If the growing popularity of facelifts, hair transplants, and biohacking is any indication, our society is afraid of mortality. Despite being inevitable and universal, death is a difficult and taboo topic. Chris Palmer sets out to change that with his book Achieving a Good Death: A Practical Guide to the End of Life.
Modern medicine’s emphasis on extending the human lifespan has, in some cases, transformed dying, once a communal and spiritual event, into a cascade of arduous procedures. Deftly synthesizing the wisdom of many experts with his own insights and experiences, Palmer offers compelling, accessible, and refreshingly honest advice on how to shape our lives and legacies so that we are better prepared to die as we see fit—highlighting agency in aging in the face of ageist norms.
Just last week, New York Governor Kathy Hochul announced that the state will join 11 others and Washington, D.C., in legalizing medical aid in dying (MAID), or when physicians prescribe a lethal dose of medications to patients with less than six months to live.
“New York has long been a beacon of freedom,” Hochul said, “and now it is time we extend that freedom to terminally ill New Yorkers who want the right to die comfortably and on their own terms.”
The governor’s rhetoric emphasizes a collective cognitive dissonance: As physician (and fellow politician) Dan Morhaim observes, “our culture celebrates personal autonomy,” but when it comes to death and dying, “we collectively abdicate” that value.
Citing Morhaim and others, Palmer provides valuable context for our relationship with mortality (along with additional information about MAID). During the nineteenth and early twentieth centuries, the average death was relatively quick and happened at home, with little involvement from healthcare providers and medical technology. Today, dying is protracted and tends to take place in hospitals or nursing homes; healthcare providers and medical technology are highly involved; and life can be prolonged with organ transplants, chemotherapy, and more.
“There is a significant difference between dying peacefully in your bed at home and dying yoked to tubes and machines in an ICU,” Palmer writes, “receiving futile care that only prolongs the dying process for perhaps a few days while providing a horrendous quality of life.”
Drawing on surgeon Atul Gawande’s [1] work, Palmer argues that, at best, physicians are uneducated about aging and dying and what might matter to patients approaching the end of their lives. At worst, they are financially motivated to perform aggressive interventions that may do more harm than good.
According to numerous studies, frail patients do poorly in hospitals, and Palmer points out that doctors nearing death tend to eschew the very treatments they give to their older patients, such as surgeries and radiation.
“I don’t want my last conscious thought to be of doctors stabbing needles into my veins, my ribs breaking from chest compressions, and a large-bore tube thrust into my throat and lungs,” the end-of-life activist writes. “When a patient is young and robust, such curative measures may make good sense despite their violence, but not for an old, debilitated, frail patient.”
But we have choices: “where to die, how much treatment to have, and how to spend the limited time we have left.”
“While, in a real sense, no death is ever ‘good,’” Palmer underscores, “planning and preparation can make death less awful and painful.”
Legislation to make MAID available to the terminally ill is one step in that direction. However, critics argue that MAID may endanger the elderly and disabled, who might feel pressured to end their lives out of fear of causing hardship to their families. Opponents also contend that such policies reinforce the toxic notion that a life with a disability or chronic illness is not worth living. Also, some individuals may seek MAID due to high treatment costs, but MAID should not substitute for accessible care and support.
Racial inequities in healthcare are also relevant; Black people might opt for MAID because they are more likely to receive inadequate pain management due to stereotypes that they are drug-seeking or pain-tolerant.[2] Palmer could have engaged more fully with these valid concerns. Fortunately, the Medical Aid in Dying Act in New York has a number of guardrails meant to ensure the patient’s decision is informed and voluntary, including a conflict-of-interest prohibition and a mandatory mental health evaluation.
Well before we are terminally ill, we need to be having routine conversations about dying with our loved ones and physicians. To that end, Palmer endorses The Conversation Project. He also suggests creating an advance directive, or a legal document outlining your healthcare wishes, and choosing a healthcare proxy—not necessarily your closest relative—when you’re young or in good health. One way to think about your healthcare wishes is to complete the sentence “I would want to live as long as I could still…”, as recommended by physician Eleanor Tanno. Another is to consider an “exit strategy,” or an illness for which you would decline treatment.[3]
Some other tips from Palmer for a “good” death:
- Write a personal mission statement; letters of gratitude to loved ones; and legacy letters, also known as ethical wills, that capture your essence, beliefs, and stories to pass on to future generations.
- Make a folder containing everything your children must handle when you die.
- Join a “village,” or “virtual retirement community.”
The author also illuminates the benefits and limitations of palliative and hospice care, delineates various eco-friendly alternatives to embalming (reader: as of writing this, I’d like to be affordably composted), and presents ideas for making funeral and memorial services more substantive—and even fun.
Achieving a Good Death is a touch dogmatic, but Palmer demonstrates in the book’s rich appendices that he practices what he preaches. In a letter to his family about his own end-of-life wishes, he shares the pain of witnessing his mother’s final years in a nursing home: “I want to prevent what happened to her from happening to me.”
“If my mental function is seriously compromised with little chance for full recovery, please seek opportunities to encourage death’s approach… Are my kidneys faltering? Let them,” he writes, giving new meaning to author Mel Robbins’ self-help concept.
The book’s main flaw—one the author himself acknowledges—is that it is primarily aimed at those with friends and families. Readers without such connections may feel less comforted than grimly recognized by Palmer’s planned memorial service playlist featuring the Beatles’ “Eleanor Rigby.”
Ultimately, Achieving a Good Death is a stimulating must-read for mortals that will leave you equipped for a more peaceful, dignified, and meaningful end.
Achieving a Good Death: A Practical Guide to the End of Life
Chris Palmer
Rowman & Littlefield, 2024
[1] Gawande, Atul. Being Mortal: Medicine and What Matters in the End. Metropolitan Books, 2014.
[2] Substance Abuse and Mental Health Services Administration. The Opioid Crisis and the Black/African American Population: An Urgent Issue. Publication No. PEP20-05-02-001, Department of Health and Human Services, Office of Behavioral Health Equity, 17 Mar. 2020, samhsa.gov/sites/default/files/meeting/documents/csap-nac-presentation-03172020.pdf.
[3] Harrington, Samuel. At Peace: Choosing a Good Death After a Long Life. Hatchette, 2018.
Web image by Medhum.org.
