IV
IT HAPPENS TO us all. Every day, around the world 160,000 people die. That’s about 60 million fresh bodies a year, roughly equivalent to killing off the populations of Sweden, Norway, Belgium, Austria, and Australia year after year. On the other hand, it’s only about 0.7 deaths per 100 people, which means that considerably less than one person in a hundred dies in any given year. Compared with other types of animals, we are awfully good at surviving.
Getting old is the surest route to dying. In the Western world, 75 percent of deaths from cancer, 90 percent from pneumonia, 90 percent from flu, and 80 percent from all causes occur in people sixty-five years of age or older. Interestingly, in the United States no one has died of old age since 1951, at least not officially, for in that year old age was banished as a cause from death certificates. In Britain, it is still allowed, though not much used.
Death is, for most of us, the most terrifying event imaginable. Jenny Diski, facing impending death (in 2016) from cancer, wrote movingly in a series of essays for the London Review of Books about the “excruciating terror” of knowing one is soon to die—“the razor-sharp claws digging into that interior organ where all dreaded things come to scrape and gnaw and live in me.” But we do seem to have some measure of defense mechanism built into us. According to a 2014 study in the Journal of Palliative Medicine, between 50 and 60 percent of terminally ill patients report having intense but highly comforting dreams about their impending passing. A separate study found evidence of a surge of chemicals in the brain at death, which may account for the intense experiences often reported by survivors of near-death incidents.
Most dying people lose any desire to eat or drink in the last day or two of life. Some lose the power of speech. When the ability to cough or swallow goes, they often make a rasping sound commonly known as a death rattle. It can sound distressing but seems not to be to those experiencing it. However, another kind of labored breathing at death, called agonal breathing, may very well be. Agonal breathing, in which the sufferer can’t get enough breath because of a failing heart, may last only for a few seconds, but it can go on for forty minutes or more and be extremely distressing to both victim and loved ones at the bedside. It can be stopped with a neuromuscular blocking agent, but many doctors won’t administer it, because it inevitably hastens death and is therefore thought unethical or even possibly illegal, even though death is just around the corner anyway.
We are extraordinarily sensitive about dying, it seems, and often take the most desperate steps to put off the inevitable. Almost everywhere, overtreatment of dying people is routine. Among those dying of cancer in America, one in eight receives chemotherapy right up to the last two weeks of their lives, long past the point where it is effective. Three separate studies have shown that cancer sufferers receiving palliative care in their final weeks rather than chemotherapy actually live longer and suffer much less.
Predicting deaths, even among the dying, is not easy. As Dr. Steven Hatch of the University of Massachusetts Medical School has written, “One review found that, even among terminally ill patients whose median survival is only four weeks, doctors were correct to within a week of survival in only 25 percent of cases, and in another 25 percent their predictions were wrong by more than four weeks!”
Death becomes apparent very quickly. Almost at once the blood begins to drain from the capillaries near the surface, leading to the ghostly pallor associated with death. “A man’s corpse looks as though his essence has left him, and it has. He is flat and toneless, no longer inflated by the vital spirit the Greeks called pneuma,” wrote Sherwin Nuland in How We Die. Even to someone unused to dead bodies, death is usually instantly recognizable.
Tissue deterioration starts almost at once, which is why “harvesting” (surely the ugliest term in medicine) organs for transplant is such an urgent business. Blood pools in the lowest parts of the body, as gravity demands, turning the skin there purple in a process known as livor mortis. Internal cells rupture and enzymes spill out and begin a self-digesting process known as autolysis. Some organs function longer than others. The liver will continue to break down alcohol after death, even though it has absolutely no need to do so. Cells, too, die at different rates. Brain cells go quickly, in no more than about three or four minutes, but muscle and skin cells may last for hours—perhaps a whole day. The famous muscle stiffening known as rigor mortis (literally “stiffness of death”) sets in between thirty minutes and four hours after death, starting in the facial muscles and moving downward through the body and outward to the extremities. Rigor mortis lasts for a day or so.
A corpse is still very much alive. It’s just not your life any longer. It’s the bacteria you leave behind, plus any others that flock in. As they devour the body, gut bacteria produce a range of gases, among them methane, ammonia, hydrogen sulfide, and sulfur dioxide, as well as the self-explanatorily named compounds cadaverine and putrescine. The smell of a rotting corpse usually becomes horrible within two to three days, less if the weather is hot. Then, gradually, the smells begin to ease until there’s no remaining flesh and thus nothing left to cause odor. Of course, the process can be disrupted if the body falls into a glacier or peaty bog, where bacteria can’t survive and proliferate, or is kept very dry so that the body mummifies. It is a myth, and physiological impossibility, incidentally, that hair and nails continue to grow after death. Nothing grows after death.
For those who choose to be buried, decomposition in a sealed coffin takes a long time—between five and forty years, according to one estimate, and that’s only for those who are not embalmed. The average grave is visited for only about fifteen years, so most of us take a lot longer to vanish from the earth than from others’ memories. A century ago, only about one person in a hundred was cremated, but today three-quarters of Britons and 40 percent of Americans are. If you are cremated, your ashes will weigh about five pounds.
And that’s you gone. But it was good while it lasted, wasn’t it?
ACKNOWLEDGMENTS
I don’t believe I have ever been indebted to more people for expert help and guidance, more generously given, than I have with this book. In particular I wish to thank two people for their especially close help: my son Dr. David Bryson, pediatric orthopedic fellow at Alder Hey Children’s Hospital in Liverpool, and my good friend Ben Ollivere, clinical associate professor of trauma surgery at the University of Nottingham and a consultant trauma surgeon at Queen’s Medical Centre in Nottingham.
I am also much indebted to the following:
In England: Dr. Katie Rollins, Dr. Margy Pratten, and Dr. Siobhan Loughna of the University of Nottingham and Queen’s Medical Centre, Nottingham; Professor John Wass, Professor Irene Tracey, and Professor Russell Foster of Oxford University; Professor Neil Pearce of the London School of Hygiene and Tropical Medicine; Dr. Magnus Bordewich of the Department of Computer Science at Durham University; Dr. Karen Ogilvie of the Royal Society of Chemistry; Daniel M. Davis, professor of immunology and director of research at the Manchester Collaborative Centre for Inflammation Research at the University of Manchester, and his colleagues Jonathan Worboys, Poppy Simmonds, Pippa Kennedy, and Karoliina Tuomela; Professor Rod Skinner of Newcastle University; Dr. Charles Tomson, consultant nephrologist at Newcastle upon Tyne Hospitals; and Dr. Mark Gompels of North Bristol NHS Trust. Special thanks also to my good friend Joshua Ollivere.