Suffering, however, is optional.

I say this as someone who has helped thousands of people with their journey and witnessed the results of their varying decisions. I believe we as humans have the ability (and the right) to choose what is worth suffering for in our lives, depending on our goals.

But what if we gain nothing from the suffering?

That is when true despair sets in and begins to whittle away at the human spirit, little by little, until all of life’s meaning fades away to nothing.

According to one survey, over 70% of Americans indicated they would wish to die in the comfort of their own homes, preferably in a way that they go to sleep and just never wake up again.

However, dying suddenly in one’s sleep occurs in only 10-20% of all deaths.

As you can guess, then, most people will require help if they are to achieve the kind of peaceful death they desire. This means that, without some degree of planning, there is a much higher likelihood of suffering and demoralization that ultimately destroy the spirit.

So in this piece, I’d like to offer some understanding of what happens leading up to death and the potential points of suffering one may experience approaching the end of life, and some suggestions of how to plan for them.

What Happens Before We Die?

Science has yet to reveal what happens after we die, and we may very well never know for sure.

But what actually happens during the final weeks, days, and hours, as the body winds down and prepares for physical death?

At a healthy baseline, our brain controls every urge and sensation that we have, as it communicates with our bodies via the spinal cord and peripheral nerves through a continuous loop of neurochemical signals and feedback mechanisms.

This complex and intricate system allows us to feel the sensations of hunger, thirst, breathlessness, and fear to name a few. Then there are the objective findings our bodies exhibit which are measurable such as body temperature, blood pressure, electrolyte levels, etc.

Health care professionals are excellent at monitoring and addressing the visible and measurable data points like vital signs, laboratory results, or what I like to call “the numbers.”

It is my professional opinion “the numbers” begin to matter less and less when one approaches death, and how one is subjectively feeling becomes much more important.

Yet, medical professionals tend not to know how to address these subjective feelings or explain how they will likely change as dying progresses. That is because these are not parameters measurable with our machines, and perhaps more importantly, we are seldom taught how to do this.

There are, however, scientific explanations that support what ancient wisdom has known for a long time. These principles can help address deep concerns frequently carried by family members regarding feeling hungry, thirsty, pain, fear, and breathlessness.

I will try to illustrate these individually, but please keep in mind these may occur at the same time. Also, everyone’s journey is unique and there may be degrees of variation.

Hunger

The Greco-Roman Stoics, Zen Buddhists, and Indian Jains hold the belief that hunger is a physical anchor by which the human spirit is tethered to this world. As death approaches, these practitioners are known to gladly accept and welcome the loss of appetite as an aid to a more peaceful transition.

Weeks and months before death, the human body begins to exhibit a change from the normal physiology that drives hunger and appetite.

Food tastes different and less appealing. Satiety occurs faster. And the brain starts to lose interest in food altogether.

From a scientific perspective, this effect is driven by generalized inflammatory signals called cytokines that inhibit and interrupt the stomach’s hunger signals (ghrelin) to the brain.

During the last days and hours of life, eating food starts to become a burden because the process described above intensifies. Most people have very little to no urge to eat, yet the brain actually feels good because the body switches over to ketosis, breaking down whatever protein and fat the body has remaining to sustain minimal vital functions as it further prepares to shut down. Attempts to force food into the stomach at this point often cause nausea, vomiting, and associated aspiration of food into the lungs.

Very often in the hospital the subject of a feeding tube is discussed during this period of time, and it is not until death occurs that it was clearly the wrong move in retrospect.

Doctors are very algorithmic; “patient is not eating → ask about artificial nutrition.” A minority of doctors have the insight to pause and ask whether it should be done or not, and even if they ask themselves, they will still largely relent and let the family do whatever they want rather than educate them on this point.

You should know that feeding tubes have not been shown to improve quality of life or even extend life meaningfully during this time period. If anything, they may worsen symptoms as mentioned above, which would cause physical discomfort and even reduce lifespan. The best it usually does, in my experience, is extending the period of suffering and lingering by a marginal amount of time.

I generally recommend feeding by mouth naturally for comfort only when the person expresses hunger and a desire to eat.

Lack of nutrition hardly ever translates into the sensation of starvation at end-of-life, and the suffering related to not eating frequently and paradoxically stems from well-meaning people trying to force feed the person who is dying, rather than an actual distressing feeling of starvation from not eating.

Thirst

Mirroring hunger, Jains, Buddhists, and Hindus view the physical drying out of the body as an important step as the body winds down towards death.

In the Bible, one of Jesus’s last words was said to be “I thirst.” (John 19:28). However, instead of a full drink of water, a sponge soaked in liquid was used to moisten his lips. It is said that this is one of history’s earliest recorded examples of palliative oral comfort care.

The example of Jesus actually matches what we know scientifically today.

Several events begin to occur as the body prepares for death.

The heart beats weaken, blood pressure drops, and major organs begin to receive less and less blood flow.

One of the results of this process is the increased secretion of the antidiuretic hormone (ADH), also known as arginine vasopressin.

ADH tells the body to hang onto fluids inside the blood vessels as well as decrease the sensation of true thirst by inhibiting it indirectly and directly.

What this translates into is the person will drink a lot less fluid because they no longer feel thirsty.

We are often asked if IV fluids can be used to supplement oral hydration with the goal of prolonging life.

You should know that approximately 75-80% of IV saline leaks out from the blood vessels into tissue spaces in even a healthy and non-dying body. The difference is that a healthy body can utilize the lymphatic system to then absorb and recirculate that fluid fairly effectively, causing minimal to no swelling.

A dying body is “leaky” due to the increased systemic inflammation, and more than 90-95% of IV fluids will leak out from the blood vessels into these spaces. This frequently overwhelms the lymphatic drainage system.

This means attempts to provide artificial hydration through the IV usually leads to a phenomenon we call “third-spacing”, where excess fluids become trapped in various tissue spaces and cause swelling (arms, legs, belly), trouble breathing (lungs), and confusion (brain).

So while a bag of IV fluids may seem harmless, it actually can cause quite a bit of suffering if used carelessly.

I generally recommend against IV fluids at end-of-life.

While the true sensation of thirst is rare in the dying process, dry mouth and cracked mucous membranes (xerostomia) in the mouth are common. It is likely this phenomenon that Jesus experienced and was subsequently relieved by the wet sponge.

Today, we similarly advocate providing people’s preferred beverages by soaking them with sponges and swabbing their mouths. Alternatively, we also use a medication called Biotene that lubricates and hydrates the mouth to prevent the uncomfortable feeling of dry mouth.

Pain

The ancient cultures believed pain to be the byproduct of the physical body’s machinery breaking down. Most agree that physical pain should be treated to varying degrees; some advocate for maintaining consciousness as much as possible (Buddhism and Hinduism), while others may believe in heavy sedation such that one feels nothing (Judaism).

Pain is one of the hardest symptoms to treat in modern medicine.

Echoing ancient wisdom, modern medicine is relearning that pain reaches far beyond biology into spiritual and existential terrain. I have watched patients with end-stage cancer endure severe, intractable pain that resisted sky-high doses of opioids—only to see that physical tension dissolve the moment they made peace with their body’s dying. Their physical disease had not improved; they had simply set down the crushing weight of their resistance.

We will only be discussing physical pain for the time being, as I believe existential/spiritual pain deserves a separate article all on its own, at a later time.

The brain cannot easily tune out physical pain. Because our survival historically depended on recognizing that something was wrong, our biology never developed a switch to ignore the alarm.

Treating pain requires a multi-step approach. My toolbox contains non-opioid and opioid medications that can be tailored to fit individual needs.

First, one must understand the source and cause of the pain. Different parts of the body can sense pain differently, and one type of medication may treat pain better over another type.

Second, depending on the state of the body, some pain medications may no longer be safe to use, even at end-of-life. So a well-trained physician will take into account kidney and liver function before selecting the most appropriate medications.

Third, personal preference matters deeply. If someone has strong preconceived notions against a specific opioid, I avoid using it unless we can openly address and dispel their concerns. Pain medications are far more effective when patients believe in the treatment and trust the person prescribing it.

Finally, as death approaches, I speak candidly with families about the realities of higher-dose pain management. We often reach a crossroads where the choices narrow: awake and in severe pain, or asleep and peaceful, with almost no middle ground. I explain that while our primary purpose is simply to ease suffering, the deep sedation required to achieve peace may inadvertently shorten their remaining time. Families need this honesty upfront so they aren't left with the haunting fear that the treatment itself caused their loved one's death.

Breathlessness

Many ancient cultures viewed breath as more than a simple mechanical movement of the lungs — they considered it sacred energy animating the soul.

Even in ancient times, healers recognized that the sensation of air hunger leading up to death provoked acute primal panic. They treated this using various techniques such as positioning the person upright, increasing airflow by fanning, using aromatics and incense, as well as chanting low-frequency prayers or mantras at the bedside to help calm labored breathing.

Neuroscience tells us multiple areas in the brain communicate with each other to sound an alarm when the body is not getting enough air or getting rid of enough carbon dioxide. The aforementioned primal panic sets in to induce hyperventilation and hopefully restore proper oxygen saturation and expel carbon dioxide.

As the body nears death, this system of alarms unfortunately serves as the perfect vicious cycle that can cause anxiety → ineffective/weak hyperventilation → body uses more oxygen and fatigues → brain feels more anxiety. Rinse and repeat.

By default I always recommend positioning in the most comfortable position and fanning of the face. Fanning of the face especially is underrated because the trigeminal nerve that supplies sensation of the face will send signals to suppress air-hunger and decrease panic when it senses cool wind hitting the face.

Supplemental oxygen can also be used to help relieve the sensation of breathlessness. However, I recommend not going overboard as higher flow rates of supplemental oxygen, especially CPAP/BiPAP or high-flow nasal cannula oxygen can feel suffocating rather than relieving. Notably, having a low oxygen saturation does not always lead to feelings of breathlessness, and I have seen people breathe very comfortably with 70-80% oxygen saturations.

Opioids can also help here.

Opioids quiet the central panic circuitry, breaking the downward spiral. A low dose of an opioid can actually increase oxygen saturation, contrary to many physician’s fear of depressing a person’s respiratory drive. By inhibiting certain parts of the brain’s signals, stopping the rapid and ineffective hyperventilation and resting exhausted respiratory muscles, it can greatly lower the body's oxygen demand.

Fear and Anxiety

Because fear and anxiety involve existential distress, I will continue their discussion in a separate article to come at a later time.

Don’t Let Needless Suffering Ruin Death

The preventable suffering of one person as they die is not just felt by that singular person.

Caregivers, friends, and families who witness this type of suffering will all have varying degrees of internal moral distress that are likely to manifest in future problems.

I hope my time spent writing this piece will help someone somewhere out there make wiser choices.

Here is a clip I really like that kind of sums it up in a slightly more aloof but still very much accurate way:

Molly is Taught the Process of Dying - Scene | Dying for Sex

One of my biggest pet peeves at work is when I hear other physicians conflate and use the term “palliative care” when they specifically mean to say hospice. That is second only to people referring to opioid pain medications using the loaded term “narcotics,” but I digress...

A lot of people understandably tense up when they hear these terms because of the cultural association with imminent death. It is easy to imagine the worst whenever death enters the chat. We naturally fear what we don’t understand, but once you clear up the definitions, I think these terms themselves stop being scary.

Let’s do some demystifying.

What Is Palliative Care?

The etymology traces back to the Latin noun pallium (a cloak) and the verb palliare (to cloak or cover). The core idea is simple: to provide an extra layer of support, comfort, and protection to someone dealing with a serious illness.

Palliative care as a formal specialty was coined in 1974, roughly seven years after modern hospice was first established. It marked a necessary separation from pure end-of-life care because clinicians realized that patients living with chronic, non-terminal conditions also needed specialized support long before they were actively dying.

My own definition is that palliative care is a specialized medical service for people with serious, chronic, or life-threatening illnesses. It helps patients and their families better understand their diagnosis and prognosis, evaluate treatment options, plan ahead, and manage distressing physical, mental, or spiritual symptoms.

It is appropriate from the moment a serious diagnosis is made (such as heart failure, advanced COPD, chronic kidney disease, dementia, or cancer).

It’s important to note that palliative care can be provided alongside all other medical treatments, including aggressive therapies with curative intent. You do not have to give up on any active treatments to get palliative care involved.

In practice, the palliative team asks the detailed questions that other busy physicians simply don’t have time to explore:

• What do I need to know about you to best take care of you?

• What is your understanding of where you are right now with your illness?

• Where do you want to be?

• How can we potentially get you there while avoiding painful pitfalls?

• If we can’t realistically get you there, what alternatives are there?

Doing this helps align medical treatment directly with what people actually want for themselves.

Because this is a lot to cover, palliative care is almost never done by one person in a vacuum. It takes an entire interdisciplinary team. My own team consists of physicians, nurse practitioners, a social worker, a medical assistant, and chaplaincy/spiritual care.

What Is Hospice Care?

Hospice was founded to counter modern medicine’s overemphasis on curing at all costs and return focus to compassionate care for the dying. Dame Cicely Saunders laid the groundwork in London starting in 1948 before formally opening the first modern hospice in 1967. The first US hospice opened in Connecticut in 1974.

Naturally, because hospice gave way to palliative care, hospice is itself considered a form of specialized palliative care.

In the United States, hospice is governed under specific federal Medicare rules.

To enroll, two main criteria must be met:

1. The Prognostic Rule: A person must have a terminal illness with an estimated life expectancy of 6 months or less if the disease runs its natural course. This must be certified by two physicians.

2. The Shift in Focus: The patient agrees to forego further curative or life-prolonging treatments for that illness, focusing entirely on comfort and quality of life. (Children are the biggest exception to this rule under federal law, allowing pediatric patients to receive hospice care alongside curative therapies.)

For the vast majority of people, hospice is NOT a facility you get sent to, despite popular belief that it is.

Instead, hospice is a way to bring medical care directly into the home instead of forcing fragile patients to travel to doctor appointments or emergency rooms. Visiting nurses, doctors, and aides work together to catch small problems before they snowball into big ones that require hospitalization.

Jimmy Carter is a great example of this in action. He enrolled in hospice in early 2023 at age 98. He ended up living in hospice for 22 months, reaching his 100th birthday surrounded by family. I often use him as a case study for what happens when a dedicated team successfully manages symptoms continuously to keep medical crises at bay while allowing the body to do what it naturally does otherwise.

Similarities and Misconceptions

Both specialties share the primary goal of reducing unnecessary hospital visits by providing additional support and spending the time to get to know you. This translates to more time spent at home with loved ones and better overall quality of life. In fact, clinical studies have repeatedly shown that patients with serious illnesses who receive timely palliative and hospice care often outlive those receiving standard (often aggressive) medical therapy alone.

Up until 2008, there was no formal subspecialty board certification in hospice and palliative medicine. Before that, training wasn’t standardized and the quality of care provided could vary widely across health systems. Today, the gap is closing as physicians complete accredited fellowship programs after their primary residencies in fields like internal medicine, family medicine, or emergency medicine. They then sit for the hospice and palliative medicine subspecialty board certification exam.

I will also say, some physicians classically viewed this field as a low-intensity specialty for a “soft retirement” or even an easy side gig. I personally have had other physicians ask me why my “talents are being wasted in palliative care.” I can only smile awkwardly and shake my head as I lack the energy to argue. My talents aren’t wasted, they are focused and deployed exactly where they’re needed.

In any case, I strongly disagree with anyone who carries that mindset, as most of our patients are medically complex and extremely fragile. One bad judgment call can cause severe harm and unnecessary suffering, and it takes immense mental and emotional energy to deliver truly excellent, personalized care.

The Bottom Line

All hospice care falls under the umbrella of palliative care, but not all palliative care is hospice care.

• Palliative Care: For any stage of a serious illness, regardless of prognosis. Delivered alongside active or curative treatment. Billed as standard specialty care through regular insurance or Medicare Part B just as any specialist physician would.

• Hospice Care: For the final chapter of a terminal illness. Focuses exclusively on comfort rather than cure when prognosis is 6 months or less. Covered 100% under the Medicare Hospice Benefit. This is the team that really helps make the magic happen when death draws near for when regular medical care has failed to provide further meaningful benefits.

The earlier people take advantage of what both services have to offer, the more control they retain over their own lives and healthcare choices.

Now over to you: Have you or a family member ever had to navigate palliative care or hospice? What misconceptions did you run into? Let’s discuss in the comments below.

If you found this breakdown helpful, consider sharing it or restacking it so more people understand these vital services.

As a double-board certified internal medicine and hospice/palliative medicine physician, I bear witness every single day to the rising epidemic of preventable suffering at the end of life.

The American medical industrial complex was built to intervene, to perform, and to fight. It is philosophically and structurally engineered to prioritize the latest technological intervention over human presence. In a system driven by volume and outcome metrics, honoring a peaceful and natural death can often feel like an afterthought.

But the system isn't acting in a vacuum. Policy makers and healthcare institutions reflect the priorities of a society that heavily avoids the topic of death like the plague. We train people to obsess over the quality of living, yet we offer little in the way of guidance on the quality of dying—unless forced to learn through personal tragedy or a close brush with mortality.

As a result, modern healthcare routinely prolongs the dying process, transforming a natural transition into a long, drawn-out battle.

This is a battle that nobody ever wins in the long run.

In my work conducting inpatient palliative care consults, I frequently meet medically complex and/or terminally ill patients to learn who they are, what they value, and what they hope to achieve with their remaining time.

As the conversations unfold, a small percentage of seriously ill people I see would actually accept death as a natural reality of life and be at peace with the idea of dying. They readily engage and partner with me on how to best plan for an eventual death that is peaceful and dignified, with suffering and burdens on their family/friends kept at a minimum.

But far more often, patients and families are mentally entrenched in deep denial, demanding every aggressive intervention available until the body simply up and quits under the weight of it all. It often takes an exhaustive amount of coaching to help them see that while the mind desperately hangs on, the body has been sending clear signals that it cannot do the same for much longer. Sadly, those signals are often ignored until the person is completely consumed by pain, anxiety, and delirium.

But why do so many people resist what their bodies are signaling to them?

I believe it traces back to our societal constructs and what we have been taught to believe are important goals in life.

Beyond basic survival instinct (which admittedly are hardwired and difficult to ignore), we are also swimming in a cultural narrative that glorifies "beating the odds." Decades of mainstream media have conditioned us with fictionalized miracle recoveries and preferentially reporting feel-good stories that are the exception rather than the rule. They have successfully convinced us that doing more is always better, and that allowing a natural death to unfold makes you a "quitter" rather than a "fighter."

But why must it be framed that way?

Don’t misunderstand me, I am not suggesting we give up our lives at the first sign of illness, nor am I glorifying or fetishizing death.

But why can’t we learn to add a little more wisdom, wellbeing, and overall magic into the normal process of aging and dying?

Why can’t a person’s end simply be allowed to be, without replacing a person’s meals with a grocery list of medications that come with a side of poking and prodding?

Frankly, I’ve grown weary of having to coach people one by one. It’s not fast enough.

So I want to start spreading some generally useful knowledge that hopefully can benefit many at once.

This is not going to be everyone’s cup of tea. So be prepared, as my philosophy stands boldly in contradiction to Dylan Thomas’s famous rally cry to “rage, rage against the dying of the light.”

Welcome to Death Magic.