Contribute Try STAT+ Today

With more than 250,000 Americans killed by Covid-19, it’s time to think about reimagining Black Friday.

Police officers in Philadelphia gave the Friday after Thanksgiving its dark name in 1966 as zealous shoppers mobbed streets and sidewalks. But it quickly came to mean a day when business owners could expect their accounts to be in the black, as opposed to in the red.

If Black Friday celebrates American consumers spending in order to live well, we could also adopt it as a day to consider what it means to die well. As the ancient Greek philosopher Epicurus ostensibly put it, “The art of living well and the art of dying well are one.”

advertisement

As a physician, I’ve met countless patients who were ill-prepared for death. The “trajectories of decline” described by geriatrician Joann Lynn make it easy not to prepare. Some people live for years with chronic illnesses but feel no need to ponder their mortality. Hospital tune-ups enable them to live seemingly forever. Others enjoy relative health until being caught off guard by a deadly illness. Still others live good long lives only to succumb to dementia, which robs them of their ability to plan.

We are habituated to living with hope for intervention or cure. To accept the impossibility of treatment is to admit defeat, which most people are loathe to do.

advertisement

How and where we die underscores how unprepared we are. Most Americans have never had end-of-life conversations or formalized their wishes for medical treatments at the end of life. Despite existing in some form since the 1970s, only 37% of Americans report having formalized their wishes through an advance directive. What’s more, most Americans say they want to die at home, yet roughly 60 percent die in hospitals, nursing homes, and hospices. There’s no question that institutional care can be a lifesaver for families not equipped to care for their loved ones at home.

If we are to realize the ideal of death at home surrounded by family, we’ve got work to do. Making a home death possible requires difficult decisions — in end-of-life conversations with family members and health care professionals — about which treatments and hospitalizations to forgo, whether homes can accommodate hospital beds, and who will do the hard work of caring for the dying.

That’s where taking a new approach to Black Friday comes in. On that day, families could pivot from giving thanks to giving thought to ending well. A simple prompt for starting end-of-life conversations might be, “Mom, Dad, if you become so sick that you can’t speak for yourself, who would you want to make medical decisions on your behalf?” And the natural follow-up would be, “Help me know how to advocate for you. Let’s talk about the benefits and burdens of particular medical interventions.” Conversation can then move to broader community-based issues such as funeral, burial, and religious or existential concerns.

It’s not the easiest conversation to have, but the payoff can be worth the effort. And since Black Friday comes every year, it’s a discussion that can build on itself over time.

A reimagined Black Friday could help Americans formalize their wishes for care at the end of life. Advance care planning documents allow people to identify health care proxies to make medical decisions if they lose decision-making capacity. Living wills specify an individual’s choice to have — or not have — cardiac resuscitation, mechanical ventilation, and other invasive procedures.

To be fair, there are good reasons why some people don’t want to prepare for death. Many of my patients fear that talk of death might “jinx” them. Some are reluctant to put their wishes in writing because they worry that doctors will give up on them. Others are concerned they’ll change their minds down the road but be too sick to say so. These concerns are real, but the potential exists for much greater harm by ignoring finitude entirely.

Reflecting on death has the potential to bring into relief that which matters most, and it can empower us to change how we live for the better. Ask anyone who is fully engaged in the process of dying. When our days are numbered, we value our relationships differently. We spend our time and money differently. We ponder life’s mysteries.

In ordinary times, we fool ourselves into thinking that the preparation for death can wait. But these are not ordinary times. When I was caring for hospitalized Covid patients this past Spring in New York City, they were frequently astonished that they had become so sick. They had not understood, as did Epicurus, that the art of dying is wrapped up in the art of living. But the pandemic has taught us that sickness and death do not happen only to other people. All of us must live with a view to our finitude.

This Black Friday, after the feasting has subsided and before the shopping begins, take a few minutes to talk with those you love about how to die well. Be frank about end-of-life wishes. Complete and sign documents.

At the same time, it also makes sense to talk about living. If Epicurus is right, to die well one must live well. And attending to what it means to live well — in light of the precarity of life — can make all the difference.

L.S. Dugdale is a physician and ethicist at Columbia University, director of the Columbia Center for Clinical Medical Ethics, and author of “The Lost Art of Dying: Reviving Forgotten Wisdom” (HarperOne, 2020).

  • Thank you for a timely idea, well stated. As an End of Life Coach, I can attest to the gift to loved ones that an ongoing conversation is.

Comments are closed.