Thousands of people are currently working on solving the problem of death. Maybe they will succeed, out of sheer boredom, and when I am 900 years old I will reread this sentence and reflect fondly on the first wasted century of my life. Meanwhile, billions of people will die—some from disease, others from accidents, and a significant number from what we commonly call “old age.” Relatively speaking, the last sounds like a pleasant way to end – a peaceful ending. But what does it actually look like? What does it mean to die of old age? In this week’s Giz Asks, we reached out to a number of experts to find out.
This article was originally published on August 3, 2020.
Elizabeth Tsang
Assistant Professor of Medicine, University of California, San Francisco
In our society, people often say that someone “dies of old age.” But no one really dies of “old age.” There are always other pre-existing conditions or new illnesses that cause related deaths. “Old age” isn’t something you put on a death certificate – most likely, it could be something like cardiac arrest, which occurs due to some underlying problem like infection, heart disease or cancer. For example, clots may travel to the lungs, stopping the supply of oxygen to a person’s brain or body, causing the heart to stop beating. When a person dies, whether they are young or old, some disease or disease process causes their body to stop working.
Illnesses in older adults may present in different ways. As we age, the body undergoes normal wear and tear, and our responses to health problems become less resilient. Young people can and do die from the same diseases as older people—heart disease, pulmonary blood clots—but older people may respond to these diseases differently. For example, with pneumonia, they may not show the normal signs of infection, instead they may have high blood sugar, if they have diabetes, or if they have dementia, they may just show changes in their mental status: More disorganized and unable to do the things they normally would. When we are older and something like this happens, we may not attribute it to an underlying disease process.
People always talk about wanting to “die in their sleep,” but this isn’t a specific phenomenon: people who die in their sleep may simply have undetected cancers or infections that happen to occur while they’re asleep when you are awake, not when you are awake. It’s also important to note that sometimes when people have a serious illness, such as end-stage congestive heart failure or terminal cancer, they may choose to “allow a natural death”—focusing on relieving symptoms and staying comfortable rather than going to the hospital and getting Aggressive treatment.
Jessica Humphries
Assistant Professor of Medicine, University of California, San Francisco, specializing in hospice care
People often say: I want to grow old in my sleep. But everyone dies the same way: their heart stops beating. This is the final step. When you fill out a death certificate, you have to enter the cause of death — anything from cardiopulmonary arrest to blood clots in the lungs to a diagnosis of cancer. I train students to think: What was the previous reason? What was the reason before? etc.
As a palliative care physician, I care for critically ill patients, many of whom are on the verge of death. My job starts with sitting with people, talking to them about the dying process, and then helping them through it. The word “natural” to me means a kind of gentleness – you don’t realize what’s happening and you don’t have to think about it.
But the reality of our death process is that it almost never happens this way. Today, it is rare for a healthy person with no medical problems to have a heart attack while sleeping at night. (By the way, although the common refrain is “dying in one’s sleep,” we rarely know if the person actually died in their sleep unless we were there to observe them—they were probably awake.)
In the United States, “natural death” often looks like this: We discover something is wrong with someone, we try to treat them—to relieve their pain, to prolong their life—and then we start to lose the battle. We then think about how to turn our attention to improving their lives as much as possible until the very end.
A word of caution: I’ve done a lot of work in Uganda and India, and would say that “natural death” in most parts of the world actually causes more suffering. In most of the world, we have virtually no access to opioids. In some ways, the most “natural” way to die is to suffer greatly. Our goal, then, should be to reduce suffering as much as possible.
David Casaret
Professor of Medicine and Chief of the Division of Palliative Care at Duke University School of Medicine and author of Shock: Adventures in Bringing Back the Recently Dead and other books
Do you want to die of old age? Well…you can’t. It’s a beautiful and picturesque concept, and there’s certainly a lot of conventional wisdom about old age and death. This is what many people want to do and it is what many of my patients try to do. Like skiers on a slopes, they dodge one life-threatening illness after another, bouncing between heart failure, prostate cancer, pneumonia and now COVID-19, all in the hopes of dying peacefully – one hopes. ——”old age”.
But there is no such thing as death from old age. This isn’t to say that your heartbeat will get slower and slower as you age, only to stop contracting again late at night. Aging puts you at risk for everything from cancer to dementia, any of which can end your life. But don’t blame old age.
For example, my grandmother died at the age of 103. She grew weaker but alert, her mental state intact, until eventually she was reading a book a day, including one of my novels, one of which she had actually finished.
But she did not die of old age. Her age and frailty put her at increased risk for hip fracture, which she did suffer. What followed was a high-risk surgery, which she performed brilliantly but was ultimately halted by a stroke. She died at an old age and in physical and mental health that most of us only achieve in the last years of our lives, but she did not die of old age. She died in a series of bad events, and her advanced age made her even more vulnerable to the effects of these events.
This raises an interesting question: What would you like to die of? What would you do if you strictly controlled your cholesterol to avoid dying from heart disease, ate lots of raw kale to avoid dying from colon cancer, and avoided smoking to avoid emphysema? Die? What’s left? (I thank my mentor, Dr. Joanne Lynn, for first putting this question in my mind 20 years ago. I still don’t have the answer).
If you managed to avoid all the life-threatening diseases in the world, what would be left? Well, my grandmother’s story is one answer to that question. She does everything right, from her healthy lifestyle to her (don’t laugh) laid-back, easy-going demeanor that keeps her remarkably calm. She did everything right, but doing everything right only gets you so far. Then, eventually, life has the final say and steps in in the form of a fall, stroke, heart attack, or pneumonia.
Something to note: I said there is no such thing as old age and death, but people do die of old age. This is a distinction to remember. Many people who live to an advanced age manage to maintain their mental acuity and most of their physical functions until the very end. Many people—perhaps most—died suddenly in their sleep. Of course, if you’re in your twenties, without any warning or time to prepare, this may not be the path you want to take. But if you’ve walked the earth for a century and encountered a warning or close call or two that prompted you to say goodbye, dying in your sleep might be a good option.
This is perhaps the biggest difference between those who die at an advanced age and everyone else. Many people who die in their 90s or older have come to terms with death. They did what they needed to do and said what they needed to say. Maybe they’ve been preparing for it for years. So, in my experience as a hospice physician, there’s usually not much of a struggle and no last-minute rescue in the form of aggressive surgery or long-term chemotherapy. They just make a settlement and sign it. If “dying old” means anything, it’s the willingness to say goodbye and move on.
Alan Andrade
Assistant Professor of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai
The Centers for Disease Control recommends that doctors no longer use the terms “death of old age” or “death from natural causes” because they have limited value to the medical community. This language is used when a physician is unsure of the sequence of events leading up to death as recorded on the death certificate, when unnatural causes such as homicide or suicide are not suspected, or in a low-resource setting where the coroner is unable to determine the cause of death. Widely used. However, these terms remain popular with the public because they indicate that the death was not an accidental or traumatic event and help avoid sensitive issues related to the cause of death. This is because we all strive to stay as “young and healthy” as possible, and we all want to avoid debilitating long-term serious illness. Like birth, death is a sentinel event associated with strong emotions and is often a topic that people tend to avoid.
Interestingly, most people are not afraid of death itself, but rather the process of dying. People who die naturally without artificial life support machines such as respirators often experience a similar death process. The factor that determines the difference in the death process is how quickly the body shuts down. This process can take anywhere from weeks to months, days to weeks, hours to days, or minutes to hours. People in the weeks to months time frame tend to experience a gradual decline in function and typically spend more time sitting or lying down and rely more on others for their personal care needs. Over days to weeks a person may find it increasingly difficult to concentrate, become less aware of their surroundings, and show less interest in food and water. People who are near death within hours to days are often unaware of their surroundings, have difficulty swallowing, breathing, and appear exhausted, as if they have just finished a sprint. People who die within minutes to hours lose consciousness and have erratic breathing patterns.
All in all, death is a natural process that is usually peaceful. Depending on the time frame and cause of death, people may exhibit symptoms such as shortness of breath, pain, or delirium, a common disorder associated with inability to concentrate and confusion. Maximizing comfort and quality for the remainder of one’s life.
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(Updated 03/04/22 with new details)
