Life asked Death, “Why do people love me, but hate you?”

Death responded, “Because you are a beautiful lie and I am the unpleasant truth.”

As I read these lines long ago, I wondered if death is indeed the most misunderstood reality of our existence. Even doctors, who witness it intimately, often struggle to define or accept it. These apprehensions are partly due to the recent rise in hostile public reactions to negative clinical outcomes.

What is Death?

Defining death is not a simple task. The concept spans the spiritual to the clinical. In the Indian context, no discussion about life and death can commence without reference to the Bhagavad Gita (Chapter 2, Verse 20):

न जायते म्रियते वा कदाचि न्यायं भूत्वा भविता वा न भूय: |
अजो नित्य: शाश्वतोऽयं पुराणो न हन्यते हन्यमाने शरीरे || 20||

Na jayate mriyate va kadachin nayam bhutva bhavita va na bhuyah |
Ajo nityah shashvatoyam purano na hanyate hanyamane sharire || 20||

Translation: The soul is neither born, nor does it ever die; nor having once existed, does it ever cease to be. The soul is without birth, eternal, immortal, and ageless. The soul is not destroyed when the body is destroyed.

While spirituality views death as a transition, the scientific world demands a more finite definition. Dutifully, the first edition of the Encyclopedia Britannica (1768) described it as: “Death is generally considered as the separation of the soul and body; in which sense it stands opposed to life, which consists in the union thereof.”

The modern definition for medical and legal purposes is more clinical. Death is the irreversible cessation of all vital bodily functions, specifically:

1. Total cerebral function (the brain).
2. Spontaneous function of the respiratory system (the lungs).
3. Spontaneous function of the circulatory system (the heart).

Understanding Brain Death

Brain death refers to irreversible brain damage manifested by complete unresponsiveness to all stimuli, the absence of all spontaneous muscle activity (including respiration), and an isoelectric (flat) electroencephalogram (EEG) for 30 minutes. Importantly, these signs must be confirmed in the absence of hypothermia or intoxication by central nervous system depressants. This definition is legally critical for determining the feasibility of organ donation.

The Medicalization of Dying

In our quest to define and conquer death, we have inadvertently medicalized it. Death, once a domestic and spiritual event, has shifted into the Intensive Care Units, surrounded by beeping monitors and strangers in masks and uniforms. This shift forces us to face an ethical dilemma: the distinction between prolonging life and merely prolonging death.

Just because medical technology can sustain a heartbeat or ventilation indefinitely, it does not always mean it should. Recognizing when the fight for cure should change into the need for comfort is probably the most difficult skill a physician has to master.

The Burden of Preventing Death

While medical students learn the definition and diagnosis of death, the conventional curriculum often stops there. There is little formal training in handling the experience of death. As a result, discussions about death are often treated as taboo.

This is likely due to the misconception that doctors must “prevent” death at all costs. This notion has become contagious; even the public often views death as a medical failure rather than a natural inevitability.

Societies attribute different meanings to mortality. Traditional communities, like many in India, consider death a natural part of the life cycle. While traditional societies focused on the “end of rebirths” (moksha) as the ultimate goal, the modern world has become fixated on the “end of death” itself.

The Concept of a “Good Death”

What constitutes a “good death”? Generally, it is one in which a person dies relatively painlessly, on their own terms, and in a dignified situation. Most adults, given the choice, prefer one of three scenarios:

• Sudden death in sleep.
• Dying at home.
• Dying while engaged in meaningful activity.

Many patients wish to take their last breath at home rather than in a hospital. This concept is so deeply embedded in Indian culture that there is a specific prayer recited in temples:

अनायासेन मरणं विनादैन्येन जीवनं | देहांते तवसायुज्यं देहिमे मधुसूदना ||

Anayasena maranam, vina dainyena jivanam | Dehante tava sayujyam, dehi me Madhusudana ||

Translation: O Almighty, please grant me three boons: a painless death, a life of dignity without dependence, and ultimate union with You after the time of my body ends.

The realization of the certainty of death brings a necessary sense of calm and humility.

Death in Hospitals

Clinical personnel are often uncomfortable declaring death and managing the ensuing emotions. Some physicians may even avoid facing the bereaved relatives. However, the relatives have their own emotions… anguish, fear, grief, and guilt… and they require closure too.

Confusion often exists in the management of those “brought dead” (DOA). Handling such situations sensitively, while remaining legally accurate, is a challenge. When relatives are mourning an unexpected loss, doctors will be required to discuss about police intimation and autopsies. Unfortunately, in medicolegal cases, we have no choice but to follow the law of the land.

Reactions to Death

In my clinical practice, I encounter death frequently. The reactions of the families vary significantly:

• The “What Ifs”: Close relatives often ask if they could have done something to prevent the outcome. “Should we have brought my father a bit sooner?”
• Guilt: There is often a lingering feeling of having neglected the patient. “I should have avoided giving feeds when my mother was not responding.” These questions require sensitive answers to prevent the family from carrying a burden of guilt for the rest of their lives.
• Relief: Occasionally, demise brings relief. When a family member has suffered from an untreatable, painful disease, death is viewed as a consolation—an anticipated end to suffering.
• Anger: Conversely, reactions can be hostile. “Your negligence and delay caused this.” It requires great self-control to explain clinical realities to an accusing, mourning family member.

Planning Ahead

The guilt and confusion family members feel,“Did we do the right thing?” often come from a lack of clarity about the wishes of the patient. To achieve the “good death” we pray for, we must be willing to discuss it while we are still well. Concepts like “Living Wills” or Advanced Directives allow people to document their choices regarding ventilation and resuscitation. By making our wishes known well in advance, we relieve our loved ones from the painful burden of making life-and-death decisions on our behalf during an emergency or crisis.

Endpiece

Imagine life without death. It would be chaotic; without resources to sustain everyone forever, the cycle of life would collapse. Death is not the opposite of life, but a part of it. It is an inevitable destiny.

“Of all the ways to lose a person, death is the kindest.” — Ralph Waldo Emerson

References

1. “Death.” In Encyclopaedia Britannica, 1st edition. Vol. 2. Edinburgh: A. B. & C. Macfarquhar, 1768. In Encyclopaedia Britannica, 15th edition. Vol. 5. Chicago: Encyclopaedia Britannica, 1973.

Shashikiran Umakanth

Dr. Shashikiran Umakanth (MBBS, MD, FRCP Edin.) is the Professor & Head of Internal Medicine at Dr. TMA Pai Hospital, Udupi, under the Manipal Academy of Higher Education (MAHE). While he has contributed to nearly 100 scientific publications in the academic world, he writes on MEDiscuss out of a passion to simplify complex medical science for public awareness.