Cemetery Art – 04/24/14

This is Part 1 of the Prince and Pauper edition of my ongoing cemetery art photo essay.

We all die, but what survives us, if anything, has lots to do with our status while we were alive.

These are images of potter’s fields, the resting place of the poor and dispossessed.  Tomorrow, princely monuments.


Aid In Dying, Part 2

“If you expect heroics from the people who attend you, even if it doesn’t include hastening your death, you’d be well advised to treat your attendants as heroes. Mutual respect and consideration, honor and compassion should be the hallmarks of your relationship with them.”


(We pick up our discussion where we left off last time. Part 1 is HERE.)

One of the most predictable questions I get when I present on the topic of aid in dying is; how do I go about finding someone who will be willing to help me? And I always answer the same way; the only way to know is by asking.

AidinDyingphoto_mediumI suggest that anyone looking for help with their end of life choices begin by interviewing those they love, to see who may have psychological, emotional, or moral reservations about assisting them in this fashion. I suggest that you never ask anyone to violate his/her ethical code regardless of how much you need help.

Once you find the person(s) you are looking for, I suggest that you check in with this person regularly to see if their level of commitment remains high, and excuse anyone who may have developed the least reservation about helping you as the time approaches. I suggest that you keep the number of people involved to the smallest number possible. One or two people at the most is my recommendation. Confidentiality and coordination of effort is essential and a large group make that virtually impossible.

At this point in the presentation I share two stories of very different death scenes to make my point. I was invited to consult on both occasions.

Jeffery was dying of AIDS. He and Alex, his lover of nearly twenty years, were preparing for his imminent death. Jeffery had a fear that he was beginning to slide into dementia, which was his worst nightmare. He wanted to short-circuit this final indignity and wanted to know if I would help them plan a strategy for proactively ending his life. I told them that I would be happy to offer them whatever information I had.street drugs

On this first visit with them I tried to assess the situation; to get a feel for the level of commitment that each person was bringing to this endeavor. There was no doubt about it, Jeffery was actively dying, his doctor confirmed the dementia diagnosis, and so time was of the essence.

I asked, “Have you guys done your homework?”

“If you mean, have we squirreled away enough medications to do the trick, the answer is no. We never gave this eventuality a thought until recently and now there’s not enough time to do that.”

“Will your doctor assist you with a prescription for a lethal dose of, let’s say, a barbiturate?”

“Doubt it. We’ve never talked to her about this. I don’t even know where she stands on the issue.”

“Well, then, how were you going to make this happen?”

“We were thinking about using street drugs, you know, coke and heroin. I also have some oral morphine left over from a friend who died last year.”

the_end_life_by_liquifiedsoul-d3fuz2nThat’s it? That’s your plan? What if you mess up on the dosage or something else goes wrong? I’ve seen it happen. You could be in worse shape than you are now and still be alive. Do you have a Plan B?”

Jeffery responded; “Alex and I talked about it some and Alex promised that he wouldn’t let me suffer.”

“But what does that mean? Alex, do you know what it is you are promising?”

The three of us talked for hours about their half-baked scheme. I tried to get them to see how implausible their plan was and how serious the consequences would be if there was a miscalculation. They would have none of it. Their love for each other and Alex’s blind commitment to Jeffery to preserve him from any more suffering was all there was to know. Alex would be as resourceful as necessary, even if it meant he had to suffocate Jeffery in the end.

Ten days later I was invited to their home again. I didn’t realize it at first, but earlier that day they had set their plan in motion. Alex had scored some cocaine, freebased it, and watched as Jeffery shot up. Both of these guys had had a long history with intravenous drug use so all of this was familiar territory. Unfortunately, Jeffery’s history with drug use complicated matters considerably. He had built up a tolerance to the drug and even though he was nothing more than skin and bones, the dose was not lethal. This is the situation as I found it. Jeffery was comatose and appeared near death, and Alex was at his wit’s end.

“He’s been like that for hours. I thought for sure he’d be dead by now. I think we’ve screwed up. What am I gonna do now?”

“I’m afraid I can’t advise you. I can only help you weigh your options.”

As I saw it, Alex had two options. He could call the paramedics and have them try to revive Jeffery with all the trauma that would involve, or he could honor the commitment he made to Jeffery and complete the plan they rehearsed.

Then there was Earl and his wife Christina. Earl was in the final stages of lung cancer. He was a hard, difficult man, plagued angerby many personal demons. Even when he was well, people used to say that he was an acquired taste, and if you ask me, that was being generous. The sicker he got, the more difficult he became. He alienated just about everyone – his sons, his friends, even the people from hospice. No one could tolerate his fury. In the end there was only Christina.

Some weeks before he died, Earl demanded that Christina call me over for a visit. I wasn’t inclined to accept the summons because I hated to see how he treated her, but Christina sounded so defeated on the phone that I relented and made plans to stop by the following day. Nothing had changed in the eight months since my last visit. Despite being a mere shadow of his former self, Earl was as abusive as ever. How had Christina been able to stand it all this time, I wondered.

“I want to die! I want this to be over now. I can’t get decent care. All these fuckin’ doctors and nurses make me sick. They don’t know what they’re doing.”

“He doesn’t mean that, Richard,” Christina interjected. “He gets good care.”

“Pipe down! I’m doing the talking. What do you know about it anyway? She don’t know nothin’ about what it’s like for me. Listen, Richard, I want to die. I want to end it right now, but I need help. I’m sick of this.”

“What kind of help do you need?” I asked.

“I read Final Exit, you know. I know how to do it. I got all these pills I can take.” Earl pointed to the cache of pill bottles in the nightstand drawer. “But I don’t want any slip-ups. I need someone to help me with the plastic bag at the right time, and she won’t help me.” He nodded in the direction of his long-suffering wife.

keep-calm-and-do-your-homework-100It was true. Christina absolutely refused to help. When I asked her why, she could only sheepishly shrug her shoulders. There was clearly much more to this than what was on the surface.

Earl then turned his attention to me. “You got to help me. You’re the only one left.”

“Earl, I won’t and can’t. It’s not that your request is out of line. It’s because I’m a stranger here. In all the years that we’ve known each other, you’ve never once invited even the most casual of friendships to form between us. You’ve always kept me out. You can’t ask me to overlook that now. You’re asking me to participate in one of the most intimate experiences two people can have in life and, I’m afraid, there just isn’t any foundation for that here. I’m sorry.”

“You’re a fuckin’ coward, just like everybody else. So you can just get the hell out and leave me alone. Damn you all!”

I hated to leave Christina alone with him, but I did as he demanded. Christina showed me to the door.

“Why won’t you help him?” I asked, when she and I were alone. “It would be the end of your misery.”

“That’s exactly why I won’t. After all these years, I couldn’t be sure whether helping him die would be an act of compassion, which would end his suffering, or an act of violence, which would end mine.”

These two scenarios provide a blueprint of what not to do if you are seriously considering having someone assist you to die. If you expect heroics from the people who attend you, even if it doesn’t include hastening your death, you’d be well advised to treat your attendants as heroes. Mutual respect and consideration, honor and compassion should be the hallmarks of your relationship with them.

You also have to have a well-thought out plan. And a “Plan B.” There’s no substitute for meticulous attention to detail. Who, what, when, where, and how. Do your homework!

Hump Day Humor – 04/16/14

last legs
never fit in
no words
playing bereaved

A ‘Code Death’ for Dying Patients


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.

Code DeathI 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!

Life is but a dream – 04/10/14

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.




What Happens to Your Body after You Die?

Weight Concerns, Life Concerns, and Intimacy Concerns

“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 heavyset manlong 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.

divorceMy divorce devastated me. I never had much confidence that I was a good lover, and when my wife left me, I figured it was because I was lousy in bed.

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.no real ending

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.

Hump Day Humor – 04/02/14

A little late today.  But better late than never!


Angel of Death, take me now

curiosity killed the cat

duck of death

how about never

Staring death in the face

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. Inner Light Group

“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.

A 'mourner' holds the hand

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

Grim Reaper imitator

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!

Hump Day Humor – 03/26/14

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.

what's bothering you


why not you you look like death


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