The Lost Art of Dying: Reviving Forgotten Wisdom

Book Title: The Lost Art of Dying: Reviving Forgotten Wisdom

Author: Lydia S. Dugdale

Publication Information: New York, HarperOne, 2020, 272 pp., 27.99, hardcover

When was the last time you asked a patient how they plan to die?

This a question Lydia Dugdale, MD, is particularly equipped to ask in The Lost Art of Dying: Reviving Forgetting Wisdom. She writes as an internal medicine physician, medical ethicist, and director of the Center for Clinical Medical Ethics at Columbia University.1

Dr Dugdale’s inspiration is a medieval genre called the ars moriendi (“the art of dying well”). In the 1400s, following the bubonic plague, clergymen circulated several handbooks on dying throughout Europe. Dugdale focuses on a popular version featuring woodcut prints, pairing five temptations faced by the dying with five virtues which the dying might strive toward: despair was to be met with hope, arrogance with humility, avarice with generosity.2 To die well, according to the ars moriendi tradition, one must first live well.

Dugdale imagines a 21st century version of this forgotten art of dying, naming the barriers to dying well in modern medicine while meeting those challenges with revived virtues. She argues that to die well we must come to terms with our mortality, live and die within community, resist the overly medicalized death, confront death courageously, acknowledge bodily frailty, and respect our spirituality.

The Lost Art opens with a bad death (a patient already close to death is resuscitated several times before ultimately dying), and closes imagining a good one, wondering how physicians and patients might “think twice about hospitalizations” (182). Dugdale recommends making judicious use of the tools already available to us as primary care physicians, such as Five Wishes3 and the Fried Frailty Phenotype.4

In addition to vignettes, the author works through history, literature, art, and religious philosophy. We learn about the bubonic plague and how it shaped the ars moriendi, the birth of hospitals in the West, and the history of burial and mourning rituals. In this way, Dugdale joins an ongoing conversation on death in medicine, including Atul Gawande’s Being Mortal5 and Jessica Zitter’s Extreme Measures.6 Both capture the stark realities of dying in the modern hospital setting, emphasizing active listening by asking patients and families candidly what they hope for in death.7 Paul Kalanithi’s memoir When Breath Becomes Air8 and Victoria Sweet’s dyad God’s Hotel9 and Slow Medicine10 follow in kind, reimagining what Kalanithi named “the pastoral role” of the physician—the doctor as metaphysical guide who practices a slow, attentive art, especially at the end of life.

Dugdale follows this pastoral approach, critiquing the popular notion of “spiritual but not religious” (142) as working against the assembly of the very communities equipped to help patients wrestle with the existential questions death brings. At the same time, she is careful to avoid truisms: “I don’t pretend to have easy answers, but I am willing to ‘go there’ with my patients” (150).

Whereas Being Mortal and Extreme Measures emphasize the patient’s autonomy, Dugdale emphasizes dependency. She seeks a renewed anthropology, where patients are understood as embodied, enmeshed neighbors who are marked by mutuality, especially in death.11–14 As Dugdale writes, “we die best in community. … In fact, we might go so far as to say that it is impossible to die well if you die alone” (p. 35). Dugdale does not specifically address the conflicts which can arise with community, such as disagreement over the dying process of a family member. She focuses instead on preparation, cooperation, and something like corporate rehearsal: “community does not materialize instantly at a deathbed; it must be cultivated over a lifetime” (p. 55).

To conclude, Dr Dugdale’s book is a grounded reflection from a physician, scholar, and ethicist on the ars moriendi. Physician readers will find that the medical stories are accessible to the layperson, and may recommend this book to patients with an interest in history or philosophy. For teachers of family medicine, sections of the book may foster reflection and dialogue with students. The book does not directly address how medical schools or residency programs could better train physicians on the art of dying. Likewise, it does not address how to fix the larger cultural, political, and institutional forces that work against dying well in modern society.15

As family physicians, this book left us eager for next steps, whether sitting down to write out our own art of dying, ensuring our clinics incorporate appointments for advanced care planning, or brainstorming with colleagues to create an ars moriendi study to explore this lost art. Perhaps there we can ask our patients, our students, and ourselves, how might we practice the art of dying well?