It was 2006, my intern year - first year as a doctor after having recently completed medical school.
Having been rostered for several months of dusk-to-dawn night shifts, I spent much of that year strolling down the dimly lit corridors of the hospital, responding to calls that usually involved mundane tasks (like replacing an intravenous line) or "putting out fires" (like stopping sick patients from deteriorating further). Several calls stand out in my memory.
One of these cases involved a lady in her 40s who developed worsening abdominal pain around midnight. Despite her relative youth, she had spent several years battling metastatic breast cancer, as well as several rounds of surgery, chemotherapy, and radiotherapy. Given that the cancer had taken residence in multiple sites throughout her body she was deemed palliative, meaning no life-saving measures were to be administered, as no prolonged survival was expected. It was not even anticipated that she would leave the hospital alive; she was there to be kept comfortable, until death.
I was called to see her about her pain, and I performed the usual drill - took a brief history, examined her abdomen and so on - then prescribed her some rapid-acting fentanyl for pain relief, charting more to be given upon request, if she needed it. I hung around for a half-hour; we spoke of everything she had done to "fight" the cancer. She spoke of what she had done since the diagnosis, how the imposition of an endpoint had forced her to focus more on what really mattered. When the pain had eased and she seemed comfortable, I wandered off to my all-too-familiar dark corridors to replace more lines and put out more fires.
Long nights. Dark corridors.
That was the first time I fully witnessed the transition from life to death, right in front of me, at 4 am on a nondescript morning in 2006. I had seen plenty of bodies until that point - autopsies, certifying death on the ward, and so on - but this was entirely different. I had been conversing with this person only a few hours previously...I may have been the last person to have done so with her. No doubt she had met and known hundreds of different people over the course of her lifetime, and yet her final moments were spent with a relative stranger. Then I saw the entire transition, from alive to...not. Seeing the lifelessness that remained afterwards, I felt sorry for her and for the loss of her future years, and strangely perplexed by the lack of life behind the eyes; the life that no longer existed, and can never be emulated by any person pretending to be dead on stage or film.
She never had the opportunity to experience her 40s, 50s, 60s...or anything after. I wondered - after several years of cancer, surgery, chemotherapy, radiotherapy and whatever else she had been through, maybe death was a welcome release? Yet after seeing her pain and grief in those final moments - not just the physical pain of whatever triggered her sudden decline, but perhaps also the sudden release of a long-subdued life regret or two, and the knowledge that here it was, that final moment of awareness - my heart tells me that she would have given anything for that cancer to have been cured, to live past 40-something years of age, to seize every moment of every day from that day onwards, and to take advantage of the increased awareness her proximity to death had forced upon her so that perhaps she could truly soar through the rest of her life...cloud-high.
"When I look back at the past and think of all the time I squandered in error and idleness, lacking the knowledge needed to live, when I think of how often I sinned against my heart and my soul, then my heart bleeds. Life is a gift, life is happiness, every minute could have been an eternity of happiness! If youth only knew! Now my life will change;
now I will be reborn."
In 1849, a young Fyodor Dostoyevsky faced a firing squad in St Petersburg, Russia (1). He had gotten himself into this tenuous position by joining a group of young intellectuals called The Petrashevsky Circle, a group that occasionally criticized the Russian politics and religion of the day. In his final minutes, Dostoyevsky experienced emotions he never knew he had; he noticed the rays of light as they struck a cathedral, realizing that all life was as transient and temporary as those rays, and he noticed the expressions on the faces of his fellow prisoners, recognizing the panic and fear behind their valiant facades. He felt vibrant, awake, and aware.
Fortunately for Dostoyevsky, the Petrashevsky execution was stayed when a cart delivering a message from the Tsar arrived at the last conceivable moment, instructing that the death sentence be withdrawn; rather than being shot, Dostoyevsky and his comrades were instead condemned to several years of hard labour in Siberia. He wrote the above quote after his stay of execution, and it was only after his brush with death that Dostoyevsky's life flourished as he became one of the most famous Russian writers in all of history.
The Petrashevsky (near) execution.
Such a reaction to a near-death experience is not uncommon; author Robert Greene has dubbed it "the paradoxical death effect" - when someone has a brush with death, it often produces the paradoxical effect of making that person feel more vibrant, awake, and alive than they ever were before (2). Greene argues that most people spend their entire lives avoiding thinking about death, when the inevitability of it should actually be continually on our minds. Making death a familiar presence allows us to understand how short life is, cleansing us of silly illusions and allowing us to perceive what really matters, resulting in a deeper sense of commitment to our relationships and life's work. Being aware of the inevitability of death intensifies every facet of the experience that is the opposite of death - that is, life.
Green also describes a negative paradoxical death effect - avoiding pain and adversity makes us feel less alive. Lacking a continual awareness of death results in a diminished understanding of life and what matters in it. Without an adequate awareness of death, life is wasted.
"My formula for greatness in a human being is amor fati: that one wants nothing to be other than it is, not in the future, not in the past, not in all eternity. Not merely to endure that which happens of necessity...
...but to love it."
The above quote by German philosopher Friedrich Nietzsche describes that when faced with something inevitable, we can either choose to avoid, fight it, tolerate it, endure it, accept it...or we can choose the option of amor fati, to love the inevitable. By loving the inevitable, even if - or especially if - it appears frightening, we grow stronger and live fuller lives. This is the very notion of antifragility; rather than avoiding or merely accepting the unknown, particularly when it initially seems like an obstacle or even a disaster, a person grows most by loving it and even incorporating it into their existence, turning an apparent obstacle or disaster into a strength (3).
Unfortunately, this is not the current case with the notion of death in the contemporary west; death is purposefully neglected. There are attempts to outmaneuver it at every turn. Youthfulness is exalted; people wistfully reminisce about their earlier years, but rarely do they wistfully anticipate their final years. In general, death is hidden, tucked away into small rooms lining dark hospital corridors. We are even hidden from the deaths of foods we eat, preferring not to think about the animal itself being slaughtered. It seems that the entire subject of death is taboo - off limits, distasteful, revolting.
The nearer the dark, the brighter the flame.