Since the beginning of 2020, the COVID-19 pandemic has resulted in more than 700,000 deaths, including the death of more than 160,000 people in the United States. Yet while death has become a daily focus for many Americans, we are often unfamiliar with terms and concepts related to mortality, such as how death is defined, what constitutes the dying process, how we know when a disease has caused “excess” deaths, or whether we can die of “old age.”
To help clear up some of that confusion, here are nine things you should know about death and dying in the United States.
1. For much of modern history, the accepted medical standard for determining death was the heart-lung standard, i.e., the permanent absence of respiration and circulation. But in the mid-20th century that view required a change. As the Christian bioethicist C. Ben Mitchell once said, “One seemingly inauspicious technology [flexible tubing] turned the world of medicine upside down . . .” That technology was flexible plastic tubing, which made possible such functions as artificial respiration and intravenous feeding. “Prior to the advent of current technology, breathing ceased and death was obvious,” said the 1981 President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. “Now, however, certain organic processes in these bodies can be maintained through artificial means, although they will never recover the capacity for spontaneous breathing or sustained integration of bodily functions, for consciousness, or for other human experiences.”
2. By the 1960s, improvements in the ability to maintain respiration and circulation made it possible to keep alive people who had irreversible brain damage and who would remain in a permanent coma. A committee at Harvard Medical School met in 1968 settled on irreversible coma as a new criterion for death. The so-called Harvard criteria of “brain death” quickly became a commonly used definition of death in American hospitals. In 1981 the President’s Commission—along with the American Bar Association, the American Medical Association, and the National Conference of Commissioners on Uniform State Laws—recommended a new definition for determining death:
An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards
This proposed definition became a model state law known as the Uniform Determination of Death Act (UDDA).
3. From 1981 to 2014, the UDDA was enacted in 41 states, as well as the District of Columbia and the U.S. Virgin Islands. Even states that haven’t formally adopted the UDDA, though, tend to have similar standards. Yet as the physician Ryan Montoya has noted, there is no uniform standard for determining death that is the same throughout the United States. For example, North Carolina doesn’t have a heart-and-lung provision while “Louisiana and Texas completely eschew the total-brain-death clause from their hospital definitions of death.” The phrase “in accordance with accepted medical standards” is absent from Georgia law and, Montoya says, appears in equally vague forms in Minnesota (“generally accepted medical standards”), Maryland (“ordinary standards of medical practice”), and Florida (“in accordance with currently accepted medical standards”).
4. When a person suffers a potentially fatal threat to their health (e.g., disease, injury), their impaired condition may be either reversible or irreversible. If the condition is reversible, appropriate medical intervention and treatment exists that may possibly restore a person to a state where they are no longer in imminent danger of dying. However, if no effective intervention or treatment is possible, the condition is irreversible (i.e., terminal), and the impaired condition will lead to death. This is what is meant when we say that a person is dying or has entered the dying process. Although we may not be able to know with certainty, we can often determine how near a person is to death, whether death is imminent or non-imminent. Imminent is when a person is expected to die in a relatively short period of time, such as hours, days, or weeks. If a person is not expected to die for months or years, then death is considered to be non-imminent. (From a Christian perspective, the dying process is the final stage of the living process, since those who are in the process of dying are still in the process of living. Those who are dying must therefore be treated with the same respect and consideration due to all living human beings.)
5. Death is classified by manner, mechanism, and cause. The manner of death is the determination of how the injury or disease leads to death. There are generally five manners of death: natural, accident, suicide, homicide, and undetermined. Death by natural causes is the result of any disease process, such as infection, cancer, or heart disease, while the others are deaths that have external causes. Mechanism of death is the immediate physiologic derangement resulting in death, such as a hemorrhage or cardiac arrhythmia. A particular mechanism of death can be produced by a variety of different causes of death. The cause of death is the specific disease or injury (whatever the manner) that lead to the death.
6. In the study of health-related issues within a population, the term mortality is related to the number of deaths caused by the health event under investigation. Mortality is usually represented as a rate per 1,000 individuals, also called the death rate. (The calculation for this rate is to divide the number of deaths in a given time for a given population by the total population.) The term morbidity is the state of being symptomatic or unhealthy for a disease or condition. It is usually represented or estimated using prevalence, the proportion of the population with a given symptom or quality. Comorbidity is the simultaneous presence of two chronic diseases or conditions in a patient. Knowing the rate of morbidity and mortality can help us determine the rate of excess deaths, which is typically defined as the difference between the observed numbers of deaths in specific time periods and expected numbers of deaths in the same time periods. According to the Centers for Disease Control, the total predicted number of excess deaths from February 1 to June 3, 2020, in the United States is between 148,482 and 202,836.
7. Mortality is also ranked using leading cause-of-death data, which represent the most frequently occurring causes of death among those causes eligible to be ranked. The latest data available in the United States (2018) shows the 10 leading causes of death were heart disease (655,381), cancer (599,274), unintentional injuries (167,127), chronic lower respiratory diseases (159,486), stroke (147,810), Alzheimer’s disease (122,019), diabetes (84,946), influenza and pneumonia (59,120), kidney disease (51,386), and suicide (48,344). Seven of the 10 leading causes of death were chronic diseases. If the same number of deaths from COVID-19 had occurred in 2018 and included only the number of death to date (August 5), the disease caused by the novel coronavirus would be the fourth-leading cause of death for the entire year.
8. Contrary to the colloquial saying, no one dies of “old age.” When someone of advanced age dies it is because they have an underlying illness, infection, or injury that caused a cessation of respiration and circulation. “It’s not like as you get older your heart beats more slowly until, finally, late one night, it just doesn’t give another squeeze,” says David Casarett, professor of medicine and section chief of palliative care at Duke University School of Medicine. “Aging puts you at risk of a variety of illnesses from cancer to dementia, any of which may end your life. But don’t blame old age.” While you can’t die of “old age,” you can be “scared to death” or die of a “broken heart.” Fear—or any strong emotion—can lead to a fatal amount of stress hormones, such as adrenaline, that can be toxic to organs such as the heart, the liver, the kidneys, and the lungs. An example is takotsubo cardiomyopathy, or broken-heart syndrome, in which acute emotional stress precipitates a sudden temporary weakening of the muscular portion of the heart.
9. According to the Bible, death is common—only Enoch (Heb. 11:5) and Elijah (2 Kings 2:11-12) never died—but not natural. Death entered the world because of the sin of one man (Rom. 5:12) but was conquered by the death and resurrection of Jesus (1 Cor. 15:21). Death is so unnatural that God sent his one and only Son as a sacrifice so that we might have life (John 10:10; Rev. 1:18). Death should therefore be considered an enemy—but a defeated enemy. Although this enemy may win a temporary victory over us, those who know Jesus will ultimately be victorious. We can therefore struggle against death knowing that when we lose our life, we will gain it back in the resurrection. We do not need to fear death, nor hold on to life too tightly. We can trust that God is in control and that for those who love God all things work together for good (Rom. 8:28). However, we should also not be foolish or reckless in ways that might hasten death unnecessarily, whether our own or our neighbors, since our lives do not belong to us. As Paul says in Romans 14:7–8, “For none of us lives to himself, and none of us dies to himself. For if we live, we live to the Lord, and if we die, we die to the Lord. So then, whether we live or whether we die, we are the Lord’s.”
For further reading: Remember Death: The Surprising Path to Living Hope by Matt McCullough