BMJ  2003;327 (26 July), doi:10.1136/bmj.327.7408.0-f

Editor's choice

Death, come closer

Death gives life meaning. Without death every birth would be a tragedy. The thought that I might be editing the BMJ for the next 5000 years is perhaps even more awful for me than for you. Gulliver was vastly excited when he travelled to Laputa and heard of the Strudbruggs, the immortals. He imagined them with their "minds free and disengaged, without the weight and depression of Spirits caused by the continual Apprehension of Death." In fact they were the most miserable of people. One of their "prevailing Passions" was envy of the deaths of the old. Truly, where there is death there is hope, not only for those who want to follow but also for those who must die.

"The fear of death is being replaced by the fear of dying," writes Jocalyn Clark, the BMJ editor who has assembled this issue (p 174). I suspect that few BMJ readers worry about burning in hell, but many must wonder how it will be when it comes to their turn to die. Most doctors have witnessed patients die undignified, soulless, high tech deaths and hoped for something better for themselves and their patients. But what does a good death look like and how high a priority should it be for health services? If death is defeat, then it won't be a high priority. But if a good death is the culmination of a good life then it must be a priority.

What is clear from reading this theme issue on a good death is that one size won't fit all. We want to be as different in dying as in living. Different cultures, times, and religions have different concepts of a good death (p 175 and p 218). Some want it sudden, some slow. Some want a quiet death with minimal medical involvement. Others want to follow Dylan Thomas and "rage, rage against the dying of the light," squeezing every last drop from life (p 224).

A few chose to kill themselves, while others would like to be killed. We wondered about excluding euthanasia from this issue, but it wouldn't go away (p 189 and p 213). Even in countries that have legalised euthanasia few chose to die that way (p 201), suggesting that perhaps it's unimportant. But pressure to legalise euthanasia seems likely to grow and combine with people wanting increasing choices on how they die. For Ivan Illich death was the ultimate form of consumer resistance, but as the baby boomers turn their thoughts to death they are unlikely to accept the squalid end that may happen in a health service preoccupied with life at the expense of death.

The diagnosis of dying is one of the most crucial that a doctor must make. Paul Glare and others show that doctors consistently overestimate the time patients have left to live (p 195). In order to help their patients to a good death they must "recalibrate" themselves, recognising that death is closer than they think. This theme issue aims to recalibrate us all.

(rsmith{at}bmj.com)

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