Richard Smith, co-Chair of the Commission.

A fundamental change to society’s care for the dying is needed

The Commission sets out five principles of a new vision for death and dying:

1. The social determinants of death, dying and grieving must be tackled, to enable people to lead healthier lives and die more equitable deaths.

2. Dying must be understood to be a relational and spiritual process rather than simply a physiological event, meaning that relationships based on connection and compassion are prioritised and made central to the care and support of people dying or grieving.

3. Networks of care for people dying, caring, and grieving must include families, wider community members alongside professionals.

4. Conversations and stories about everyday death, dying, and grief must be encouraged to facilitate wider public conversations, debate, and actions.

5. Death must be recognised as having value. “Without death, every birth would be a tragedy.”

The Commission recognises that small changes are underway—from models of community action to discuss death, national policy changes to support bereavement, or hospitals working in partnership with families. While wholescale change will take time, the Commission points to the example of Kerala, India, where over the past three decades, death and dying have been reclaimed as a social concern and responsibility through a broad social movement comprised of tens of thousands of volunteers complemented by changes to political, legal, and health systems.

“Caring for the dying really involves infusing meaning into the time left. It is a time for achieving physical comfort; for coming to acceptance and making peace with oneself; for many hugs; for repairing broken bridges of relationships and for building new ones. It is a time for giving love and receiving love, with dignity. Respectful palliative care facilitates this. But it can be achieved only with broad-based community awareness and action to change the status quo,” says co-author Dr. M.R. Rajagopal, Pallium India, India.

To achieve the widespread changes needed, the Commission sets out key recommendations for policy makers, health and social care systems, civil society, and communities, which include:

  • Education on death, dying, and end of life care should be essential for people at the end of life, their families and health and professionals.
  • Increasing access to pain relief at the end of life must be a global priority, and the management of suffering should sit alongside the extension of life as a research and care priority.
  • Conversations and stories about everyday death, dying, and grief must be encouraged.
  • Networks of care must lead support for people dying, caring, and grieving.
  • Patients and their families should be provided with clear information about the uncertainties as well as the potential benefits, risks, and harms of interventions in potentially life-limiting illness to enable more informed decisions.
  • Governments should create and promote policies to support informal carers and paid compassionate or bereavement leave in all countries.

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Hard Conversations About End Of Life Wishes

— Should Young Adults Be Included?

By Carolyn Rosenblatt

Talking about one’s end of life wishes is typically uncomfortable for most. We think of the subject as one for our aging parents to have with us when they are “old”. We don’t usually think it is a necessary subject for younger adults to know about. The truth is, many younger adults are already caregivers and they must deal with these issues.

A real life example is that of Anna, a bright and ambitious teenager when her father had to retire from work on disability. Three years later, he passed away. Anna was an only child, living with her mom. The last thing anyone expected was for her mother to have a health issue.

Anna’s mother, Linda had already retired from teaching at a university. She had a pension and some income from rental real estate. She was working part time in the field of education. At only age 59, Linda began to show signs of memory loss. She was diagnosed with early onset dementia and had to stop working. Anna and Linda lived on Linda’s income. Linda’s dementia progressed. At age 21, just graduating from college and starting her career, Anna became the agent and power of attorney for her mother. Eventually Anna had to sell the family home to pay for her mother’s care. Over time, Linda became a behavior problem and Anna had to place her in a care home. Eventually Anna had to sell off her mother’s invested assets to pay for Linda’s increasing care needs. When the money ran out, Linda qualified for Medicaid but then the choices of care for her were extremely limited. Anna found a low cost board-and-care home for Linda two hours away. It took Anna half a day just to make a visit.

Anna was faced with every decision about her mother all on her own. She got advice from time to time at AgingParents.com but it was a huge burden to manage all this while getting her first jobs and establishing her own career. When end of life decisions had to be made Anna did her best to honor what she thought her mom would want. Linda had not ever talked about her end of life wishes with her young daughter. It was a heavy burden on Anna. When the doctors asked her what she wanted to do at decision time for Linda, she was in tears. She guessed, without being sure and it was emotionally wrenching for her.

The Takeaways

None of us are guaranteed a long retirement with our health intact. None of us need let our family members down by failure to discuss what we want in our last days. The struggle to figure out all the things Anna had to do for her mother was an extremely stressful burden. We owe it to our offspring, or others who would have responsibility to assist us in declining health, to be clear about what we want. We use Advance Healthcare Directives, also called Healthcare Proxies or Power of Attorney for Healthcare to give written instructions to our loved ones. That makes it much easier on them when the time comes. When Linda could no longer say what she wanted, due to Alzheimer’s disease, Anna had to try to imagine what Linda would want. The process was traumatic. She did well regardless, and went on years later to have a family of her own. Hard as it is, she will not repeat her mother’s lack of discussion on this important topic with her own child.

If there is one thing to take from this true story, some of which I witnessed personally, it is that any young adult deserves to know the wishes of an aging parent or any parent with a health issue. Linda could have done that upon becoming widowed. There is a free, downloadable version of an Advanced Healthcare Directive available on the internet, from your doctor’s office or your nearest hospital. If any part of it is unclear, a conversation about it with a medical professional can help.

Above all, fill it out and sign it as the document requires, with either a notary or witnesses. With this simple step, you are saving your younger loved ones from conflicts and distress about what to do near the end of your life. And equally as important, take the document out and show it to every adult in your family who will be appointed to carry out your wishes. Make it easier on them at a possibly difficult time. It’s the responsible and caring thing to do. If you need some help, free guides are available at The Conversation Project to get you started.

Complete Article ↪HERE↩!

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When patients don’t want to be saved

— Navigating the right to die

By Jules Murtha

  • Patients have a right to shape their end-of-life care with advance directives and other palliative care options.
  • Clinicians can better serve patients of different faiths by approaching care with cultural competency.
  • When ethical dilemmas regarding palliative care arise, clinicians can return to the basic ethical principles: autonomy, beneficence, nonmaleficence, fidelity, and justice.

The relationship between morality and death is a historically significant one. Modern death in America often entails care provided by strangers in an institution flooded with machinery, far from the comfort of one’s family and home. Many physicians and scholars deem this a poor way to die.

Now, some patients nearing the end of their lives have an alternative to prolonged suffering in a hospital: Medical-assisted death. The moral logic supporting a patient’s right to terminate their life by means of lethal medication, either through self-ingestion or with a doctor’s help, is based on harm reduction. Legal, ethical, and professional controversies related to this practice are still surfacing.

The process of terminating care

Death is inevitable. The degree to which one suffers, however, can be modified by choosing appropriate end-of-life care. According to a 2021 article published by SAGE Open Medicine, mitigating suffering, optimizing quality of life, and providing comfort in death are the goals of palliative care.

What is an advance directive?

When a patient is no longer capable of communicating their desire to terminate treatments, advance directives are useful. An advance directive is a legal document specifying the kind of care a patient wants to receive, should they lose the ability to communicate due to a serious injury or neurodegenerative disease. Patients who complete them must be at least 18 years old.

Advance directives may include the following:

  • Living will: A legal document that describes medical or life-sustaining treatments patients may want if they become permanently unconscious or terminally ill. Writing a living will gives patients the power to make decisions for themselves when unforeseen circumstances arise.
  • Do not resuscitate order (DNR): The formal request that hospital staff do not perform CPR on an individual if their heart or breathing stops. DNRs do not have to be a part of a living will. They are accepted in all states.
  • Durable power of attorney for healthcare (DPA): Legal in most states, a DPA specifies whom is held responsible for a patient’s healthcare decisions if the patient is unable to make them on their own.
  • Physician orders for life-sustaining treatment (POLST): Designed for patients with serious illnesses, physicians complete POLSTs to ensure patients receive their desired care.

Advance directives may be especially helpful for patients who endure immense suffering. A patient with terminal cancer, for example, may document their request that hospital staff forgo  a respirator if they stop breathing. This gives the patient power over their own healthcare—which includes the right to die—and mitigates suffering by offering peace of mind.

Cultural competency and self-determination

Another factor for clinicians to consider when providing end-of-life care is each patient’s cultural and religious beliefs. When clinicians establish cultural competence—the ability to implement care with a patient’s cultural, religious, and social needs in mind—the quality of care improves.

The importance of cultural competence in healthcare extends to patients’ mental health and daily life. According to a 2021 article published by StatPearls, health-related anxiety diminishes in patients when they can turn to their faith.

Religion and spirituality inform some patients’ healthcare decisions regarding diet, medicine, modesty, and gender of their health providers. They can also inform practices surrounding death. For example, several religions strictly prohibit euthanasia, including Mormonism, Hinduism, Islam, Jehovah’s Witnesses, and others.

The influence of religion

On the other hand, physicians may legally refuse to provide certain types of standardized care that aren’t conducive to their own religious beliefs. This is often the case for Catholic doctors who refuse to perform abortions or sterilizations, as written in an article published by the American Medical Association Journal of Medical Ethics.

Doctors who choose not to provide emergency treatments based on conscience laws may be subject to tort liability, giving patients who are harmed by medical inaction the opportunity to sue for medical malpractice.

To avoid this situation altogether, physicians can abide by transparency requirements and protect patients from medical refusals by informing them about the practice. Patients may then seek appropriate care elsewhere, if possible.

Increased cultural competency and better palliative care options for patients of specific faiths is dependent on education. Patient care improves when physicians acquire cultural competence through proper training. Healthcare institutions fare better overall when their staff, including non-clinicians, are prepared to notify patients about medical refusals and a patient’s right to self-determination.

How medical ethics can aid physicians in palliative care

When doctors face ethical dilemmas regarding palliative care or a patient’s right to die, they can look to the universal ethical principles for guidance. According to SAGE Open Medicine, these principles include autonomy, beneficence, nonmaleficence, fidelity, and justice.

Medical ethics hinge on a healthcare professional’s ability to respect the autonomy of their patients. Autonomy, which is a patient’s right to self-determination, can be protected by advance directives before a patient loses the ability to create one. Patients have the right to terminate or refuse treatment altogether, which physicians should support out of respect for patients’ autonomy.

Reducing harm

When a patient no longer has the ability to create an advance directive, doctors must pursue treatment plans most beneficial to the patient. Physicians in this position can practice nonmaleficence by choosing care plans that cause the least possible amount of harm.

Justice and fidelity are served by doctors who are honest with their patients about prognoses and care options, including a patient’s right to terminate treatments. Truth-telling, as well as fair distribution and knowledge of health resources, is necessary in order to effectively respect patients’ self-determination.

While “dying badly” is still the norm in most of the US, there are 10 jurisdictions in which patients can pursue medical-assisted deaths. According to the Yale Journal of Biology and Medicine, Oregon, Montana, New Jersey, and Colorado are just a few.

What this means for you

Where legal, physicians can inform patients of their right to self-determination, granting them peace of mind and control in their final days. Regardless of your own spiritual or religious beliefs, acquiring cultural competence will improve the care physicians provide to patients. Finally, when end-of-life care presents physicians with ethical challenges, they can take a cue from the five ethical principles guiding healthcare professionals: autonomy, beneficence, nonmaleficence, fidelity, and justice.

Sources

  1. Akdeniz M, Yardımcı B, Kavukcu E. Ethical considerations at the end-of-life care. SAGE Open Medicine. 2021;9:205031212110009.
  2. Campbell CS. Mortal responsibilities: bioethics and medical-assisted dying. Yale J Biol Med. 2019;92(4):733-739.
  3. Familydoctor.org editorial. Advance Directives and Do Not Resuscitate Orders. Familydoctor.org. 2021.
  4. Kogan R, Kraschel KL, Haupt CE. Which legal approaches help limit harms to patients from clinicians’ conscience-based refusals? AMA Journal of Ethics. 2020;22(3):209-216.
  5. Swihart DL, Yarrarapu SNS, Martin RL. Cultural religious competence in clinical practice. In: StatPearls. StatPearls Publishing; 2022.

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Which country is the best place to die?

Scientists ranked countries on their end-of-life care. The U.S. fared poorly.

By Ross Pomeroy

Key Takeaways

  • Researchers conducted an international survey to determine what constitutes good end-of-life care and which countries are the best at providing it.
  • They scored 81 countries, most of which earned a grade of “C” or below for their palliative care. The United Kingdom ranked first. The U.S. ranked 43rd.
  • Higher income, universal health coverage, and wide availability of opioids for pain relief were generally associated with better scores.

Death is an inevitable part of life — a mysterious climax that all humans face, evoking wonder and trepidation. That’s why dependable end-of-life care is so vital. While only some of us break bones, develop cancer, or catch an infectious disease, we all die eventually. To depart with dignity in relative comfort shouldn’t be a rare privilege.

Regretfully, new research published in the Journal of Pain and Symptom Management shows that many countries do not offer their citizens a good death.

Eric Finkelstein — a professor of health services at the Duke-NUS Medical School, Singapore, and the Executive Director of the Lien Centre for Palliative Care — led an international team of researchers to conduct a sweeping analysis of countries’ end-of-life (palliative) care. Finkelstein and his colleagues first set out to characterize quality end-of-life care, reviewing 309 scientific articles to determine the factors involved. A few that they identified included:

  • The places where health care providers treated patients were clean, safe, and comfortable.
  • Health care providers controlled pain and discomfort to patient’s desired levels.
  • Health care providers provided appropriate levels and quality of life extending treatments.
  • Costs were not a barrier to a patient getting appropriate care.

The researchers settled on 13 factors in total. They then surveyed 1,250 family caregivers across five different countries who had recently looked after a now-deceased loved one to ascertain the relative importance of each indicator. Here’s how the factors ranked:

Credit: Finkelstein et al. / Journal of Pain and Symptom Management

Finally, the researchers sought out hundreds of experts from 161 countries to rank their respective country’s end-of-life care based on these weighted factors, asking them to “strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree” with whether their country’s healthcare system generally met each palliative need. To be eligible, experts had to be “either 1) a representative of the national in-country hospice-palliative care association or similar national professional association with an established leadership role, 2) a health care provider (physician, nurse) involved in provision of palliative care, or 3) a government employee or academic with knowledge of palliative care in the country.”

At least two experts were required to respond from a specific country for the researchers to consider the nation’s score valid. In all, 81 countries comprising 81% of the world’s population ended up being ranked.

Credit: Finkelstein et al. / Journal of Pain and Symptom Management

The United Kingdom earned the highest score in the study, followed closely by Ireland, Taiwan, Australia, South Korea, and Costa Rica. These were the only countries to earn an “A” grade, scoring 90 or above. Ukraine, Argentina, South Africa, and Lebanon were a few of the 21 countries to merit an “F” grade, scoring 60 or below.

Finkelstein found the results disheartening.

“Many individuals in both the developed and developing world die very badly – not at their place of choice, without dignity, or compassion, with a limited understanding about their illness, after spending down much of their savings, and often with regret about their course of treatment,” he said in a statement.

Higher income, universal health coverage, and wide availability of opioids for pain relief were generally associated with better scores.   

Of note, the United States earned a “C”, ranking 43rd of the 81 countries with a middling score of 71.5. Commenting on why the U.S. ranked so poorly, especially compared to other high-income countries, Finkelstein said that Americans often spend tons of money on excessive, often futile treatments and surgeries aiming to extend life at the dusk of one’s existence — sometimes just for weeks or months — rather than focusing on ensuring quality of life at the end.

A key drawback of the study is that each country’s ranking was determined by an average of only two experts. While the researchers made clear that these experts are quite knowledgeable and respected, it seems hardly fair to rate an entire country’s end-of-life care system based on the opinions of just two individuals, each of whom is undoubtedly biased by their own experiences.

The experts were also asked for their thoughts on what facilitates good end of-life-care in a country. Collectively, they suggested that investment from the national government, patient-centered, integrative care, and universal healthcare with free access to palliative care services contributed greatly.

Complete Article ↪HERE↩!

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Have you considered what happens to your online life when you die?

One way to feel better about the future is making sure the right online data is passed down to friends, family, and partners.

By Roger Fingas

Most of the time people prefer to dodge the topic of death, for the obvious reason that it spawns a lot of uncomfortable thoughts. Yet the realistic and responsible thing to do is acknowledge it and prepare, since death is unavoidable and has huge ramifications for friends and family. This extends to your online life — so what sort of steps should you be taking to soften the digital transition for people left behind?

Step 1: Take advantage of posthumous account settings

Major tech platforms like Apple, Facebook, and Google offer tools to control how your data is handled when you die. Facebook for example lets you appoint a “legacy contact,” someone who can download your data, “memorialize” your account, and/or have your data deleted outright. If you don’t want anyone getting your Facebook content after you go, you can specify that ahead of time. Google offers some of the best tools via its Inactive Account Manager, which shares data selectively and/or deletes your account automatically after a set period. You can read more details in the feature linked below.

Whether or not a company offers dedicated tools, the bereaved can usually request that your online accounts be deactivated. This requires evidence of your death, of course, typically a death certificate. Things can get much tougher if someone wants data access — Apple requires that legacy contacts have both documentation and a special access key, and if they haven’t been appointed as a contact, they’ll have to get a court order if they’re in the US.

The key point here is that if a service is critical to your online life, you should be exploring the options it offers now instead of waiting until you’re knocking on death’s door. It’s one of the easiest things you can do to reduce the burden on loved ones.

Step 2: Share your logins

Under normal circumstances, sharing app and website logins is the last thing you’re supposed to do. But it only takes a moment to realize that if you haven’t written those logins down, you may be denying partners or family critical information — even money, if it’s trapped somewhere like a bank or a PayPal account. Logins are regularly excluded from the data companies are willing (or able) to share with the bereaved.

That makes it vital to build a logbook with usernames and passwords for every online service a loved one might need to access. Major items to check off include:

  • Bank accounts
  • Insurance accounts
  • Phone/TV/internet
  • Government services
  • Online payment services (PayPal, Venmo, etc.)
  • Chat/messaging apps and social media
  • Smart home platforms
  • Cloud storage
  • Photo libraries
  • Music, reading, and video subscriptions
  • Online stores

You might be tempted to use a password manager as a shortcut, but it’s risky.

Your logbook can be something as simple as a text or Excel file, as long as it’s easily accessible. Even better is one on paper, since that can’t be deleted, corrupted, or hacked. Either way, you need to keep your log both updated and protected, for instance by storing a paper logbook in a fireproof container.

If you’re sufficiently thorough, a bonus of this approach is that you might not even need the tools in Step 1. If a trusted person can log into your accounts directly, they can download all of your data and shut things off at will.

You might be tempted to use a password manager as a shortcut. This is risky, however — not only do all of the right people need logins and technical literacy, but they could also eventually be shut out if the app is subscription-based and you’re no longer around to pay. It’s not the worst solution, just one to approach with caution.

Step 3: Make plans with your loved ones

Both the first and second steps can be pointless if you don’t actually talk to your loved ones about them. They need to know what being a legacy contact entails, for example, and the legal hoops they’ll have to go through to retrieve your data or shut down an account. If you have a logbook, it’s important that people know how to find it.

Although the conversation can be tough, your loved ones should know the steps you took and how you’d like your online life to be managed.

This can be one of the toughest parts of preparing for your digital afterlife. No matter how technically savvy they are, a partner isn’t going to enjoy talking about your death, and the conversation gets even more harrowing with young children or elderly parents.

At some point, you’ll probably need to sit down with a legal advisor and add online data to your will. While we can’t make any guarantees, it may make things smoother if you’ve legally authorized access or deletion ahead of time.

Think of it this way — if you can overcome all of these issues, you’ll probably feel a little calmer about the future as a reward.

Complete Article ↪HERE↩!

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Scared of dying?

Here’s how to beat back the fear and find peace.

Death ‘is life’s change agent,’ Steve Jobs said in a famous 2005 speech.

By Morey Stettner

If you’ve lived a full life, you’re more apt to accept death. You’re able to wrap your mind around your demise without anger, panic or woe.

Yet for many retirees, the prospect of their own passing is immobilizing. A flurry of negative emotions vies for attention, from fear (“I’m afraid of a long, painful decline”) to regret (“I won’t see my grandchildren grow up”).

If you experience what psychologists call death anxiety, you’re not alone. Roughly one in five adults say they’re afraid of dying.

Older people may feel less haunted by death, especially if they’re terminally ill and receive hospice care. Surrounded by nurses and aides who prioritize emotional support and comfort, hospice patients tend to view their impending death with serenity.

On the other hand, some otherwise healthy seniors cannot bear to think about death. Whether it’s the realization that they have fewer years left, to dread that months or years of physical suffering await them, a dark cloud of foreboding invades their everyday life.

What separates those folks who take death in stride from the ones who let it eat away at their wellbeing?

“Part of it is having a more relaxed, flexible attitude and a willingness to rescind control over how we will die,” said Katherine King, an assistant professor of psychology at William James College in Newton, Mass. “A lot of us don’t tolerate uncertainty very well.”

If you have a controlling personality, pondering your death can cause agitation. Coping with such a sweeping, impossible-to-control force can prove crippling.

Another source of death anxiety relates to your overall satisfaction with how you’ve navigated your spiritual, creative and financial life. Generally, those who are fulfilled in these areas accept with equanimity that death is the next stage.

Steve Jobs qualifies as someone who attained a measure of fulfillment. Confronting his pancreatic cancer, he described death as “very likely the single best invention of life.”

Like many terminally ill people, he waxed philosophical about death. While we’ll never know if he cursed his bad luck in private, he took a more reassuring position in public.

“It is life’s change agent,” he said in his now-famous 2005 commencement address to Stanford University graduates. “It clears out the old to make way for the new. Right now the new is you, but someday not too long from now, you will gradually become the old and be cleared away.”

Aging in itself enables some people to accept death. The more funerals we attend, the more we start to see death in a new light.

“Losing people around us like friends and loved ones creates a feeling that it’s time,” King said. “It’s a natural preparatory process. As you get into your 80s and 90s, it can seem like the next task” on your to-do list.

But for those who continue to resist (“I’m not ready to die!”), honest self-reflection can help.

Ask yourself, “Do I have any unfinished business to tend to?”

“People who fear death tend to believe they haven’t completed their lives,” said Connie Zweig, a retired psychotherapist in Los Angeles, Calif. “So the key is to move toward completion, whether it’s completing a relationship where you still feel wounded or a business project that’s important to you. It’s that longing to reach a resolution.”

By taking steps to repair ruptured relationships, reclaim discarded dreams or intensify your search for spiritual or religious affirmation, you can address the nagging feeling that something’s missing. Checking off all the boxes in your life thus reduces death anxiety.

Speaking of religion, it can work for or against you when you’re grappling with the notion of your demise. Naturally, your beliefs about life after death play a big role.

“If you think you’ll be buried and a tree will grow there, that’s enough for some people,” said Zweig, author of “The Inner Work Of Age.” “Others are more religious and their beliefs can either give them solace or dread.”

Regardless of what’s driving your fear or sadness about death, detaching yourself from your inner demons can work wonders. It’s liberating to rise above your anxiety and, like Steve Jobs, take a big-picture view of what life’s all about.

Zweig recalls counseling a 70-year-old woman who was grieving from the loss of her parents, brother and best friend. Unlike some people who grow to accept death as they mourn the passing of loved ones, Zweig’s patient expressed mounting stress as she thought about her end-of-life.

“I suggested that she meditate,” Zweig said. “She learned how to quiet her nervous system and quiet her mind so that she could watch her thoughts about death and let them go. They became less gripping and less overwhelming.”

After a few months of meditation, the woman attained a heightened state of calm in mind and body. Even her breathing gave her comfort.

“Each time I breathe in and out, I’m practicing dying,” she told Zweig. The regularity of her breathing reduced her fear and gave her strength to persevere.

“In that way, she acclimated to those previously disturbing thoughts,” Zweig said. “She found peace of mind.”

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Dying Young

— Americans Under Age 25 Face Higher Death Rates than Peers in Other Affluent Nations

New report shows lower life expectancy for young Americans; ‘aggressive action’ needed to increase survival rates for infants, children, young adults

Americans ages 15 to 24 are twice as likely to die as their peers in France, Germany, Japan and other wealthy nations, while the infant mortality rate is up to three times higher in the United States. That’s according to a new report released today by the Population Reference Bureau (PRB) that cites violence, poverty and racial disparities as the primary drivers of high death rates and lower life expectancies among children and young people in the United States.

Dying Young in the United States: What’s Driving High Death Rates Among Americans Under Age 25 and What Can Be Done? provides the most comprehensive look at deaths among young Americans before the start of the COVID-19 pandemic. The report, prepared in collaboration with researchers from UNLV, the University of Colorado Boulder, University of North Carolina at Chapel Hill, and Duke University, finds that injuries, suicides and homicides are the leading causes of death among children and young adults, and premature birth and congenital abnormalities are the top causes of infant mortality.

In 2019 alone, nearly 60,000 people under age 25 died in the United States, including almost 21,000 infants. Poverty, race/ethnicity, gender, parental education, family structure and regional location are important factors in mortality risk among young Americans, with children and young people in southern states at greater risk for early death, the report finds.

“These differences are particularly striking because we tend to think of early life deaths as random, either from congenital problems or ‘freak accidents,’ but these consistent, robust patterns show that risk and protective factors related to death in early life differ depending on the resources and circumstances of families,” said Elizabeth Lawrence, an assistant professor of sociology at UNLV and a co-author on the report.

The research team was led by Richard G. Rogers, professor of sociology and fellow of the Institute of Behavioral Science at the University of Colorado Boulder, and Robert A. Hummer, professor of sociology and fellow of the Carolina Population Center at the University of North Carolina at Chapel Hill, with funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health.

“The death of a child or young adult is a tremendous tragedy for parents, for families and for our society,” Hummer said. “As the report shows, a significant number of young lives could have been saved through policies and interventions addressing safety and social and economic inequities, making these losses even more tragic.”

Among the key findings:

  • While mortality rates for young people have been steadily declining in other wealthy nations, including Canada, Japan and the United Kingdom they’ve remained stagnant or risen in the United States among every age group under 25.
  • Six of the 10 states with the highest age-adjusted death rates for ages 1 to 24 are in the South: Alabama, Arkansas, Louisiana, Mississippi, South Carolina and Tennessee.
  • Despite having one of the world’s highest income levels, the United States has one of the highest infant mortality rates—about three times as high as Finland, Japan, and Slovenia, largely because it has higher percentages of preterm births.
  • Economic and racial disparities are drivers of higher infant mortality rates among Black mothers compared with white mothers, with the death rate for Black infants twice that of infants born to non-Hispanic white mothers.

“We are publishing this report to inform policymakers and provide the data and evidence needed to prioritize social, economic and health policies and programs that could reduce the number of preventable deaths among young Americans,” said Linda Jacobsen, vice president of U.S. Programs for PRB, a nonprofit that analyzes and publishes data on population and health trends.

While it’s too early to fully assess the impact of the COVID-19 pandemic on mortality patterns, the authors warn that growing mental health and substance abuse problems experienced by young Americans during this period could contribute to rising death rates in the wake of the pandemic.

To reverse these trends, the authors recommend reducing child poverty through direct payments and expanded tax credits, alongside funding for child care, preschool, housing, nutrition and health care. 

“One action that is particularly pressing now is reinstating the child tax credit that recently expired,” Lawrence said. “Providing resources for the neediest families of our nation could do a lot of good in promoting the survival and well-being of babies and children.”

Researchers also call for addressing racial and ethnic barriers to improve access to quality health care and reproductive health programs. Improving treatment for and prevention of mental illness and substance abuse, as well as enacting broad safety measures related to guns and gun ownership, could also save many young lives.

“Immediate and aggressive action is needed at both the federal and state levels to stem death rates among those under the age of 25 in the United States,” Rogers said. “More purposefully supporting infants, children, young adults and young families is an essential way to ensure a brighter future for all Americans.”

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