We need to talk about Death

In the early days of the pandemic, during those balmy April days when the sun shone down on grassy verges bursting to life at the sides of empty roads, whilst health care staff were managing levels of agonising illness and mortality they had never experienced before, it only took a blackbird singing or a particularly kind WhatsApp message to bring tears to my eyes. So much to lose and so much to live for. I was reminded of a famous response from Dennis Potter when Melvyn Bragg interviewed him on television just a few days before he died. 

‘The blossom is out in full now, it’s plum tree, it looks like apple blossom but it’s white. It’s the whitest, frothiest blossomest blossom that ever could be, and I can see it. Things are both more trivial than they ever were and more important than they ever were, and the difference between the trivial and the important doesn’t seem to matter. But the now-ness of everything is absolutely wondrous.’

 Then there is Clive James’ poem, The Maple Tree.

Your death, near now, is of an easy sort.

So slow a fading out brings no real pain.

Breath growing short

Is just uncomfortable. You feel the drain

Of energy, but thought and sight remain:

Enhanced, in fact. When did you ever see

So much sweet beauty as when fine rain falls

On that small tree

And saturates your brick back garden walls,

So many Amber Rooms and mirror halls?

In the face of such suffering, the world seemed exquisitely beautiful, almost unbearably so.

My Dad had Covid19 back in March. I thought he would die and spent a sleepless night or two making the odd adjustment to my Will and writing letters to my children, aware that I might need to take over his care and that there was a possibility of succumbing to the virus myself. I had conversations with my Mum and sister about keeping him at home, where at least they could be with him. Desperate to be doing something useful, I made four masks out of two old bras and sent them off to help minimise the chances of them being infected! In the event he recovered, but, for a few days, we all lived with the very real likelihood that he might die and I was painfully conscious of our enforced separation.

In those early days, many of us hoped that that one of the good things to come from the pandemic would be a more comfortable attitude to thinking and talking about death. So much of my career as a psychiatrist and psychotherapist has been working with people whose mental health symptoms mask profound grief, people whose losses have been overwhelming in a society where death is a taboo and communities sadly lacking in rituals that facilitate mourning. There was a hope that the threat of the pandemic would be a stimulus to families all over the country  to talk with their older relatives about the possibility of getting ill and where they  wanted to die. I don’t think this happened. Perhaps it felt too unbearable. Whereas the disincentives to being admitted to hospital during a pandemic were obvious and most people, if asked, express a preference to die at home anyway, there was little comfort for individuals and their families facing a socially-distanced death and funeral.

But if such a major threat to society such as Covid19 doesn’t result in a greater capacity to face the precariousness of our existence and the truth that death is ultimately inescapable, there is a price to pay. Dennis Potter and Clive James had both faced the reality of their impending death and could live each day more fully and see and think more clearly as a result. Many don’t manage to face reality in this way and the ripples of denial distort and inhibit their thoughts and feelings , and those of people around them.

Over the years I have worked with a number of doctors who can’t quite face the reality of death and have suffered a mental breakdown as a result. In some cases they have suffered an early loss that they irrationally feel responsible for and they come to realise during therapy that their work as a doctor is over-determined by a need to keep people alive at whatever cost to them and, in some cases, the patient.

More generally, confronting the reality of endings, finite limits, and the inevitability of our own deaths can be an important part of therapy in a society that discourages such insight. The idea that leading a good life is intimately linked to facing the reality of our lives being finite, has been around at least since Aristotle and one has only to examine the behaviour of infamous leaders, both past and present, to see the destruction wrought when  such truth is denied.

Living and working up close with death hooks into our deepest existential fear, and if this fear can’t be faced, it will drive, not just individuals, but our healthcare organisations and society at large, to anxiety-driven neurotic – even psychotic – behaviours. At worst, hospitals become ‘keep death at bay factories’ and society becomes so risk averse that our humanity and essential sense of co-operative kinship suffers. Denial distorts the truth and this makes rational, creative thinking more and more difficult. Things become stuck. There is a sense of going round in circles and being doomed to repeat the same mistakes.

I have become a bit of a news junkie over the last few months so awarded myself a two week blank-out whilst we were on holiday. Switching back in brought a horrible sense of a time warp: local mayors still outraged at the lack of communication from central government, a Parliamentary motion trying to establish the right of healthcare staff to have access to testing. It seems we are going backwards rather than forwards.  And we could all give countless examples of contradictory communications, policy initiatives with such obvious unintended consequences that they are likely to make things worse rather than better, and revealing quotes from those in power exposing just how little they understand of what’s going on. It’s hard not to reach the conclusion that something is interfering with the capacity to think. As the reality of how we’re managing gets worse, it becomes harder to face the truth. And those in power become increasingly out of touch, with triumphant manic responses, and vanity verging on the psychotic, becoming normal. 

But maybe, buried within the political hubris, deeper even than the desperately avoided panic and  shame at how they are governing, is a shared fear of death that cannot be named. There were a few weeks from the end of March through to May, where the situation felt very frightening, with the prime minister in ICU and deaths of young healthcare workers reported daily on our screens. It gradually became clear that we had the highest excess death rate in the world and were failing to protect our frontline workers.

Could it be that we were so traumatised by this that we have become somehow fixated, unable to move on because we can’t articulate the important questions? It is vitally important with a new disease constantly to reappraise the situation.  This means being able to think about the reality of death (and indeed ‘Long Covid’, but that’s for another day) taking into account all the evidence as it accrues.  The capacity to do this seems to be largely confined to the medical media, with the odd more questioning in-depth item buried late at night or in the inner pages of the main-stream media. More generally, the frame and tone is taken from the official media briefings and the response to them. There seems to be a major split between those who basically create and follow such main-stream news, and subgroups who challenge the received wisdom, but in many cases come up with answers that are even further removed from reality. At times there appear to be angry splits between ‘death deniers’ and ‘mortality panickers’, rather than balanced, thoughtful consideration.

Here are some of the questions I would like to see intelligently explored more widely. None of them have simple answers. They require serious attention and clear thinking unclouded by anxiety responses to the reality of death.

• Why are those journalists so obsessed with ‘cases’- whatever that means – unquestioning of the significance of test results and relatively uninterested in actual rates of illness, hospital admissions and deaths?

• I know how shocking the death rates were early in the pandemic, but now we have abit more idea of what we are dealing with, what are the current risks of dying from this disease? Are they significantly higher, for example than seasonal ‘flu?

• Who is dying from this disease now? Again, I know that at the start of the pandemic, at least 85% of deaths from Covid19 were people with years of good quality life ahead of them. But is that still the case? The ONS reports that most people who die from or with Covid19 have co-morbidities: some of these may be relatively minor, some may not. Without more detail, this does not tell us enough.

• Why is there no proper public conversation about the risk of dying from Covid19 compared to the risk of dying from other conditions? This would bring a helpful perspective. Instead we continue to talk about Covid19 as a uniquely dangerous condition.

• When are we going genuinely to start the difficult job of balancing the risks of dying from Covid-19, with the increased risks of death from suicide and untreated or under-treated conditions made more likely by the way we are managing the pandemic?

• The initial aim of social management was clear: namely to slow down the infection rate so that the NHS would not be overwhelmed. What is the aim now? Is it to eradicate the virus? And if so, is this realistic?

In his last post, John wrote of the insidious undermining effects of anxiety on our collaborative relationships in these challenging times. The profound existential fear aroused by the thought of  death and dying that I have discussed here can result in various levels of denial or hysteria if unmanaged.This creates muddled thinking and undermines progress.