There is an old joke that asks the question, “How do you want to die?” The answer is a quipping one: “I want to die like my grandfather, peacefully in his sleep. Not screaming, yelling, and in terror like all his passengers.” A silly joke asking a very important question.
One of the early steps in Stephen Covey’s book 7 Habits of Highly Successful People is to start with the end in mind. He means to begin by visualizing a life goal and then build foundations and processes that help to accomplish that eventuality. Those goals may or may not be achieved, but the eventuality of death will happen to us all. So how do you want to die?
I would like to tell you a great way to die, but before I get there, I have to tell you some stories.
In 1991 my oldest brother David had a dream that essentially pushed our younger brother and me to go on a five-week trip to and through Alaska. We drove to the Canadian border from San Antonio, Texas—and that was just the halfway mark. (We made it work, but this is not how I recommend traveling North.) Our first stop was Skagway, Alaska to do the fairly grueling Chilkoot trail, a 33-mile stretch of the Yukon Gold Rush. The elevation gain is incredible, with up and down sections repeating ad nauseum. We began the three-day trek with 35-pound packs and were out of food by the last day. On our second day, we were concerned about a group camping nearby—three friends, one in their late 70s, the other two in their 80s. We were discussing whether to share our food with them when we heard the distinctive sound of a bottle of wine opening! We later wondered if we should offer to help them at the pass itself…and they beat us to the top. Had we known we would have been asking them for their help throughout the trip as they were clearly living their best lives while ignoring the number of their birthdays.
We had done the trail. A three-day hike that was a great accomplishment in life. We sat in silence among debris and trash from me that had lived and loved and worked so hard and died one hundred years before us. A humbling moment.
Fast forward 10 days from there. We were in Denali National Park where cars are not allowed. Ingress is by yellow school buses to which the animals have acclimated. We had plans to camp for 7 days, so we packed heavy 55-pound packs and rode the bus for five hours before embarking on a flat 7-mile hike to our site.
The moment we strapped on the packs it was vastly different— I still use this illustration with patients about the benefits of losing 20 pounds. We trudged our way through thick high brush, calling out every 20 or 30 seconds “Hey Bear!”; walking up and surprising an Alaskan grizzly is not wise. After a rest break on the first day, we all struggled like crazy to get on our feet again. David in particular struggled, he slipped and found himself on his back with the backpack weighing him down, as helpless as an overturned turtle. Far from being angry, David laughed uproariously, and the three of us laughed continuously for a long time. From time to time over the years, we talk about that trip to Alaska and always include that moment.
Fast forward now to the Christmas of 1998. My family as a rule would gather for at least a weekend around Christmas to celebrate, and this Christmas was no different. I clearly remember my brother David asking me a question that puzzled me at the time. He asked, “You know that feeling you get when you pass out while you’re laughing really hard?“ I told him that I did not know what he was talking about, and I left it at that. A month and a half later on Valentine’s Day, there was another family gathering to celebrate my mother’s and my brother David’s birthdays (his 35th.) I was unable to go but my wife made it. She mentioned that David was experiencing balance issues and she had seen him hit a wall once while walking down a hallway. He assured everyone that he had seen his doctor and had an MRI pending. A few days after returning from that Valentine’s visit he had the MRI results—and an appointment his primary care doctor had scheduled with an oncologist. I was able to go with him to that oncology appointment. I was completely convinced that he had an acoustic neuroma—difficult to treat, but treatable.
David and I went into the appointment room together. It was a small exam room in the Cancer Treatment and Research Center of the University of Texas Health Science Center at San Antonio. Along one wall was a bank of X-ray view boxes and MRIs attached to the wall. Instantly I was disappointed in the center because they had clearly left the previous patients’ MRI up and allowed David and me to enter. I briefly glanced at the X-rays and could see an obvious large tumor…the previous patient was, as our Alabama relatives would say, an absolute dead person. I was approaching the end of my third year of residency in family medicine, and I knew this was a grave patient privacy violation. The physician eventually came in and began to talk to us and to my shock, quickly turned to the x-ray view boxes and directed our attention to the MRI. I had to ask the doctor twice to confirm that that was indeed my brother’s MRI on the wall.
David had a large glioblastoma multiforme in his brainstem. What he was describing as fainting when laughing out loud was pressure being put on the brainstem with Valsalva and shutting down brainstem function. Unfortunately, my prognosis was correct. He had a terrible brain tumor and only a few months to live.
After a biopsy, he received the best treatment at the time for that disease, which was radiation coupled with cisplatin. Futility was obtained quickly and by early June it was clear that he was beyond hope of a cure. He and his wife had their fourth child during this treatment regimen, and he had well over ten thousand people praying for him all over the world through his church’s network, and yet his health continued to decline. My wife and I were scheduled to graduate in July from our residency in Corpus Christi, and after the ceremony, we drove like the wind to San Antonio. David had been on hospice for a few weeks and was near death, slipping in and out of consciousness as we sped there.
When I arrived around 6 pm I saw David in his hospital bed, essentially in a coma, but he lightly squeezed my hand and seemed to mouth what he often called me, O’Kenny.
Sitting around David was his wife, my two sisters, my younger brother, my mother, and myself. We were a mix of somber and comforted, telling stories and occasionally laughing. As it approached midnight with my brother’s death rattle rhythmically sounding, we started recounting the stories of our time in Alaska. We started to tell the story about shouting “Hey Bear!” and laughed about the turtle that was David. We all laughed—the long and hard laugh of a family in pain together.
After a bit, just after midnight, we stopped laughing and settled into quiet. Total quiet, as we all noticed together that David had died.
There is much that is unknowable about the final stages of death. Many hold that hearing is one of the last senses to go, as some who have been in comas and recovered relay things heard while comatose. I believe David’s hearing was intact in those final moments. I believe he laughed, which pushed that pressure on his brainstem over the edge, and surrounded by love and family, my brother died laughing.
How do you want to die?
Do you want to die remembering wonderful moments? You won’t unless you make those memories and eschew working all the time. Do you want to die surrounded by love? Then live loving. If you want to die rich and unmourned, that too is in your grasp.
I want to die laughing.