How Do You Want to Die?

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.“ As silly as that line is, it does ask 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 start by visualizing the goal in life that you may have, and then build foundations and processes that can 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 very good way to die, but before I get there, I have to tell you some stories.

In 1991 my oldest brother David had a dream and essentially pushed our younger brother and myself 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. We went up on the unpaved Kasier highway and returned on the the longer, but paved, Al-Can highway. 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 left with 35-pound packs and by the last day, we were out of food. On our second day, we were concerned about the group behind us—three friends, one in their late 70s, the other two in their 80s. They camped nearby and we were discussing if we needed to share our food with them when we heard the distinctive sound of a bottle of wine opening! We wondered later if we should offer to help at the pass itself, and they beat us to the top.

We had done the trail. A three-day hike that was a great accomplishment in life. Now fast forward 10 days from there. We were in Denali National Park. In that park, cars are not allowed but ingress is by yellow school buses that the animals have acclimated to. 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 fairly flat 7-mile hike to our site. 

The second we strapped the packs on it was vastly different—and 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!” as walking up and surprising an Alaskan grizzly is not wise. We ended up quitting at mile 5 of 7 and sleeping the week on a slight incline—that’s how tired we were. After a rest break on that first day while walking into the camp area we all struggled like crazy to get up again. David in particular struggled, then 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 would 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 I was puzzled by at the time. He asked me, “You know that feeling you get when you pass out when you laugh really hard?“ I had to tell him truthfully that I did not exactly know what he was talking about, but I left it at that. A month and a half later in February, right at Valentine’s Day, there was another family gathering to celebrate my mother’s and my brother David’s birthdays (his 35th.) That trip I was unable to go but my wife, who is also a doctor, was. She mentioned that David had been having some balance issues and she saw him hit a wall once walking down a hallway. He let everyone know 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 very disappointed in the center because they had clearly left the previous patients’ MRI up and allowed David and me to enter. I literally glanced at the X-rays for between 1 to 2 seconds and could tell that the previous patient was, as our Alabama relatives would say, an absolute dead person. There was an obvious very large tumor that even from a glance at several feet I could identify. I was approaching the end of my third year of residency in family medicine and I knew enough that this was a grave patient privacy violation. The physician eventually came in and started 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 very first prognosis was correct. He had a very 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 quite 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 he continued to fail. 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 in separate cars to San Antonio where my brother was to spend our last few moments with him. He had been on hospice for a few weeks and was very near death. He was slipping in and out of consciousness as we sped there. 

When I arrived after traveling far too many miles per hour than I would admit in writing, I arrived and went up to see David in his bedroom, where he had a whole hospice situation set up. In his hospital bed, he was essentially in a coma, but as I arrived, he lightly squeezed my hand and seemed to mouth what he often called me, O’Kenny.

That was about 6 PM. Later in the evening, my wife was nearby in another room with our young daughter. 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 we approached midnight with my brother’s death rattle rhythmically sounding, we started to recount the stories of our time in Alaska with all the ups and downs we had on that trip. 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 can relate things that they heard while comatose. I fully believe that 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 literally died laughing.

How do you want to die? Do you want to die remembering wonderful memories? 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 un-mourned, that too is in your grasp.  

I want to die laughing. 

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