When is it time to let go? When does a person stop being a person? When does someone stop being themselves? As the end approaches, boundaries fade. Categorical systems collapse. We are left trying to make sense of vast amounts of continuous variables our brains find so hard to process (Kahneman, 2011). Wading through the mud, laboriously trudging forward, far away from safe, neat, controllable scenarios, we must, however, make decisions. We must face consequences; we must explain them.

How do you translate “an ejection fraction of 28%” to your non-medical sister? Do you take out your second-year physiology book and explain its meaning, and continue this route for all parameters (rising creatinine levels, fluctuating vital signs, altered mental state) or do you condense all the information into the statement “Mom is fragile”? Being the only doctor in the family can be (fill in the blank).

This manuscript is a reflection on this subject: what happens to the person, the caregivers, the family, and individual family members when death approaches. More specifically, what happens when death is so close it stops being a categorical variable and cannot be described as anything but dimensional. I can only tell this from my perspective: many aspects of my story shape my interpretation. I am a doctor, psychiatrist, daughter, mother, sister, and wife. I am all of these, and many more, and none of them at the same time. My category-loving brain struggles but manages to understand: there is something deeper to what makes me what I am. Human beings have spent centuries pondering the subject. We are formed by millions of cells, individually created and dying daily, yet the identity of Self lingers. Moreover, the concept of death, the moment when we no longer exist, seems unequivocal. But is it?

In 1981, the United States approved the Uniform Determination of Death Act, “with the intent to provide a clear, consistent legal distinction between life and death,” which is, coincidentally, currently being revised (Lewis, 2022). Further evidence on the difficulty of drawing the line comes from research on postmortem genetic transcription, where the term thanatotranscriptome was coined. I cannot help but ponder the irony of studying processes intrinsic to life while calling them “after-death”. How can something be dead if it still produces something? The issue is brilliantly explored by Addy Pross in his book What is life? How chemistry becomes biology. There is obviously a difference between the components of a cell (matter) and the interaction between them (life), but what kind of difference? (Pross, 2012). Javan et al. (2024) also explore the process of death and its complexity from a scientific perspective.

How does this expansion of death affect those experiencing the process? As knowledge and technology evolve, the ability to restore homeostasis increases, creating ever-expanding horizons until the point of no return. Yet one is forced to answer the following questions: “Return where? What was the last point one would come back to?” Is it when there was a heartbeat? Even if the body is now missing a part (a limb, an organ, a whole section)? Even if the personality has changed? Even if a machine is attached to the body? And what about when 20 medicines are needed for this homeostasis to exist? As technology evolves, it becomes clear to me: as doctors, we do not save lives, we postpone death. We expand death, transforming it and combining it with life.

What impact does this have on the person nearing death and those around her? My personal experience is that you are faced with “mourning by a thousand cuts”: an uncountable number of losses, all accompanied by the relief—albeit a slowly fading one—of retaining the core person with you.