The Lost Art of Dying

Why a Book on the Art of Dying? [00:00]

Dan Doriani: Hello, and welcome to Working with Dan Doriani, a podcast where we explore faith, work, culture, and the way believers can make a difference in their corner of the world.

Hey, everybody. Welcome to another podcast. Today I’m delighted to have Dr. Lydia Dugdale, who is not only an MD but also has theological training in the field of ethics, which led her to start something that sounds pretty awesome: the Program for Medicine, Spirituality, and Religion at Yale, one of our finest universities. You founded it, and you directed it for a while. Now you’re at Columbia. You’re still a practicing physician, you speak widely, and you’ve written a wonderful book that I really like called The Lost Art of Dying. As we were saying before we got started, people used to write books about that all the time. Now if you talk about the art of dying, people think, “Is this, like, how to commit suicide well? What is wrong with you?”

Lydia Dugdale: That’s right.

Dan Doriani: Have I introduced you well? And what led you to write this marvelous book on this very old topic, the art of dying?

Lydia Dugdale: Well, let me say first, I would be remiss if I didn’t mention that I co-founded and co-directed the Yale Program for Medicine, Spirituality, and Religion with my good friend, the Reverend Dr. Benjamin Doolittle. So I don’t want to take all the credit there.

Dan Doriani: You want to make sure people don’t think Doolittle did little.

Lydia Dugdale: Doolittle does a lot! It was very much a partnership, and since I left Yale in 2019, he has continued to steer that ship. It’s a wonderful program.

Dan Doriani: Excellent. Credit where credit’s due.

Lydia Dugdale: That’s right. So I finished writing my book, The Lost Art of Dying, in 2019, and it was released in the middle of the pandemic in 2020. It’s a book that really riffs on the bubonic plague of the mid-1300s and how that was, in a sense, an impetus for people to begin thinking about their mortality and preparing for death. The central theme is that if you want to die well, you have to live well, and living well takes a certain amount of intentionality. You don’t just live well without being reflective about how you’re living. You need to look forward, face up to how you are living, and then adjust course along the way so that you live well in order to die well.

Dan Doriani: Can I just say, so everybody understands: bubonic plague took people’s lives sometimes within 24 hours or less, and very commonly within a week.

Lydia Dugdale: Yes.

Dan Doriani: So you had to be ready to die at any moment.

Lydia Dugdale: That’s correct.

Dan Doriani: I know you know this, but for our listeners who may not: the plague took people away within 24 to 168 hours. But it’s also true that the literature was for children, too, and for families, because so many children did not reach the age of 10. So tell us about the literature. That’s a great opening point: to die well, you have to live well.

Lydia Dugdale: The genre of literature that developed in the aftermath of the bubonic plague really started coming on the scene in the early 1400s, and then with the rise of the printing press, it took off. Initially it was tied to the Western Church. The early 1400s are before the Catholic–Protestant divide; we just have the Western Church. The author of the earliest version is anonymous, but based on the kind of writing and what we know about the leadership of the Western Church at the time, we think it was likely tied to the church.

Of course, with the Protestant Reformation, there are Protestant versions. By the 1800s, there are Jewish versions. There are even straight-up secular versions. The former president of Harvard University, Drew Faust, has written a really beautiful book on death and the Civil War called This Republic of Suffering. She talks about how at the time of the Civil War, whether you were from the North or the South, whether you were religious or not, attending to the preparation for death as part of your living was just part of being brought up well.

Dan Doriani: Universal.

Lydia Dugdale: Yes. You learned your table manners, you learned the art of conversation, the art of courtship—from another era—and you would also learn the art of dying. So this became a very, very popular genre of literature. It was all over the West, in many different languages and many different iterations, for more than 500 years. It really fell out of favor about 100 years ago.

Dan Doriani: It’s alien to our consciousness today.

Why We Lost the Art of Dying [05:15]

Dan Doriani: I have so many questions for you, I’m trying to decide what to ask next. I think I want to start here: why is it so alien to us today to consider that we should prepare? Part of it has to do with the medicalization of death, which is a theme throughout your book—and, though you don’t use this phrase, the hospitalization of death as well. People generally die in a hospital now. You’re not absolutely against that, but you think it’s generally better to die at home if possible, with your family or friends around you. Dig into the medicalization and hospitalization of death and how that contributes to our neglect—our general denial—of death. Describe it whichever way you like.

Lydia Dugdale: Most people die in institutions, not necessarily hospitals. Institutions would include hospitals, nursing homes, and inpatient hospices. About 60% of Americans die in a facility. About—actually, I take that back—about 31 or 32% die at home, and then there’s about 8% where we’re not sure.

Dan Doriani: But there’s also hospice at home.

Lydia Dugdale: Correct, and I think hospice at home would still fall under home deaths, as opposed to an institutional hospice.

So why is it that we’ve lost this art of dying? Think about just the last 100 years of medical history. We have the discovery of antibiotics in the 1920s. When I’m speaking to rooms full of people about the bubonic plague, I show them photographs of the plague and say, “Clearly these photographs are not from the 1300s.” We still see plague today. I ask them if they know where it is—it pops up every so often in sub-Saharan Africa. Then I ask, “Do you know how we treat it?” The interesting thing is that bubonic plague is treated with azithromycin, or a Z-Pak, which most people have heard of. Five days of antibiotics, and you go from mortality that is almost 100% to life. It’s extraordinary how antibiotics have changed the course of human history.

So we have antibiotics in the ’20s, and by the 1940s they’re widespread. In the ’40s we also see the rise of chemotherapy. By the ’50s and ’60s we have early experimentation with organ transplantation and the mechanical ventilator. Everybody is now familiar with the mechanical ventilator because of COVID—are there enough vents, is there a breathing machine? All of that became ubiquitous in the ’60s and ’70s. Before the ventilator was the iron lung; some of your listeners may have seen photographs of those, which are quite extraordinary. Now there are even mobile ventilators you can take home. It’s changed respiratory disease and made it possible to live quite a long time even with terrible lung disease. By the 1970s we have combination chemotherapies. So anyone born after World War II has lived in an era where the idea is that disease does not need to kill you—that if you just wait long enough—

Dan Doriani: A cure will arrive.

Lydia Dugdale: —a cure is around the corner, before you die. That’s right.

Dan Doriani: And now there’s new data out on pancreatic cancer, which was a death sentence 20 years ago.

Lydia Dugdale: Which is still largely a death sentence—

Dan Doriani: That’s how Tim Keller died, right?

Lydia Dugdale: Although some people have survived. You know Ben Sasse, right? He has been very public about his illness. This is a terrible cancer. Whenever doctors hear “pancreatic cancer,” we all think, “Oh, shoot.” But there are new treatments out, and they seem to be pushing the envelope, so it might not be as bad as has traditionally been thought. Anyway, my point is that since World War II, we have come to think death is more or less optional if we just live long enough.

Dan Doriani: A problem that can be solved if you apply the right techniques.

Lydia Dugdale: That’s right. Just wait a little bit longer.

Dan Doriani: So there’s the medical piece. Why else has the art-of-dying tradition gone away?

Lydia Dugdale: Interestingly, the time in history when it really fell out of favor comes on the heels of World War I—four years of global loss of life—

Dan Doriani: Pointless loss of life.

Lydia Dugdale: —pointless loss of life, and an extraordinary loss of civilians. World War I was not just combatant deaths. And even before the war is over, you have the outbreak of the influenza pandemic of 1918. Epidemiologists actually think it ran from 1918 to 1920, with four major waves.

Dan Doriani: Which carried away millions of people, including young adults in great numbers. It was indiscriminate. It wasn’t just the infirm and the aged, as with other flu epidemics, or in contrast to COVID. And the death rate was vastly higher.

Lydia Dugdale: That’s correct. So you have six years of sustained global death, up to 1920. Think about how all of us felt during COVID. I remember we were trying to plan a vacation—canceled it, rebooked it, canceled it, four or five times—and finally, I’m not going to travel; we’ll just stay home and keep doing the same thing again and again. Think how we all felt on the other side of COVID: I’m so sick of death. I’m so sick of this virus. I’m so sick of my life being interrupted.

And in the United States, at least, you get to the 1920s, a time of immense economic prosperity, plus significant social transition. Women get the right to vote. They cut their hair and shorten their skirts—the flappers. There’s jazz music, motion pictures, the rise of the automobile—

Dan Doriani: New independence.

Lydia Dugdale: So why think about these sad things? Why think about death when you can get on with living?

Dan Doriani: Everything was so wonderful, and they were so tired of 1914 to 1920.

Lydia Dugdale: That’s correct.

Dan Doriani: And it hasn’t recovered. You’re helping us, if I may, recover the need to contemplate our mortality.

Lydia Dugdale: Trying.

When Saving a Life Isn’t a Mercy [11:55]

Dan Doriani: You tell a story early on about Mr. Turner and how you saved his life, quote-unquote, twice—and regret it. My goodness, surely it’s awesome to say, “We restarted his heart.” Why is it tragic? And going beyond his case, why is it tragic in general to put forth extraordinary effort when someone needs to face the fact that their body is worn out?

Lydia Dugdale: All of our body parts have shelf lives. Heart disease is still the number one killer of Americans. When an elderly person has a fatal heart attack, that’s a demonstration that the heart is giving out. If someone is young, it might be because a large cholesterol deposit got lodged in a major blood vessel—

Dan Doriani: Or a genetic issue.

Lydia Dugdale: Or a genetic issue, less commonly. But the classic whopping heart attack in a 40-year-old who hasn’t been taking good care of himself is something where, with good therapy, the heart will bounce back. It’s a young heart. When you have a patient in his 80s or 90s, the odds of that heart being resilient are very low. Add multiple other illnesses. The patient I described, Mr. Turner—not his real name, of course—had widely metastatic cancer that had come back after being adequately treated 20 years earlier.

So here’s a man riddled with incurable cancer, already very elderly, and his heart stops. Even if we can get his heart technically beating again—which we did twice; the third time we were unsuccessful—we knew for sure it would stop again pretty quickly.

Dan Doriani: Within a day or two?

Lydia Dugdale: Oh, probably within hours, which is what happened. Each time, we got his heart back for 90 to 120 minutes, and then it stopped again. And by stopping, he’s dead, right? A stopped heart is a dead body. We resuscitated him, then a second time, and then we were unable to resuscitate him the third time.

Dan Doriani: And this was at his family’s request.

Lydia Dugdale: At his family’s request. And I’ll note that his family was deeply Christian. There’s a study by some of my colleagues at Harvard showing that people who describe themselves as highly supported by their religious communities—in that study, largely Christians—were more likely to die in the intensive care unit, insist on life support, and refuse hospice and palliative care.

Dan Doriani: So in short, highly Christian people tend to want technology, even though—

Lydia Dugdale: Even though they believe that when they die, they’re going to meet the Lord.

Dan Doriani: That’s right. And your book hypothesizes that the reason is that we’re hopeful God may answer our prayers—God is good, and God works through physicians, which of course he does.

I want to make something very clear. You regret that you were called upon to do something that caused him great pain and didn’t do him any good in the long run. But you’re not against medicine. You’re a medical doctor. I just came from treatment for an acute problem in my knee—I tore my meniscus. “Acute” sounds terrible, but it’s actually good, right? It means not chronic. So you’re in favor of acute treatment—

Lydia Dugdale: I’m in favor of chronic treatment, too, if it’s appropriate!

Dan Doriani: Right, you’re not against—

Lydia Dugdale: No, I’m not against treatment. Let me just say: I am a gainfully employed medical doctor at a very large healthcare system in New York City. I believe in medicine.

Dan Doriani: So what we’re talking about here is not refusing treatment. We’re talking about refusing to face the fact that our life is finite, and that we want to die well.

Dying Alone vs. Dying Lonely [16:10]

Dan Doriani: Your book describes some of the things that make up dying well: being surrounded by family and friends, if possible; low pain, if possible—

Lydia Dugdale: Actually, let’s go back to dying in community.

Dan Doriani: Oh, I was going to let you comment on any of them.

Lydia Dugdale: I’m going to comment on that one right now.

Dan Doriani: Okay, great.

Lydia Dugdale: There’s a distinction we need to make. Friends and family may be present as someone is dying, but maybe they go home for the night, and then that person gives up the proverbial ghost. That is not a lonely death. We see this all the time: people who don’t want to be a burden often wait until everybody goes home, and then they allow themselves to die. It’s so interesting. We have patients who hold on, hold on, hold on. Their granddaughter arrives, they have that final conversation with her, and then they die. There’s almost a will—and I don’t mean an “I’m seeking death” kind of will—but people somehow know when the time is right.

I mention that because a gentleman once came up to me and said, “I’m so glad I read your book, because for the last 20 years I’ve felt guilty that my father died a lonely death.” The scenario was exactly this: “I was with him in the hospital. I went home, and he died alone in the middle of the night, and I’ve been racked with guilt all these years because he died alone.”

Dan Doriani: And you said, “This is not a lonely death.”

Lydia Dugdale: No. There’s a difference between dying alone and dying lonely.

Dan Doriani: So you can die alone—and many people want to die alone, I hear you say—meaning nobody else is in the room. But that doesn’t mean you’re lonely.

Lydia Dugdale: That’s right. People don’t have to be holding your hand at that moment for you to have died in community.

And the other thing is: what is community? Many people have said to me, “Look, I’m an introvert,” or “I don’t have brothers and sisters; my family’s all gone.” What I tend to tell people is, think about who you want at your deathbed, and then do the work now of nurturing those relationships. You don’t need 20 people there. One or two. But who are the one or two you want to know, no matter what, will be there? Then really make sure you’re investing now, so that—

Dan Doriani: Your dying will be better, but your living will also be better.

Lydia Dugdale: Right.

Dan Doriani: The personal use I made of your book was to say, “Let me make sure I have all the good conversations I need to have with people, carefully, over the years,” including my grandchildren who live nearby. We love each other very deeply. But to be able to say, “Look, we may not be able to do this forever. One of these days I won’t be able to play ball with you. One of these days I’m going to leave. Let’s make sure we remember this and enjoy this.” That’s part of it.

Lydia Dugdale: It is.

Dan Doriani: It’s also part of it to keep nurturing friendships as we get older, because the opportunities for friendship peak in high school, college, and the early adult years. Everybody’s there, and then it winnows, especially if you live to be 90. You’ve got to keep those relationships strong. That’s a theme you advocate strongly in the book. That’s not a question—just riff on it if you want.

Lydia Dugdale: Human beings are by definition relational creatures. There are all these studies showing that people who suffer from social isolation or loneliness not only have much higher rates of all kinds of diseases—diabetes, high blood pressure, stroke, heart disease—they also have much higher rates of mortality. People die from loneliness.

A side note: Canada is sort of notorious right now for its use of medical aid in dying. Medical assistance in dying is what the acronym stands for in Canada—

Dan Doriani: MAID laws, they call it.

Lydia Dugdale: M-A-I-D, yes. In 2024, there were something like 3,400 people in Canada who elected to be euthanized—to be put down, as it were—and one of the reasons they gave was loneliness. So loneliness does drive mortality. It drives death. If we don’t thrive in social isolation, and we do flourish in relationship, then we need to be nurturing relationships. And it’s not just for the end of life; it’s for all of life. That’s where living well is so tied to dying well.

Dan Doriani: Which is why we want to be with our church friends, or our garden club friends, or our tennis friends—

Lydia Dugdale: Car repair friends. It doesn’t matter. I once read a study that said it’s actually better for you to smoke two packs of cigarettes a day and have friends than to not smoke and have no friends.

Dan Doriani: Wow.

Lydia Dugdale: Now remember, we’re not advocating smoking two packs a day. It’s just an interesting study that makes the point.

Getting Off the Conveyor Belt [20:55]

Dan Doriani: You also use a masterful metaphor: the conveyor belt. And we’re not against the conveyor belt either. I tore my meniscus—I get in the system, give my name, see a doctor, get the treatment, get a plan for recovery. We’re not against conveyor belts. But sometimes, you say, we have to slow down and find a way to hop off. Slow medicine. Dr. Dugdale, what does that mean? What is the conveyor belt?

Lydia Dugdale: The conveyor belt is really tricky, because it’s hard to know when it’s going too fast and when you should hop off. It’s the idea that you go into the hospital for one thing, and something else happens—maybe a side effect, or something foreseen that you hoped wouldn’t happen. You go in for surgery, and now you have an infection. The infection leads to delirium; you’re not thinking straight. Then in the middle of the night, delirious, you try to get out of bed—

Dan Doriani: And you fall.

Lydia Dugdale: —and you fall. Now you’ve got not only the reason you went in for surgery but a hip fracture. And hip fracture mortality is really high. We see this kind of thing all the time.

Dan Doriani: So there’s a good conveyor belt. If I break my arm, I go to the ER—or, if I did it playing sports, the sports clinic, which is better—and they say, “We’re going to take you in.” Step one. “We’re going to get an X-ray.” Step two. “We’re going to splint it.” Step three. After a few weeks, they take it off and help you restrengthen your arm. That’s the good conveyor belt. But there’s a bad conveyor belt, and that’s what you’re describing.

Lydia Dugdale: I guess what I would distinguish is that the good conveyor belt is usually just a well-working machine for a one-and-done type of issue. The conveyor belt I’m concerned about is the one with no end in sight: the frail, elderly patient who has one thing after the next after the next. If a child goes in for major surgery, everybody is going to route that child to the finish line no matter how many foreseen-but-hoped-against things happen. But when it’s a frail elder, and it’s one thing after the next after the next, and they’ve already lived a long life, and they might not even have the cognitive capacity to engage the world—

Dan Doriani: To make a good decision.

Lydia Dugdale: —and I’m not saying those lives are less valuable. Please, please hear that. I’m not saying that. But I am saying that sometimes the goods of medicine are pushed too far, and we don’t accept the natural end of life. That’s what I want to make space for. I’m not advocating for hastening death in an unnatural way. But why are we dragging out the dying process in an artificial way?

Dan Doriani: Somewhere in the book you describe—these aren’t your exact words—”We tried chemotherapy one, our best hope. It didn’t work. We tried chemotherapy two, the best hope after number one. It also didn’t work. Now we’ve got heart failure. Now we’ve got a lung issue. We’ve got diabetes. Do we really want to try the third most likely form of chemotherapy?”

Lydia Dugdale: That’s right.

Dan Doriani: But some people press and press, because they’re not willing to face their mortality.

Frailty, Not Age [24:40]

Dan Doriani: So let me ask you to do something, and I’ll give it to you two ways. First, address our listeners who are a little bit older, who maybe have a serious disease, or who have a loved one—parents, grandparents, an aunt or uncle. What would you like to say to them about aging? Second, your corner of the world is medicine, which is largely taken up with the elderly who are very ill. If you could change your corner of the world, what would you say? What would you do?

Lydia Dugdale: In the last chapter of my book, I talk about frailty risk scores. I’ve given a lot of thought to how to advise my patients. Is it an age cutoff? No.

Dan Doriani: It’s not an age cutoff—you say that in the book.

Lydia Dugdale: Yes. I have taken care of 97-year-olds who play tennis three times a week, and I’ve taken care of 50-year-olds who are wheelchair-bound and fully dependent for everything. So there’s no such thing as an age cutoff. But the frailty risk scores that have been developed across medical disciplines are really helpful for giving families a sense of whether Mom or Grandma should maybe avoid a major medical intervention. The one I describe in the book is, I think, the easiest for a layperson to work with. It asks things like: How much of the day is Mom in bed? If she’s in bed most of the day and just not getting out—

Dan Doriani: Sleeping and sleeping and sleeping.

Lydia Dugdale: —that’s not a good sign. Can she walk faster than a mile and a half an hour, or is she walking super slowly across the floor? Is she losing weight without even trying?

Dan Doriani: For no medical reason.

Lydia Dugdale: Yes—she’s just losing weight.

Dan Doriani: Because she’s in bed all day, not eating.

Lydia Dugdale: Right. Can she hold a coffee cup? If she drops it or can’t really grip anything, that’s another bad sign. So there are these sorts of ways of assessing.

I started thinking about this very early on, as a medical student on my GI surgery rotation. There was a 98-year-old woman going in for a hemicolectomy—removing half of her colon for colon cancer. A big surgery for a 98-year-old woman, and I thought, “What are we doing?” She was not going to bounce back well from surgery at all, and she already had some degree of cognitive impairment. But her family could not imagine her dying without treatment, so they sent her through surgery. I saw her after the operation, but then you switch services, and I don’t know how long she lived. I can imagine that for a very elderly woman who had to be wheeled in, who already wasn’t walking at baseline, who was very thin and wasted, she probably didn’t live very long after that surgery. Is that the way to live out your last days of life?

Ready to Die [27:55]

Dan Doriani: Pastorally speaking—I’ve been a pastor for some years, though mostly a professor—it’s been fascinating to talk to people who have lived a good life. They’ve had a happy marriage; maybe there were real challenges, but they worked it out. Everybody has challenges. One woman especially sticks out in my mind: 85 years old, a razor-sharp mind, serious cancer all over her body. I said, “So, how’s it going?” And she said, “I am ready to die.” She’d been given 48 hours—probably somewhere between 24 and 72 hours to live—and she said, “I’m fine. I’ve lived a good life. I’ve loved my husband. I’ve loved my children. I have no loose ends. I’m ready to meet the Lord.”

That’s one of your main points: being ready to die. And we’re not accusing somebody who wants treatment for Mom at the age of 98 of having bad relationships.

Lydia Dugdale: That’s right. But it’s vastly easier to let go when you’ve done what you have to do in this life. The idea behind the ars moriendi, this art-of-dying genre of literature, is that you’re doing that work every day, because you don’t know when the end will come. We live as if we’re all going to be so, so old, but we don’t know.

Interestingly, COVID was a bit of a wake-up call. I did many, many book talks during COVID, because that’s when the book was released. In my experience, it was really the boomers who engaged the content of my book. Anybody younger—even people who had severe COVID and post-COVID syndromes and chest pain—did not really want to think about their mortality afterward. They wanted to get on with living. The boomers, though, saw that COVID meant mortality for their generation. I received letters from all kinds of people, and they were really amazing: “Look, I’m not a believer in anything, but I read your book, and I don’t want to die without being reconciled to my children. So I’ve committed to getting together with my adult children twice a year. We’re all meeting at such-and-such a location. We’re going to invest in our relationships. I don’t want to leave this world without that in place.” I get letters like this, and I think, this is it. This is really the art of living—attending now to all the things we want in place before the end of our lives.

Dan Doriani: Which would include reconciliation with a friend, perhaps, where there’s a ruptured relationship—not just family.

Lydia Dugdale: Correct.

A Word to Medical Professionals [30:25]

Dan Doriani: I’m going to go a different direction. We have a variety of physicians and people in the medical field listening. You’re a physician, and you challenge your tribe: we’re trained to be rescuers, saviors, heroes, and that might get in the way of the best care. You tell a story about someone who is all ready to die—no more treatments—and then somebody says, “Well, there is one more thing.” Wait, we said we weren’t going to do that. That’s the rescuer mentality coming in. What would you say to your beloved, wise, gifted, and skilled medical colleagues on this front?

Lydia Dugdale: I think doctors and nurses need to do their own work of anticipating their own mortality and doing their own preparation, because I think that is the biggest obstacle to really good end-of-life care.

Dan Doriani: That’s a big statement. Did you mean to say it’s the biggest obstacle?

Lydia Dugdale: In many ways, yes, because there are always going to be resource issues. Resource issues never go away. I can imagine a counterargument—the lack of palliative care in rural America or sub-Saharan Africa—

Dan Doriani: Right. But doctors have to face their own mortality. And doctors, you say, are a profession that generally likes to avoid thinking about death, because “we can cheat death. We can save people.”

Lydia Dugdale: Yes, and there’s a financial impetus to do another procedure.

Dan Doriani: And it’s the heroic thing. It’s doing something, not doing nothing. It’s the savior mentality.

Lydia Dugdale: Correct. My colleague Jeff Bishop, who’s here at Saint Louis University, says medicine is about doing, not about thinking. My sense is that’s right on the money. Why would you pause and reflect with a dying patient—

Dan Doriani: When you could do something for them.

Lydia Dugdale: —when you can do open-heart surgery and keep moving forward? I want to say two other things. First, I have had colleagues say to me, “I don’t know why you’re interested in thinking about death.” I remember one woman saying, “I myself am so afraid to die that I do whatever I can to avoid talking to patients about death.”

Dan Doriani: That’s a physician who won’t talk to her patients about death. You would think that comes with the job.

Lydia Dugdale: You would think. But here’s the other thing I want to say. Hospice and palliative medicine—the work of relieving uncomfortable symptoms and accompanying people to the natural end of their lives—used to be the work of all doctors. It is now a subspecialty. And since there’s a specialty, why would every doctor, so to speak, learn to do that work when it can be outsourced to a specialist?

Dan Doriani: Especially given how psychologically painful it is.

Lydia Dugdale: Yes. And if you’re a surgeon, you can’t bill for it. That’s not what you bill for.

Dan Doriani: We were talking about this before we started. My father got a pacemaker when he was almost completely gone mentally, against his repeated, explicit, written and verbal instructions: “Do not perform any heroic measures.” He recognizes me a little bit, once a month. I’ve always wondered whether that decision was more a matter of my mother’s immense tenderness, or whether somebody had something to gain by encouraging her: “Are you sure? Are you sure you don’t want to do this?” Of course, there’s a procedure, and there’s financial reward. I don’t mean to be critical, but I couldn’t help but ask.

Lydia Dugdale: It’s always tricky to know when it’s more one than the other. I’m sure someone read your mother as not wanting her beloved to die, and she derives great joy from sitting with him and accompanying him. Look, I’m an ethicist in a hospital, and sometimes we do violate patients’ legally stated wishes at the insistence of a wife of 58 years who says, “You’ve got to do something to save my husband. How can you let my husband die when I know you can—”

Dan Doriani: “—do something to extend his life another four days.”

Lydia Dugdale: Correct.

Dan Doriani: So we want to make it really clear: there’s nothing wrong with a desire to extend life. But there comes a time when that desire is causing nothing but misery, and sometimes inflicting a lot of pain. That’s another theme in your book. One woman, a patient of yours, wanted treatment, and afterward she woke up and said, “I wish I hadn’t told you to treat me this way,” because her life was so much harder now.

Lydia Dugdale: Oh, the woman I resuscitated. Yes.

Dan Doriani: She got what she wanted, and once she got it, she realized she didn’t actually want it.

Lydia Dugdale: I think that’s right. It’s a really fine line.

Ordinary and Extraordinary Means [34:55]

Lydia Dugdale: There’s a bioethicist, Dan Callahan—one of the grandfathers of bioethics. He’s gone now, but I remember him telling me he didn’t think we should be ethically required to do more than we could have done in a pre-technological era.

Now, if you talk to a neonatologist—a newborn baby doctor—they’ll say, “Oh, no, no, no. We are past the era of taking disabled babies and setting them aside,” which is what happened in the U.S. until not that long ago, 50, 60, 70 years ago. Children born with disabilities would be set in the back of the nursery, and no one would attend to them—

Dan Doriani: Not nourished.

Lydia Dugdale: —and they would be allowed to die. So neonatologists are very nervous about that idea. But I think it’s a helpful way of thinking—again, not set in stone—about medical treatments for the extremely elderly in particular, or for people with really bad disease across the board. Should we really be required, ethically and morally, to continue all of this stuff that wouldn’t have been available 100 years ago?

The Catholic Church, I think, does some of the best bioethics work around, and the Catholic tradition distinguishes between ordinary and extraordinary means. Various clergy, councils, and popes have written that even though we’d think of nutrition and hydration as ordinary, there could be certain clinical scenarios in which even—

Dan Doriani: Feeding tubes, intravenous feeding—

Lydia Dugdale: —feeding tubes and fluids are extraordinary. In fact, we know that’s true, because in some forms of cancer, giving nutrition just makes the cancer speed up. So in that circumstance, it would be extraordinary.

So taking care of people—washing them, sitting with them, holding their hands, spoon-feeding as tolerated—all of that is very, very rich human care.

Dan Doriani: Labor-intensive.

Lydia Dugdale: Hard labors of love. If we could package that up and sell it, that’s the kind of care I want to see for people at the end of life.

Dan Doriani: Of course, it’s not sold. Most of it is provided unpaid.

Lydia Dugdale: Yes. And people have to take leaves of absence from work.

The Hard Work of Caring at Home [37:50]

Dan Doriani: Let me tell you a story and let you comment on it. A friend of mine and I were tennis buddies for 25 years. The last thing we did together was win a championship in a certain league, to our immense pleasure. A month later, he started having severe pain in his back. He went to a chiropractor—back spasms, he played hard. Then three ribs broke, and—

Lydia Dugdale: Cancer.

Dan Doriani: It was cancer, which had started in his liver and spread. He was also in my church—he was an elder, and I was his pastor. We had a relationship. Hours after he got his diagnosis, he called me and a couple of other people and said, “Dan, will you come see me every week until I’m better or with the Lord?” He knew it was a big ask. I said, “Yes, I will come every week if I possibly can. I won’t make it every single week, I have to tell you that.”

And I would go and just sit with him. We would tell stories and talk about whatever he wanted to talk about. His wife would say, “Hi, Dan. Do you want a drink of water? I’m leaving.” And I’d say, “Yes, by all means, go. I’ll sit with him.” The rule of thumb for pastors is 20 minutes when somebody is really sick, and he absolutely would not let me leave. I was there for an hour every single time. We would reminisce. Sometimes we would hold hands. I was so glad he asked me to come every week, because otherwise I would have come once a month or so. I was so glad to do that with him. That’s the closest I’ve come, I think, to what you’re talking about.

Lydia Dugdale: Caring for people up until the end can be the hardest thing some families go through. To qualify for home hospice, which I think is a marvelous way to die—

Dan Doriani: He was under home hospice at the end.

Lydia Dugdale: —you need to commit to 24/7 care. That ends up being a lot if it’s just a wife, or a wife and one or two kids. Another colleague of mine—a very accomplished, prestigious university professor—said, “You know, Lydia, we cared for my dad at home. It pretty much broke us. It was the hardest thing.” Because you’re not only holding hands. You’re washing and bathing, changing diapers, running the IVs. You’re doing medical work. That’s not what you signed up for when you pictured holding hands and spoon-feeding Grandma. That’s what a lot of families don’t realize. Dying at home is a beautiful thing if it can happen, but it can be so hard.

Dan Doriani: Add to that: it’s one thing if the grandma you’re caring for is a very little lady, but—

Lydia Dugdale: If it’s a large man, it’s a totally different story.

Dan Doriani: And if he’s 80 and his wife is 80 and she’s trying to take care of him, she can injure herself.

Lydia Dugdale: Oh, for sure.

Dan Doriani: I’ll just say, your book made me think of Psalm 90: “Teach us to number our days aright,” and give us a heart of wisdom. Which then reminded me of Job 28, a chapter that marvels at technology. The technology of the time was mining, and he’s just blown away by it—damming up the water, dangling by ropes, searching out the darkness with lights—and then he says, “But where can wisdom be found?” (Job 28:12). It’s one of those spots where there’s no answer. Job doesn’t say where you find wisdom for the right use of technology. So we’re trying to do that together. In a sense, I think it’s your life’s work.

Rapid Fire: Saving Lives, Miracles, and Ivan Ilyich [41:35]

Dan Doriani: Let me ask you a couple of quick, rapid-fire questions—less than a minute, if you can. What is it actually like to save someone’s life? With CPR, like you’ve been talking about, or however.

Lydia Dugdale: That’s the way we typically save lives, though there are so many different ways. With CPR—and for me this is in the hospital; I’m not resuscitating people out in the field—you have a body that’s still warm, the guy is young, and you’re pretty sure he just had a massive heart attack. It’s a team effort. Somebody starts the process of getting a breathing tube in. Somebody’s masking him until the tube is inserted. Somebody’s doing chest compressions. Somebody’s starting a large IV in the groin. Somebody’s at a cart handing over medications to try to kick-start the heart. It’s the all-hands-on-deck experience, and you’re waiting for the pulse, waiting for the pulse, waiting for the pulse.

Dan Doriani: And?

Lydia Dugdale: And you keep running rounds. There’s a whole algorithm you follow, and you keep running rounds until you get the pulse back. When somebody says, “I’ve got a pulse,” and it’s a young person, you think, “Okay, this guy’s got a shot at leaving the hospital alive.” Because in contrast to what we see on television, most CPR fails—

Dan Doriani: Almost 90%.

Lydia Dugdale: Yes, meaning we might get the heartbeat back, but they don’t leave the hospital alive. But a young person, yes.

Another way of saving a life is putting in a breathing tube. Someone comes in with horrible asthma, or horrible pneumonia, or lungs failing from some other disease, and you get that breathing tube in, and suddenly their color comes back. They’re on the brink of death but for the breathing tube. That’s an extraordinary way of saving a life. And another is severe sepsis, where the infection is just devastating the body. You run fluids in, start IV antibiotics, provide breathing support, and very quickly the body comes around.

Again, it’s the miracle of all of this. People often ask me, “Do you see miracles in medicine?” I believe in miracles, but I don’t see the kind—

Dan Doriani: The kind that are on TV.

Lydia Dugdale: Yes. I don’t see Lazarus coming out of the grave after however many days. But isn’t it a miracle that we can transplant organs?

Dan Doriani: It is. It’s astonishing.

Lydia Dugdale: And isn’t it a miracle that we can save people who would have died in droves from diseases in an earlier generation, with just a dose or two of antibiotics?

Dan Doriani: Can’t we say that 400 years ago, probably half the people listening to this podcast would have died before reaching adulthood?

Lydia Dugdale: Yes, that’s right.

Dan Doriani: We both probably know hundreds or thousands of people whose lives were saved when they were three, four, six, or ten, when they had a raging infection or something.

Lydia Dugdale: Correct.

Dan Doriani: So we give thanks for that.

Is there a book or media of any kind—TV, movie, documentary—that gives people a good look at the life of a doctor in the hospital?

Lydia Dugdale: Well, I’m really bad. I don’t watch TV.

Dan Doriani: Do you read books? I offered you the book option.

Lydia Dugdale: I do read books—yes, you did offer me the book option. But I don’t like doctor books, and I don’t watch any of that doctor stuff.

Dan Doriani: It could even be a short story.

Lydia Dugdale: The book I would recommend is The Death of Ivan Ilyich.

Dan Doriani: Oh, yes.

Lydia Dugdale: I commend it because it’s such a gorgeous demonstration of how complicated illness and dying are—family relationships, community relationships, the lure of striving and achievement and losing all that. Who is with you to the end? It ends up being his servant, who is really the only one who understands him at the very end. And then there are the questions of the divine, and what happens ultimately when we die. It’s a gorgeous book, and that’s the one I would recommend. In terms of the life of a doctor, I can’t help you there.

Dan Doriani: No, that’s good. Just one.

The One Thing You Need to Hear [46:20]

Dan Doriani: You’re trying to change your corner of the world. If you could sit down with everybody facing challenging decisions of this kind, could you craft a statement or two about why you say what you say? What principles are driving this? And if you could epitomize it in one takeaway sentence—”Listen, there’s one thing you need to hear”—what would it be?

Lydia Dugdale: I think the Psalm 90 verse is exactly right: we grow wiser by reflecting on our mortality. If we live with the idea that the end will come, we live very differently. You told me before we started that when you were 26 or so, you read a bunch of books on the art of dying, and they didn’t make sense to a 26-year-old—

Dan Doriani: By which I don’t mean I couldn’t understand the sentences. I couldn’t understand why so many people were writing books about the art of dying.

Lydia Dugdale: I’m confident you understood the sentences. What I say to college students when I speak on campuses is this: as a college kid, you very rarely have that incredible meal—so divine you could never cook it yourself, and you could never afford it. But let’s say your rich roommate’s family comes to town and takes you to the nicest restaurant in St. Louis. The chef is on fire, Michelin-rated, whatever. If you ate that way every day, you wouldn’t appreciate it. But when you eat that way once in four years, or 12, or 20, you savor it, and you appreciate everything about the experience. Living with that kind of intentionality helps us not waste the days we are given. And it’s not just about maximizing—that’s not what I’m saying. It’s about flourishing, ultimately: living into the fullness of the life we’ve been given, and doing that in community, in relationship, in relationship with the divine. All of that together, I think, leads to the best life possible.

What principles guide me? I was just taking care of so many patients who died terribly. So it’s really a desire to help people understand what it’s like in the hospital and what medicine can do. A year or two ago, I was speaking to a room full of middle-aged New Yorkers—my people, my demographic—about the art of dying, and I was shocked that they had no idea what mechanical ventilators really do. They didn’t know about dialysis replacing kidney function. They weren’t sure about heart pumps or ECMO.

Dan Doriani: They thought it was kind of like getting a bone set—pretty simple stuff?

Lydia Dugdale: They just didn’t know. They had no idea it’s brutally difficult. They had been healthy. They came to my talk because they have aging parents, but they’d never been exposed to any of this. If you’re not in healthcare or healthcare-adjacent and haven’t bothered to learn these things yourself, why would you know? That was a wake-up call for me. It’s not that people are ignorant. It’s that they have no exposure to this until they’re in some advanced state of illness, and then everything comes cascading down. They’re on the conveyor belt—this happens, and that happens—and they end up dying a death they never would have wanted.

And again, it’s not just about wish fulfillment. That’s part of it, but it’s also about making peace with God and neighbor, which probably matters much more than whether you had a medical procedure you wish you hadn’t. Have you made your peace with God and neighbor?

In the book I write about a woman I was called to see in the hospital. The nurses told me she was being “difficult”—that euphemism, the difficult patient—and it turned out she was in existential crisis. She was an older single woman, very close to the end, and she knew she was dying. A lot of times patients know when they’re dying; they give us little clues, if we listen, if we slow down enough. She was in existential dread because she had willfully ignored the religious questions for most of her life, and now she wanted someone to help her quickly make sense of them so she would know what she believed.

Dan Doriani: Whoa.

Lydia Dugdale: I sat there watching her deteriorate right in front of me. There’s no quick pill you can give to alleviate existential dread. You could knock her out, but that’s not the kind of pill somebody needs. And so I thought, if this work on the art of dying can help patients avoid highly medicalized deaths, get off the conveyor belt when it’s prudent, make peace with their neighbors and families and reconcile, and understand a little better how we have always died and the rituals that have guided us—

Dan Doriani: And that we will all die.

Lydia Dugdale: —and that we will all die—

Dan Doriani: Don’t buy the transhumanist dream.

Lydia Dugdale: That’s right. Then this feels like a project worth pursuing.

Closing [51:55]

Dan Doriani: My friends, we have spent some time with Dr. Lydia Dugdale. I can’t recommend her book, The Lost Art of Dying, highly enough. I know the vast majority of you who listen to this podcast are believers, and you trust that upon death, by faith, you will enter the Lord’s presence. But not all of you, and we’re happy to have all of our listeners. We want all of you to think about the ultimate questions, to understand who Jesus is and what he has done, and to be reconciled to your families, so that we can die well and enter eternity with joy. Thank you for being with us. Thank you for your time.

Lydia Dugdale: My pleasure. Thanks for having me.

Working with Dan Doriani is a production of the Center for Faith and Work St. Louis. We seek to promote faithfulness in the workplace, in education, in discipleship, and in the stories of believers who’ve applied their faith at work. If you want to put your faith to work and change your corner of the world, visit faithandworkstl.org. We’ll help you start a cohort with like-minded believers who also want to practice their faith at work. This podcast is donor-supported; to keep us going, please donate on our website. Maybe more importantly, you can support us by listening, subscribing, sharing, and posting about us on your favorite platform—or go old school and tell a friend.