Until It’s Over
The Art of Dying Well: A Practical Guide to a Good End of Life
By Katy Butler
a review by Pam Munter
Any book about death and dying is actually about life and living. This axiom is echoed in Katy Butler’s The Art of Dying Well: A Practical Guide to a Good End of Life (Scribner, 2019). Her articulate book joins the spate of best-sellers on this theme, most recently Atul Gawande’s Being Mortal, Barbara Ehrenreich’s Natural Causes, and Paul Kalanithi’s When Breath Becomes Air. Butler offers step-by-step rules to follow as we march toward extinction, from building resilience in one’s 50s, to the end-stages of actively dying. Like taxes, death may be inevitable but it can be planful, allowing a near-orderly departure with no unfinished business.
“We live in a time when advanced medicine wards off death far better than it helps us prepare for peaceful ones.” Like Ehrenreich, she advocates taking responsibility for living better today and for maintaining as much control as possible over the process of dying. Some of her early advice is overly familiar: exercise regularly, eat well, cut out smoking, cultivate friendships, pursue passionate interests, file an advanced directive and establish a power of attorney. Other suggestions seem limited if not laughable, such as getting to know neighbors who could become caregivers later on. “Can you turn neighbors into friends, and friends into honorary siblings?” She edges into God language now and again, dissonant in her otherwise secular flow of information and guidance. In one chapter, she even provides prayers from several religions. In this, she narrows her audience and may alienate others.
Butler traces life’s downturns in consecutive chapters. In “Slowing Down,” the decline is more felt than seen—achiness, problems with vision, hearing. It’s here she begins to rail against unnecessary testing and hospitalizations. “In all things, don’t let the cure be worse than the disease.” Reducing screenings, she says, can help avoid over-medicalization, which is sometimes economically driven, and not always in the patient’s best interests. Rather than divide the body into specializations, she says a geriatrician is invaluable, a physician with a more global perspective, specializing in the diseases associated with aging.
The “new normal” continues its downward shift when it becomes apparent “getting better” is not likely. “Disability sometimes arrives suddenly in the form of a stroke, and more often comes on little cat feet, as an accumulation of small impairments.” Her suggestions here are pragmatic: reconfigure the house for “aging in place,” reduce the daily stressors. If that’s not feasible, consider a move to assisted living. At nearly every stage, however, she reiterates the importance of staying as active as possible and of planning ahead early for the inevitable.
At the stage in which it appears life is nearing an end, palliative care is added to the repertoire, easing pain and suffering without further attempts to effect a cure. It’s “the preeminent medical ally for anyone who wants to live a good life while coping with a debilitating illness.” Research shows people who seek this level of care have fewer health crises and spend less time in the hospital. Curiously, it’s only at this late stage that she mentions the imperative search for meaning. Contemplating what matters, optimally, needs to occur not only when one is given a terminal diagnosis, but throughout the course of one’s life. And yet, she reports that hospice nurses have told her, “People die as they’ve lived.” If there’s no previous soul-searching, no emotional intimacy (with self or others), it’s unlikely such an exploration will be productive or even salutary.
In each chapter, Butler employs stories and anecdotes to illustrate the trajectory toward death. Some of them are helpful while others seem too long and interfere with the flow. Her prose is sufficiently vivid and explanatory that lengthy examples are distractions. Toward the end, she veers offline into suggestions for caregivers, which seems a departure from the how-to focus for the dying person. When she maintains her strong mission and focus, the book is a practical, even inspiring, guide for dying. Still, it’s unlikely that this would remain on a bookshelf for future reference. Would someone in his/her 50s continue to refer to this book over decades? Probably not.
Her most noteworthy contribution is to underscore the importance not only of advance planning (and working through denial, no small feat) but the need for families to talk among themselves about this outcome well before there’s a medical need to do so. “Dying is not an emergency. You can prepare for it, you can cooperate with it, and you can draw on wells of fortitude and love that you may not know existed within you.” Her warning about over-medicalizing the dying patient is as much a political statement as a moral one. Those who work with the dying are often the lowest paid workers in the medical food chain but no less committed to the well-being of the patient.
In days of yore, death had prescribed rituals, often religious in origin. People didn’t live as long as they do today and usually died at home. Now fewer than a third do. Death, she writes, “has largely been pushed into the upper reaches of the life span.” Is this a good thing? Wisely, she lets the reader decide. Butler thinks more healthcare dollars should be spent to help people die peacefully than spending money to prolong life for its own sake.
Pam Munter has authored several books including When Teens Were Keen: Freddie Stewart and The Teen Agers of Monogram (Nicholas Lawrence Press, 2005) and Almost Famous: In and Out of Show Biz (Westgate Press, 1986) and is a contributor to many others. She’s a retired clinical psychologist, former performer and film historian. Her many lengthy retrospectives on the lives of often-forgotten Hollywood performers and others have appeared in Classic Images and Films of the Golden Age. More recently, her essays and short stories have been published in more than 100 publications. Her play Life Without was produced by S2S2S, and nominated four times by the Desert Theatre League, including the Bill Groves Award for Outstanding Original Writing and Outstanding Play (staged reading). She’s a Pushcart nominee and has an MFA in Creative Writing and Writing for the Performing Arts. Her memoir, As Alone As I Want To Be, was published by Adelaide Books in 2018.