By JESSICA NUTIK ZITTER, M.D.
Sadly, but with conviction, I recently removed breathing tubes from three patients in intensive care.
As an I.C.U. doctor, I am trained to save lives. Yet the reality is that some of my patients are beyond saving. And while I can use the tricks of my trade to keep their bodies going, many will never return to a quality of life that they, or anyone else, would be willing to accept.
I was trained to use highly sophisticated tools to rescue those even beyond the brink of death. But I was never trained how to unhook these tools. I never learned how to help my patients die. I committed the protocols of lifesaving to memory and get recertified every two years to handle a Code Blue, which alerts us to the need for immediate resuscitation. Yet a Code Blue is rarely successful. Very few patients ever leave the hospital afterward. Those that do rarely wake up again.
It has become clear to me in my years on this job that we need a Code Death.
Until the early 20th century, death was as natural a part of life as birth. It was expected, accepted and filled with ritual. No surprises, no denial, no panic. When its time came, the steps unfolded in a familiar pattern, everyone playing his part. The patients were kept clean and as comfortable as possible until they drew their last breath.
But in this age of technological wizardry, doctors have been taught that they must do everything possible to stave off death. We refuse to wait passively for a last breath, and instead pump air into dying bodies in our own ritual of life-prolongation. Like a midwife slapping life into a newborn baby, doctors now try to punch death out of a dying patient. There is neither acknowledgement of nor preparation for this vital existential moment, which arrives, often unexpected, always unaccepted, in a flurry of panicked activity and distress.
We physicians need to relearn the ancient art of dying. When planned for, death can be a peaceful, even transcendent experience. Just as a midwife devises a birth plan with her patient, one that prepares for the best and accommodates the worst, so we doctors must learn at least something about midwifing death.
For the modern doctor immersed in a culture of default lifesaving, there are two key elements to this skill. The first is acknowledgment that it is time to shift the course of care. The second is primarily technical.
For my three patients on breathing machines, I told their families the sad truth: their loved one had begun to die. There was the usual disbelief. “Can’t you do a surgery to fix it?” they asked. “Haven’t you seen a case like this where there was a miracle?”
I explained that at this point, the brains of their loved ones were so damaged that they would most likely never talk again, never eat again, never again hug or even recognize their families. I described how, if we continued breathing for them, they would almost definitely be dependent on others to wash, bathe and feed them, how their bodies would develop infection after infection, succumbing eventually while still on life support.
I have yet to meet a family that would choose this existence for their loved one. And so, in each case, the decision was made to take out the tubes.
Now comes the technical part. For each of the three dying patients, I prepped my team for a Code Death. I assigned the resident to manage the airway, and the intern to administer whatever medications might be needed to treat shortness of breath. The medical student collected chairs and Kleenex for the family.
I assigned myself the families. Like a Lamaze coach, I explained what death would look like, preparing them for any possible twist or turn of physiology, any potential movements or sounds from the patient, so that there would be no surprises.
Families were asked to wait outside the room while we prepared to remove the breathing tubes. The nurses cleaned the patients’ faces with warm, wet cloths, removing the I.C.U. soot of the previous days. The patients’ hair was smoothed back, their gowns tucked beneath the sheets, and catheters stowed neatly out of sight.
Then, the respiratory therapist cut the ties that secured the breathing tube around the patients’ neck. As soon as the tubes were removed and airways suctioned, families were invited back into the room. The chairs had been pulled up next to the bed for them and we fell back into an inconspicuous outer circle to provide whatever medical support might be needed.
I stood in the back of the room, using hand motions and quietly mouthing one-word instructions to my team as the scene unfolded — another shot of morphine when breathing worsened, a quick insertion of the suction catheter to clear secretions. We worked like the well-oiled machine of any Code Blue team.
Of those three Code Death patients, one died in the I.C.U. within an hour of the breathing tube’s removal. Another lived for several more days in the hospital, symptoms under watch and carefully managed. The third went home on hospice care and died there peacefully the next week, surrounded by family and friends.
I would argue that a well-run Code Death is no less important than a Code Blue. It should become a protocol, aggressive and efficient. We need to teach it, practice it, and certify doctors every two years for it. Because helping patients die takes as much technique and expertise as saving lives.
Complete Article HERE!
What does “life is but a dream” mean?
Sometimes when something unbelievable happens, it’s so outrageous (usually in a good way) that it seems like you’re in a dream.
Life is what you make of it. So if you dare to dream, envision what you want it to be – it becomes your reality. It goes right along with the saying “You can be anything you want to be…”
In dreams anything is possible, impossible becomes possible. In life there are limitations with unseen forces that work along with our motives to confuse us more on the path to fulfillment. Life is but a dream – nothing is so easy as to dream it and make it happen right that moment without obstacles standing in way.
“Sex was a taboo subject when I was growing up, just like death and dying, come to think of it. And since I never even came close to conforming to the ideal body image, I always had a hard time of it. I was teased mercilessly as a kid for being fat. Boy, kids can be really cruel.”
My friend Raymond is 50 years old. He is a social worker employed by a home health care agency. He is thinking about applying for a position in the agency’s hospice program, but he’s not quite sure he’s ready for the responsibility. “I need to better understand my own feelings about death and dying before I can hope to assist anyone else.” He hopes I can help him do this. “If I’m going to do this work, I want to do it well.”
Raymond’s mother died of ovarian cancer when he was seven years old, but he never really processed the loss. Now a dear friend of long standing, Joann, is also dying of cancer. Joann’s imminent death has opened the floodgates of his unresolved grief associated with his mother’s death. “I’m both drawn to Joann and repulsed by her all at the same time. And she knows it. It’s so crazy. You should see me. I’m confused and disoriented, which is not at all like me.”
Raymond reveals that a recent visit to his doctor disclosed that he is at high risk for heart disease. Raymond is considerably overweight. “I guess I’ve pretty much let myself go to seed. I’ve always been a big guy, big-boned, as my mother would say, but now I’m just Fat with a capital ‘F’”. The heart disease news, while shocking, didn’t come as much of a surprise.
Three years ago Raymond went through a very acrimonious divorce. “My life shattered before my eyes.” His three children, two girls and a boy, live with his ex-wife in another state. He gets to see the kids only on holidays and for a month during the summer. “After the divorce, I just didn’t care if I lived or died. I ballooned. I put on over a hundred pounds in a matter of months. Hey, wait a minute. Maybe that’s why I’m considering this hospice move, and why I’m so ambivalent about Joann. Maybe I need to recover a sense of meaning for my life.”
“You want to talk about that, Raymond? Sounds to me like you’re avoiding something and it’s not just about mortality. Is it sex and intimacy?”
“I’ve never been comfortable talking about sex, particularly my own sexuality. To be honest, I’ve replaced sex with food in my life. I’m not proud of this, but turning to food was a lot easier than trying to figure out the whole sex thing.
Intimacy, on the other hand, is a different story altogether. I’m real good at that. In fact, I believe that more intimacy is possible over a dinner table than in the bedroom. I mean, just think about it. Intimacy is about a meeting of souls. Sex is about bumping parts. Maybe that’s why I excel in the kitchen. I’m a much better chef than a lover.
Sex was a taboo subject when I was growing up, just like death and dying, come to think of it. And since I never even came close to conforming to the ideal body image, I always had a hard time of it. I was teased mercilessly as a kid for being fat. Boy, kids can be really cruel.
When I was older, I guess I still let that haunt me, because I never had any confidence about my role as a husband and lover either. I know there wasn’t any expertise involved in getting my wife pregnant. In fact, I wonder how many of us would be here today if conceiving a child involved any kind of skill at all.”
“It’s true what you say, Raymond, our culture is plagued with mixed messages about sexuality and intimacy. We can easily become obsessed with the image of the perfect body, with youth and beauty. All of this can get in the way of finding a comfortable place for us to express ourselves as intimate and sexual beings.
Can I ask you a question? How important is sexuality in your life? Some people haven’t any interest in sex, and that’s just fine for them. But I sense that you’re not like that. Am I correct, or are you content with the status quo?”
Raymond thought for a moment then responded; “I know I’ve built up this wall of fat to keep people out. And I can see that this crazy defense mechanism of mine will most likely kill me if I don’t get a handle on it. Listen, I don’t aspire to being the world’s greatest lover, but it would be nice to stop running for cover every time the subject comes up.”
“Thank you for being so honest about that, Ray.
I believe it’s never too late to relearn new and healthy ways to deal with our sexuality. This re-education process begins with dispelling the myths and misconceptions that our culture passes off as sex information.
I suggest that you begin by doing some reading around the topic of male sexuality. I think you will find it both informative and supportive. There are a number of good books available, and I’d be happy to suggest some titles, if you like.
Once you’re more comfortable with the basics, you could then move on to being with a partner. Earlier you said that you feel that more intimacy is possible over a dinner table than in the bedroom. An interesting thought and very insightful too. And that leads me to a suggestion! Why not bring some of the intimacy of the dining room into the bedroom? This way you would be combining something you know how to do really well with something you’re just learning. You could invite a partner to join you for dinner in bed. Eating could be part of your sex play. Plan a menu of finger food, and other things you could feed one another. Make it playful. Sex, like eating, shouldn’t be work. And maybe when you get real good at eating in the bedroom, you could try having sex in the dining room.
When you’ve finished your sex play, take a long walk together. The exercise will do you good and you’ll have a perfect opportunity to do some talking about sex. I suspect that sex, sexuality, and sensuality continue to confuse you because you know very little about any or all of these things. Talking with others about their experiences broadens out our own life experience.
Thing is, I don’t think couples talk nearly enough about sex with one another. Learning to communicate is key to having a happy and healthy sex life. Talking about sex is especially important for couples that have been together for a long time. It keeps them from getting stale and prevents them from presuming each knows all there is to know about their partner.
Why not get interested in life again, Ray? Have a little fun. Sexuality isn’t a mystery. It’s a wonderful miracle.
By Chen Ximeng
As Song Hua (pseudonym) lay in her open casket, nearly a dozen people dressed in black stood above the 34-year-old shedding tears and paying heartfelt tributes. Incense burned from an altar flanked by wreaths as moving music played in the small, candlelit chapel in downtown Beijing. But this wasn’t any ordinary memorial service. After all, Song wasn’t actually dead.
“I really wanted to experience what it feels like to die,” said Song, whose faux funeral was attended by 10 “mourners” playing the roles of family members, friends and colleagues.
Death might be a certainty in life, but it is a major taboo in Chinese culture. Visiting ancestors’ tombs for Qingming Festival, which falls on April 5, used to be the closest most people were comfortable with getting to death, but now a growing number of people are participating in educational activities that help them to develop a rational understanding of death.
Try before you die
Song’s fake wake last month was organized by the Inner Light Group (ILG), a Dongcheng district-based counseling agency that has provided the service to around a dozen people since last year. Each wake costs 100 yuan ($16.11) and runs for two hours.
Faux funerals have been popular in Japan and South Korea since 2010, but they are still relatively new in China. They give people like Song, whose battle with depression had caused her to contemplate suicide, a glimpse of the impact their deaths might have on loved ones while reminding them of their own mortality.
“I couldn’t accept myself and wanted to end it all. I knew it was wrong, but I felt trapped in an abyss of grief and despair. I thought, ‘Why not leave the world?’” said Song.
Before Song’s faux funeral, she was required to give a farewell letter to her “relatives” played by ILG members. She was then draped in a white sheet and laid in her casket at the center of the 30-square-meter chapel before the agency’s 45-year-old founder and mock celebrant, Jia Dao, told the somber audience of Song’s death by suicide.
“I lay face-up in the casket as my ‘parents,’ ‘siblings’ and ‘colleagues’ circled me,” explained Song.
Everything seemed to be progressing like any normal funeral until a ‘colleague’ who had apparently returned from abroad to attend Song’s ‘funeral’ held her hand and sobbed about being left heartbroken.
Upon hearing his words, Song was stirred from her motionless state and tears rolled from the corners of her closed eyes.
“Their words were so sincere and warm that it connected deeply with my heart. Since then, I haven’t thought about suicide once. I can now accept death naturally,” said Song.
Ashes to ashes
For those who want to take their near-death experience a step further from a funeral, the Life and Death Experience Center in Shanghai might be the best option. Visitors can write their own will and epitaph, as well as nominate organs they wish to donate.
The experience culminates inside a 4D “crematory” that shows the living what the dead never see, hear or smell: roaring flames turning skin, hair and bones to ash.
The center, which has attracted more than 400,000 yuan from over 200 investors since July 2013, is slated to open later this year.
Ding Rui, one of the center’s co-founders, was inspired to create the grisly tourist attraction after climbing into a real crematory himself in November 2011 while working as a trainer for volunteers at Hand in Hand, a Shanghai-based NGO that provides palliative care.
“When I was inside the crematory, I felt breathless for a moment and very close to death,” recalled Ding.
Although Ding knew he was safe, staring at flame vents positioned above his head and at his sides was an unnerving experience.
“Being inside [the crematory] strengthened my resolve to open the center to teach people about death. I wanted to simulate the vivid feeling of being cremated and also experiencing rebirth,” said Ding.
Dying to experience the other side
His time spent caring for people nearing the end of their lives led Ding to realize problems with Chinese being “unable to openly talk about death.”
“After taking care of more and more dying patients, I found that people’s fear of death is infectious like a virus,” said Ding, adding that his biggest concern from experience in palliative care was seeing how few people – from the elderly to their family members – struggled to directly face death.
No one lives forever, but sometimes people can be uncomfortable at being reminded they are mere mortals.
“The deep impact of Chinese culture is a major reason why few people are comfortable talking about death,” said Wang Zuoji, deputy director of the Beijing Folklore Committee and a member of the capital’s non-tangible cultural heritage committee.
In Chinese culture, the number four is considered unlucky because its pronunciation in Putonghua is close to “die.” Similarly, a clock is never given as a gift because it sounds similar to the word for “end.” Even the sight of chopsticks placed upright in a bowl of rice can cause superstitious Chinese to shudder due to its resemblance to incense.
“Some customs and taboos have no scientific reasoning, existing only to reject anything related to death or bad luck,” said Wang.
Preserving dignity at the end
Ding said he shared a feeling of powerlessness with those he cared for in palliative care, noting that medical apparatus used to extend people’s lives often came at the cost of individuals’ dignity.
“People dying don’t have the right to decide matters relating to their death, which are instead handled by relatives often influenced by others’ opinions,” said Ding.
Most people spare no effort to give their loved ones the best medical care possible, even if it means extending their life for a short time only. Life-support machines and medical ventilators are often used to keep alive patients unable to talk or move out of bed.
In a society that values filial piety, many relatives don’t dare assist or speed up a parent’s death. Despite a December 2013 survey by Shanghai Jiao Tong University finding that more than two-thirds of Chinese have an open, tolerant attitude towards euthanasia, the practice is banned under Chinese law and there are no signs it could be legalized any time soon.
“In some regards, palliative care doesn’t work in educating people about death,” said Ding.
“We want to put it in the spotlight by letting people experience the closest thing to it. Death education is important because no one knows when their number is up.”
Learning about death
Wang Yifang, a professor at Peking University’s Health Science Center, recalled how one of his colleagues learned after teaching a class in 2009 that his father was terminally ill. Accepting fate gave both father and son peace of mind.
“My colleague shunned technology and medical care that would extend his father’s life, choosing instead to provide palliative care at home. His father died graciously,” said Wang Yifang.
Since 2009, Wang Yifang has taught a course about life and death that helps students come to grips with an issue avoided most of their young lives.
“My course provides theory-based education, while death simulation is a more radical version of interactive education,” said Wang Yifang.
Approaches to death education vary in China. It currently isn’t included in curriculums of schools, with opinions among experts divided over whether it should be added.
Medical students in Taiwan are required to lie in a coffin and read farewell letters, while students at a high school in Hainan Province visit funeral parlors to inspect how ashes are stored after cremation.
Chen Yue, a counselor at the Sunshine Psychological Counseling Corporation in Beijing, has taught a class since February about death education.
Attendance is low, however, with even some fellow counselors unable to sit through classes due to the grim nature of its subject.
“Parents need to take the initiative in teaching their children about death. The subject of death is horrible, but neglecting it makes it even more terrifying to children,” said Chen.
“China has a long way to go in death education, which can not be achieved in the span of one or two generations. People need to dramatically change their perception of death, but this can only be done little by little.”
Complete Article HERE!
Humor takes the sting away; it humanizes us; it helps us keep our perspective. Humor enriches us; it educates us; it brings us joy. Humor doesn’t dissolve the pain or make our life any less poignant, but it does help make things more bearable. That’s my philosophy, and I’m happy to share it with you on a weekly basis. I hope that if you enjoy what you see, you will take the opportunity to share it with others.
The task of interpreting the symbols on a headstone or memorial is a daunting one. Although most of the symbols that you will see DO have a textbook meaning, it is quite possible that the headstone or memorial you are looking at was put there simply because someone liked the look of it. Therefore, it will have no meaning beyond the taste of the deceased or those left behind to morn. The point is that many people choose a memorial motif not for its textbook meaning, but simply because they like the ornamentation or design, because it feels “right” or appropriate.