The Naturalness of Dying

Evidence that dying occurs as a natural, final event in the wholeness of human life is culturally, artistically, and scientifically persuasive. Very elderly patients eventually undergo a process of functional declines, progressive apathy, and loss of willingness to eat and drink that culminates in death, even in the absence of acute illness or severe chronic disease. Despite clinical resemblances to depression and dementia, aging itself and a loss of will to live are the most probable explanations for natural dying. Acceptance of the naturalness of dying, however, directly conflicts with the medicalization and legalization of death that characterizes modern society's treatment of dying elderly patients. We prefer instead to believe that dying results from disease and injury, which may yield to advances in medical technology. The progressive move of the dying out of the home and into acute and long-term care facilities suggests that medicalization may be an irreversible process. Viewing dying as an independent diagnosis in patients who are obviously undergoing terminal declines from aging and chronic diseases can facilitate communication about spiritual and palliative care needs, which tend to be neglected in the medicalized view of dying. Physicians and nurses may need to assume the role of medical stewardship to help prevent the overtreatment and overtesting of modern medicine's approach to the dying. The emotional burdens of caring for the dying elderly, however, must be addressed openly through collaborative work, institutional policies on limitation of treatment, and support building among physicians and other caregivers. (JAMA. 1995;273:1039-1043)