While the prospect of entering old age, say beginning when we hit seventy, comes with some serenity, so too does it come with fear. Those of this age group have seen the ravages and indignities that could befall themselves having witnessed the experiences of their families and friends, as well as their exposures to cultural and social representations (movies, novels, art, TikTok, Facebook). Their fear ranges from mild concern to outright panic, and their reactions range correspondingly. Those with mild to moderate fear might take up exercising or some brain work, see their doctors regularly, and adopt wearables. Those in utter panic will consider much more drastic actions. In all cases, the reactions to these fears boil down to fighting destiny. 

Lionel Shriver, in her novel, Should We Stay or Should We Go, takes on the case of the panicked, and imagines what they might be willing to do to avoid the horrors that can attend old age and how their actions could turn out. She does this through the story of Cyril and Kay Wilkinson.  

The Pact 

Cyril Wilkinson and his wife Kay make a pact. On Kay’s eightieth birthday, when Cyril is already eighty-one, they will commit suicide together. Cyril, a physician in the British National Health Service (NHS) secured a supply of secobarbital as the means to their ends. It was 1991. They have planned well ahead; another twenty-nine years will pass before Kay’s eightieth in 2020. 

Motivating the pact was the death of Kay’s father after “a good four years of steady deterioration, followed by a solid ten of nothing but degradation” from dementia. (p. 7) Kay recalls “how he was physically so unpleasant,..managing the nappies alone was such a trial, because he fought and kicked a great deal, and sometimes, which was mortifying, got a soft little erection—honestly,  my own father.” (pp. 2-3) Then “the chasing and corralling and undressing…I was halfway between a daughter and a sheepdog. And in between these and many like events, pictures of Kay’s father kept popping up in her head, such as one showing him “naked below the waist, purple with rage, and covered in feces.” (p. 9) 

They had just arrived home from his funeral service and were reflecting on what they had been through. At one point, Cyril says, “Your father frankly made me suicidal—or homicidal—or both. Half an hour in his presence passed like a mini ice age,” and then promises Kay, “I will do almost anything to keep the two of us from acceding to such a fate.” (p. 12) Kay is dubious. 

That’s what everyone says…Everyone looks at what happens to old people and vows that it will never happen to them…Somehow they’ll do something so their aging will proceed with dignity…Everyone thinks they have too much self-respect to allow a stranger to wash their private parts…Then it turns out that, lo and behold, they’re exactly like everyone else! And they fall apart like everyone else, and finish out their miserable end of their lives like everyone else. (pp. 12-13) 

Cyril counters, “in order to retain agency over your own end of life, you have to be willing to give up some small portion of it that’s not particularly rubbish.” (p. 31) But, he admits the plan amounts to “placing a high-stakes wager.” (p. 32) Kay dithers over the next few months, but then her mother begins showing signs of dementia; “I’m all in,” she tells Cyril. (p. 17) 

The Pact Wobbles 

Cyril and Kay proceed through the subsequent twenty-nine years, with Kay raising their three children, retiring, finding new work and passions; Cyril going on and on about politics, the NHS, old people; and both watching their remaining parents pass on, traveling to far-flung locations, becoming grandparents, aging. Then the day arrives; happy birthday, Kay? 

The four years preceding Kay’s eightieth birthday overlap both the decision of the United Kingdom (UK) to leave the European Union (“Brexit”) and the Covid-19 pandemic. Thus, during the time Cyril and Kay are beginning to wonder whether they will actually leave or remain on Earth, the UK is deciding whether to leave or remain in the European Union. And while Cyril and Kay are seemingly willing to die rather than fight the ravages of old age, millions of people are willing to fight the ravages of Covid-19 rather than die. These juxtapositions pop up often giving the Wilkinsons’ decision added poignancy, and play a part in their newly manifesting doubts about the pact as the established date of its execution nears.  

At this juncture, Shriver conjures twelve different endings that still take the form of high-stake wagers. Through these alternative paths, we see if the wagers are well placed. We also gain insights on common and contemporary issues concerning aging, as well as on some hypothetical and futuristic possibilities. Among them are these: 

• The surprises still left between people after more than forty years of marriage 
• The possibility of a person with dementia as happy 
• Whether being sensible and prepared for old age is always rewarding 
• The prospect of outliving enjoyment, purpose, or interest in life 
• What life might be like when a drug reverses aging and makes elderly people twenty-five years old again, forever 
• Elder abuse within an institution and within a family 
• The adventurousness and desperation people approaching old age can exhibit 

Though each of the alternative endings comprise individual chapters, they are not wholly independent of one another as they each borrow ideas, paragraphs, dialogs, and sentences from the others. Some of them peel off into separate tales. Shriver does not limit these through lines to just those within the book. In one case Shriver samples another of her books, So Much For That, and in another, she riffs on an American in England who bloviates on BBC 4 and in a widely-circulated newspaper, who happens to be Shriver in real life. These interminglings make for more dynamic prose, and add some coherency to all the different alternatives presented. 

Destiny’s Grandparents 

None of the alternative endings stand out as the one they should follow. Shriver, though, offers other ways of accommodating the challenges and frights of approaching old age. Throughout the chapters, and with mostly dialog between Cyril and Kay as they think through their choices and decisions, she puts an emphasis on destiny, risk, and bravery.  

When Kay is arguing against the pact, she tries to impress upon Cyril that destiny has a part in what becomes of them, and that they cannot control all of it. “Our destiny isn’t wholly in our hands. I realize you don’t like that about the world, but there’s an upside: our destiny isn’t wholly our responsibility, either. Or, if we end badly, our fault.” (p. 241) Shriver emphasizes the point by making destiny a component of each alternative path they take. Destiny can’t be completely controlled, so embrace it, or at least accept it, Shriver may be saying.  

As they did with their original plan for Kay’s eightieth, the Wilkinsons would have to wager that the outcomes of any of their alternative paths would be more preferable than the status quo. Kay acknowledges that this reality has been the case throughout their life when she asks Cyril, “every decision we make is a gamble, isn’t it?” (p. 202) So, why not give them a go? 

The pact Cyril and Kay make can seem brave, but Shriver is not having it, and especially not when compared to the bravery needed in old age. “Real bravery and nobility,” Kay tells Cyril, “entail losing everything you love by degrees like everyone else, and taking what comes like everyone else, and dying when you least expect it and when you don’t want to, like everyone else.” (p. 75) “Buck up,” Shriver could have added. 

We should stay: it’s destiny, with risks, be brave, eat your ice cream.  

Should We Stay or Should We Go
HarperCollins, 2021: 266 pages 

Image Credit
Title: The Voyage of Life: Old Age 
Artist: Thomas Cole, 1842 
Source: Obelisk Art History  Public domain 

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 fewer 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.