Doctors need to learn about dying, too

By Susan Svrluga

Doctors will finally be reimbursed for talking about death with their terminally ill patients, but, Michael Nisco argues, very few of them know how to do that.  Nisco, the hospice national medical director for Amedisys Home Health and Hospice Care, has taught at Stanford and Harvard medical schools. He founded the physician specialty training program in palliative care at the University of California San Francisco Medical School.

He writes that medical schools must do a better job of preparing physicians to help patients even when they can no longer heal them.

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Dying Patients Deserve Physicians Educated in End-Of-Life Care

By Michael Nisco, MD

Starting this year, Medicare will, for the first time ever, reimburse physicians for having end-of-life discussions with terminally ill patients.

In the ideal scenarios, doctors ask patients to identify how and where they want to spend those final days, and then recommend the best options.

Question is, will physicians, as a result, be motivated to initiate more of these crucial conversations? Will patients? And will this long-overdue reform ultimately improve, both clinically and economically, how well the U.S. health care system delivers end-of-life care?

Nobody knows for sure. But this much is certain: Many physicians have received no training along these lines. Few are educated in how to carry on this kind of talk with patients in the first place, much less in shepherding patients compassionately toward death.death-cab-for-cutie-transatlanticism-reissue

In 1999, only 26 percent of residency programs in the United States offered a course on care at the end of life as part of the curriculum, the Journal of the American Medical Association reported. Indeed, of 122 medical schools researchers surveyed more recently, only eight had mandatory coursework in end-of-life care.

Physicians all too often skip having an end-of-life discussion, or at least delay it as long as possible, even in the face of a major health crisis. Physicians are rarely prepared to conduct such momentous conversations with patients, least of all about anything as sensitive as advance care directives. We typically think and act short-term rather than looking ahead. But it’s more than that: Such conversations guarantee deep discomfort.

Acknowledging the approach of death means delivering a poor prognosis — and admitting to ourselves that we’re about to fail our patients forever. Doctors are hardly immune to living in denial. We can be unduly optimistic about how long even the sickest of the sick are going to stay alive.

After all, nobody wants to look death in the eye.

Code DeathAnd in bypassing this opportunity and doing what we believe to be right, we’re actually committing a wrong, bringing serious consequences. Patients pay the price. Those who need to be alerted to and informed about end-of-life care may wind up ill-advised and even ignorant about the choices available and what they might mean.

Terminal patients should have the opportunity to enter hospice care sooner than most do to take advantage of its clinical, emotional and spiritual benefits. They should also be granted the right to die at home if they so choose rather than in a hospital or a nursing home.

Pressure for these discussions to be imperative rather than optional is growing, and fast. The decision from the Centers for Medicare & Medicaid Services to compensate doctors for having these talks is only the latest breakthrough on this front.

In 2014, the Institute of Medicine came out with an influential report, “Dying in America: Improving Quality and Honoring Individual Preferences near the End of Life,” that, among other calls to action, urged Medicare to approve such reimbursements for these counseling sessions. The American Medical Association soon urged the same. Massachusetts even became the first state to pass a law requiring doctors to discuss with terminally ill patients how they want to be cared for at the end of life.

Of course health care professionals in current practice should adopt the proper protocols, too. Accordingly, Amedisys Home Health and Hospice Care has undertaken its own national educational initiative. Over the last year, more than 3,000 of our employees, across our 80 hospice centers, have come together to watch the PBS documentary “Being Mortal,” based on the book by Atul Gawande, and discuss how to apply its lessons to caring for our patients every day.

We’ve secured Continuing Medical Education accreditation so we can credit every physician, nurse practitioner and physician assistant who completes an online course featuring the film. We’re also screening the film for physicians, nurses, social workers, home health workers and the general public at hundreds of locations across the country.death-poems-death-poetry-dark-poems-dark-poetry

The broader solution here, at once simple and complex, is that more medical schools should develop curricula about performing end-of-life care in general and conducting discussions about it in particular.

We have to change how people die in this country – and, more specifically, teach the next generation of physicians how best to care for the dying. Here’s a prescription to get us started:

  • Care at the end of life should be taught as an essential clinical skill throughout the continuum of medical education.
  • Medical students should be exposed in all stages of training to dying patients and multidisciplinary teams who can instruct in a humane model of palliative care.
  • Medical schools must train and hire more educators to demonstrate state-of-the-art palliative care for medical students, residents, fellows, medical school faculty, and physicians in practice.
  • The following major goals should be the focus: establishing suitable communication skills; acquiring essential technical knowledge for treating symptoms and relieving pain; and learning to address the psychosocial, cultural and spiritual needs of patients.

Unless action is taken, we may see more physicians telling stories like this one, from Charles von Gunten’s “Why I Do What I do”:

The young man was ‘end stage’ and we could do nothing for him. He was short of breath and unable to talk and looked terrified. I had no idea what to do. So I patted him on the shoulder, said something inane, and left.  He died hours later. The memory haunts me. I was ignorant and failed to care for him properly.

These improvements are already desperately overdue. Palliative care is the responsibility of all physicians, yet only an estimated 6,500 physicians are certified in hospice and palliative care. Only if we improve our overall approach will our patients and families ever truly have a chance to complete their life’s journey with honor and dignity.

Complete Article HERE!

Experiences, Dreams, and Visions: Easing the Patient With Cancer Toward End of Life

By 

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Dreams have been the subjects of songs and psychoanalysis, puberty and poetry. There are sweet dreams and there are nightmares … and then there are the dreams that comfort the dying. Although the dreams of hospice patients have not been subjected to a great deal of research, one recent study demonstrates that they can be meaningful and comforting for the person who is dying.

End-of-life experiences (ELEs) occur frequently in people who are near death and can take different forms.1 End-of-life dreams and visions (ELDVs) are one type of ELE.2 These often manifest as visions that occur during a wakeful state, or dreams that the patient remembers after sleeping.

DREAMS AND VISIONS OF DYING PEOPLE

Christopher W. Kerr, MD, PhD, and colleagues at the Center for Hospice and Palliative Care in Cheektowaga, New York, in partnership with James P. Donnelly, PhD, of Canisius College, Buffalo, New York, undertook a study to document ELE phenomena in patients at the facility. As part of the study design, they examined the content and subjective significance of ELDVs, and related their prevalence, content, and significance over time until the patient’s death.1

tumblr_nu422woJmN1r1vfbso1_500The study included 59 patients ranging in age from 34 to 99 years who were in their last weeks of life. The patients were interviewed daily about their dreams and visions while they were in the hospice inpatient unit. They were asked to report on the content, frequency, and comfort level of their ELDVs. If it was possible to continue the interviews after a patient was discharged, the interview was conducted at the patient’s home or at the facility to which the patient was transferred. The researchers met with the patients each day until they died, were unable to communicate, found communication too stressful, or until the patient became delirious.1

Of the 59 patients in the study, 52 (88.1%) reported having at least 1 dream or vision. Almost half of the dreams or visions (45.3%) occurred while the patient was sleeping, 15.7% occurred while the patient was awake, and 39.1% occurred during both sleep and wakefulness. The patients reported that nearly all ELDV events (99%) seemed or felt real. Most patients reported a single ELDV each day (81.4%); some reports were of 2 (13.2%), 3 (4.1%), or 4 events (1.4%) on other days.1

RATING THE DREAMS

The patients rated the degree of comfort or distress they associated with their ELDVs on a scale of 1 to 5, with 1 meaning extremely distressing and 5 meaning extremely comforting. The mean comfort rating for all dreams and visions was 3.59, with patients rating 60.3% of ELDVs as comforting or extremely comforting, 18.8% rated as distressing or extremely distressing, and 20.7% rated their dreams as neither comforting nor distressing.1

The patients felt that their dreams and visions were realistic, whether they occurred during sleep or while awake. They related dreams and visions of past meaningful experiences and reunions with loved ones who had already died, and who reassured and guided them. Others reported feeling as if they were preparing to go somewhere.1 The researchers noted that often patients’ dreams before dying were so intense that the dream continued from sleep to wakefulness, seeming to be reality. However, those patients who had ELDVs died peacefully and calmly.1tumblr_nnbt0hGiMC1qb47plo1_540

The most common dreams and visions included friends and relatives, either living or deceased. The patients found that dreams and visions that featured the deceased (friends, relatives, and animals/pets) were significantly more comforting than those of the living, of the living and deceased combined, or of other people and experiences. As participants approached death, comforting dreams and visions of the deceased became more prevalent.1

NOT DELIRIUM

Clinicians should note that ELDVs are not hallucinations, and they are not the result of medications or confusion. These phenomena play an important role. Their content holds great meaning to the patient who nears the end of life. Patients who experience these phenomena are not delirious; they think clearly and are aware of their surroundings. In contrast to patients who are in a state of delirium, ELDVs typically occur in persons who have clear consciousness, heightened acuity, and awareness of their surroundings.

Although the phenomena bring a sense of impending death, they also evoke acceptance and inner peace. These are crucial distinctions, since if a dying patient with ELDVs is considered delirious and is treated as such, the medication may interfere with the comforting experience that ELDVs can bring to the dying process. Not being able to derive that comfort at the very end of life could lead to isolation and unnecessary suffering for the dying patient.

Oncology nurses and other clinicians can play an important role in the dying process by not assuming that the patient experiencing ELDVs is delirious and needs more medication.

“The results of this study suggest that a person’s fear of death often diminishes as a direct result of ELDVs, and what arises is a new insight into mortality. The emotional impact is so frequently positive, comforting, and paradoxically life affirming,” the hospice team explains.1 The person is dying physically but emotionally and spiritually, their identity remains present as manifested by dreams/visions.

“In this way, ELDVs do not deny death, but in fact, transcend the dying experience, and present a therapeutic opportunity for clinicians to assist patients and their families in the transition from life to death, thereby providing comfort and closure.”1

REFERENCE

1. Kerr CW, Donnelly JP, Wright ST, et al. End-of-life dreams and visions: a longitudinal study of hospice patients’ experiences. J Palliat Med. 2014;17(3):296-303.

Complete Article HERE!

Two Designers Want To Turn Your Body Into A Tree With These Eco Burial Pods

Two Designers Want To Turn Your Body Into A Tree With These Eco Burial Pods

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Modern burial practices are an environmental nightmare. Toxic chemicals from the embalming process leach into the air and soil. Caskets and burial vaults use a tonne of materials. And memorial parks clear acres of land while soaking up significant amounts of water and pesticides to keep lawns green.

And cremation isn’t any better. It releases noxious chemicals into the atmosphere in the process. What, then, is the most environmentally friendly way to die?

“The best way is to allow your body to feed the earth or ocean in a way that is sustainable for future generations,” Susan Dobscha, a professor of marketing at Bentley University and editor of an upcoming book about the green burial industry called, Death and a Consumer Culture, told Tech Insider via email.

And a team of two Italian designers have devised a concept on how to do that.

Their project, called Capsula Mundi, aims to create eco-friendly egg-shaped burial pods that will house a body in the place of a casket. The corpse will be placed in the fetal position within the pod and draped in a cloth of natural fibres. The team is also designing smaller versions of these pods which can inter ashes instead of a body.

The biodegradable package, which will be made from potato and corn starches, would then be plunged into the ground and a tree of the deceased’s chosing would be planted on top. Over time, the mixture of microbes and nutrients from the decaying corpse would feed the tree, effectively sprouting a new organism – the perfect circle of life.

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This eco-pod is the brainchild of Italian designers Anna Citelli and Raoul Bretzel, who met at a furniture fair in Milan in 2001. It is not just meant to be a work of art, but is supposed to give back to the earth in a real way that many static pieces of art do not.

It’s also meant to challenge some of the most deeply ingrained rituals and customs concerning the dead.

“Our main goal… has been to sensitise people about the unbearable way the modern culture currently deals with death,” Citelli and Bretzel told Tech Insider via email.

Though Citelli and Bretzel aren’t sure how much the capsules will eventually cost, they will likely be much cheaper than a traditional burial, which typically sets a family back an average of $US10,000 ($14,200 AUD). This includes the undertaker and cemetery fees, and costs associated with the burial vault, flowers, clothing, and transportation.

This doesn’t mean that it will be easy to revise how we honour the dead, however.

These eco pods won’t be interred willy nilly, but would be memorialised in a ‘natural burial site’ that would eventually become a forest. There are a smattering of natural burial sites across the US and other countries around the world. For example, the UK was one of the first to establish a natural burial ground, called The Woodland Burial, in 1993.

But these ‘natural’ burials – including the eco pods – are currently illegal in Italy. According to Citelli and Bretzel, Italian law states that coffins can only be made out of wood and tin, and must be buried in a protected, controlled, and closed area. They’re currently trying to change this law.

While the definition of a ‘natural’ or ‘green’ burial varies, the general idea is to allow the body to recycle back into the earth naturally. They usually forego chemical preservatives, such as the use of formaldehyde in the embalming process, or unnecessary materials, such as metal caskets and concrete burial vaults.

There are also some logistical and scientific challenges.

A vertically-lying body, like that in an eco-pod, is less likely to supply as many nutrients to the soil as a horizontally-lying one, Tony Hale, co-director of a green burial documentary A Will for the Woods, told NY Daily News. But vertical or horizontal, science suggests that humans are ripe sources of compost material, as many new burgeoning projects suggest.

Citelli and Bretzel are beginning to produce small egg-shaped capsules for burying ashes, they said, which will be ready by early 2016. The handling of ashes is generally more forgiving when it comes to the law, but different regions have their own regulations. Some countries and states within the US forbid scattering ashes on some public lands or in the ocean within 3 miles (4.8 kilometres) of a shore. Italy has not allowed scattering of ashes at all since 2001, and only permits them to be buried at a cemetery or kept in an urn in the home.

Citelli and Bretzel currently do not have a date for the body-sized eggs, though their plan is to go ahead with production despite the challenges.

“This is amazing and really pushes us forward in this project,” Citelli and Bretzel said. “This precious legacy is the gift that the person [gives] to the community and to the future.”

Complete Article HERE!

Life is but a dream – 01/12/16

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.

How to Tell What’s Going to Kill You

What should you fear? The answers are different at each stage of life—and vary dramatically for different groups of Americans.

Fort Rosecrans National Cemetery
Fort Rosecrans National Cemetery

By ANDREW MCGILL

In general, the probability of death is pretty simple to calculate. It’s 100 percent. We all die.

But the devil is in the details. Humans fear catastrophe and disaster, and accordingly, tend to worry about horrifying events: gunfire, a terrorist attack, lightning strikes. The fact that such grisly ends rarely come to pass—especially if you stay inside during thunderstorms—doesn’t seem to reduce such concerns.

Every year, the U.S. Centers for Disease Control and Prevention publishes a compendium of how many Americans died the year before. There’s plenty to be learned about freak accidents—two people died in 2014 from “ignition or melting of nightwear”—but the data also shows how exceptionally hardy human beings are.

In any given year of their lives, Americans far more likely to keep chugging along than not. Even at the frail age of 85, you have a 92 percent chance of surviving to the next year.

Pretty good odds! But this is where probability comes in. After all, life is not a single roll of the dice, but thousands. Survival is rarely dependent on a single, cataclysmic moment of chance, but years of smaller risks — the 0.089 percent chance of heart disease at age 50, then 0.098 percent at 51, and 0.109 at 52.

In the end, it’s the additive power of probability that kills us. And at each turn of the calendar, the odds usually go up.

Here’s an experiment. Using CDC data from 2009 through 2014, we coded a program that simulates a person’s lifespan and calculates the odds of dying at any given year. For every year of life, it runs this virtual person through the litany of ways to expire. If their number isn’t called, they advance to the next year.

Of course, one lifetime isn’t very informative. So it repeats the experiment 10,000 times, creating a whole town of clones.

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Running this simulation for someone of your own demographic characteristics may prove interesting; comparing your risks to those who have different traits, though, is likely to prove even more illuminating. Different segments of the American population face radically different challenges as they move through life.

There are crucial implications to that simple fact. Every day, policymakers steer resources toward addressing some of these risks, and as a result, away from others. At the same time, Americans who face different risks may back political candidates who address their needs, or donate their time and money to causes that seek to combat the diseases most likely to strike them or those around them. Resources may not end up where they do the most good; often, they wind up devoted to the risks facing segments of the population best-positioned to secure them. Striking the proper balance among these competing demands is among the hardest puzzles facing politicians, policymakers, and the general public.

This isn’t a perfect simulation, as it uses current data across many years of life to generate a new lifespan. For instance, people born today are probably far less likely to die of lung cancer than current 80-year-olds, thanks to the decline in smoking. It uses data on Americans, who face different risks than other populations. And because of CDC data restrictions, the simulation only runs until the virtual person’s 100th birthday.

Even so, the lesson is clear: Lives are defined by the little risks we take, not the big ones. And to paraphrase T.S. Eliot, we’re far more likely to die not with a bang, but a whimper.

Complete Article HERE!

The Smell of Loss

By

The Smell of Loss

THE first time it happens is a dark winter’s afternoon, not quite a year after her death. I’m at my desk working, and there it suddenly is: sharp, glassy-green, with that faint, musky undertone that catches at the back of your throat.

I recognize it instantly: the scent that hung in our hall every time she came to supper. The perfume that clung to her coat, her scarves, detectable sometimes for hours on my babies’ hair after she’d been carrying and kissing them.

That first time, it’s a shock. Her perfume is something I’ve long forgotten (in her final months, mostly bedridden, she was beyond all that). But here it is — absolute and definite and quite overpowering. It lasts for three, maybe four minutes, long enough for me to get up and start searching the room for its source (my daughter, Chloë, has a few of her cardigans — did she leave one in here?).

Then, just as suddenly, it’s gone.

When I tell Chloë (who says that the cardigans have long since lost their scent), she rolls her eyes. “Oh my God, now you’re smelling dead people!” We laugh — and I soon forget about it.

Helen was my mother-in-law. She lived a happy, active life, but in her mid-80s her health and brain began to fail. After a couple of years of hip replacements and minor strokes, she died one warm April evening with her family all around her. As deaths go, it was probably a good one.

But in the weeks and months that followed, I was surprised at how often I’d find myself poleaxed by grief at the sheer fact of her absence.

Helen was in her 60s when I met her, a recent widow. A willowy blonde in an elegant camel-hair coat, she was a dead ringer for Lauren Bacall (“What nonsense!” she’d protest if someone said so, her eyes lighting up all the same). She was shy, but always well read, groomed and immaculate in her habits (and a tad judgmental about those who weren’t).

On our first meeting, waiting while her son — my new boyfriend — parked the car, she asked if I agreed that his recent attempt at a beard made him look like a used-car salesman. I burst out laughing and that comment set the tone for our whole relationship.

Helen was my ally, my champion (frequently even against her son, Jonathan). It’s hard not to love someone who’s always on your side; I’d never had that kind of approval from anyone.

When our babies came along, she threw herself into grandmotherhood. Her constant availability — to help out, to comfort, to babysit — was one of her most loving gifts.

The second time it happens, some weeks later, I am in the cellar, pulling wet clothes out of the washing machine. And there it suddenly is, filling the air around me. “Helen?” I say — and then blush.

I ask Jonathan if he knows the name of the perfume she wore. He has no idea. I ask his sister. “Something by Hermès?” she offers. At a department store perfume counter, I sniff a confusing number of bottles. Only one stands out — a touch of that glassy greenness: Calèche (and it is Hermès). But I can’t be certain.

At supper, a month later, all five of us around the table, the Bolognese being served, I ask, “Can anyone else smell that?”

“Smell what?”

“Perfume. Just like the one Granny used to wear.”

I watch their blank faces.

“You can’t smell it? Really? None of you can smell that scent?”

Several months pass before the next episodes: two in one week, both in my study. The second time, the perfume lingers for so long, perhaps 15 minutes, that I’m determined to get to the bottom of the phenomenon.

I pace the room, inspecting shelves, drawers, the sofa — there has to be an explanation! How can an ostensibly sane person repeatedly experience such a definite smell and fail to locate the source?

But I do fail. And then, just like every other time, it’s gone.

A friend, Mike, comes to lunch and I end up telling him the whole crazy story. I wait for him to laugh; instead he gives me a beady look. “Well, it’s a ghost, isn’t it?”

Jonathan makes a noise of exasperation and Mike turns to him. “What on earth else is it going to be?”

It’s true that I am interested in ghosts — they stalk much of the fiction I write. It’s also true that I did once, on a winter’s night long ago, see a form that startled me from sleep and which I have never been able to explain. But do I really believe in ghosts? I don’t think so.

What I do believe in — am perpetually fascinated by — is the gulf between what humans are capable of imagining and what may actually be there.

I tell Mike that even if I did believe in ghosts, it would be extremely uncharacteristic of Helen to haunt me like this. It’s not so much that she was resolutely rationalist (though she was), more that she’d be embarrassed to come back in this demonstrative fashion.

Later, I Google “smelling perfume of dead person” and find an excerpt from a book about “after-death communication” by an American academic and self-styled skeptic named Sylvia Hart Wright. She claims there is convincing research on the subject and cites the example of her late husband who, after his death, appeared to make frequent contact by turning electrical appliances on and off.

I email her to ask if she can account for my experiences. She writes back to say that my episodes are “perfect examples of a common phenomenon.”

“My gut feeling,” her email concludes, “is that when you smell your mother-in-law’s perfume, her spirit is visiting you in some fashion, trying to communicate to you her continuing closeness and support.”

A nice idea. I wish I could say that my own gut feeling supported it.

Next, I email Jay A. Gottfried, a neuroscientist who runs the Gottfried Laboratory at Northwestern University, which investigates the links between brain activity and sensory perception.

Professor Gottfried tells me that what I describe is known in his business as “phantosmia” or “phantom smells.” The sense of smell, he says, is our most ancient, primal sense and has “intimate and direct control over emotional and behavioral states.”

“This is especially true for personal, meaningful memories that tend to get stamped into our brains very robustly,” he explains. “Thus it is possible that a seemingly random trigger or thought — perhaps even outside your conscious awareness — has triggered some aspect of your mother-in-law memory.” In some ways, he says, “it is true that your mother-in-law is ‘visiting’ you, to the extent that your memory of her is strong, and that the vividness of her perfume makes it seem like she is there.”

I read that last sentence several times over. It seems reasonable. But could it explain so many episodes? And what about the persistence of the perfume, lingering often for minutes at a time: Can a triggered memory — a random sensory “thread,” in his words, snagged from the “patchwork” of the unconscious — do that?

I put all of this to him in a carefully concise email, and then add — because I can’t resist it — “I would just love to know: Have you ever, as a scientist, experienced something you feel you can’t explain?”

He doesn’t reply.

I decide to try another branch of science.

FLORIAN Ruths is a consultant psychiatrist at London’s Maudsley Hospital. I know Dr. Ruths from attending a course he taught a few years ago. I am slightly embarrassed to approach him with such an eccentric-seeming inquiry, but Dr. Ruths’s reply is affable and serious.

“A sensory experience without an appropriate stimulus,” he explains, “is called a hallucination,” and these are “not unusual in grief reactions.” In less clinical terms, he tells me I “have been given a wonderful sensory memory cue that brings back your beloved mother-in-law in such an immediate and emotionally charged manner.” Maybe, he writes, “it is a very wise trick of your brain of maintaining such a fond memory of her, and an emotional connection to her.”

The idea of a “wise trick” of the brain is a seductive one. But the phrase “grief reactions” bothers me. I did grieve when Helen died, very much so, and for several months. But after five years?

If this “grief” now takes any shape, it’s a simple longing to see her again. How wonderful it would be to call her, hear her pick up the phone, shyly pleased, and to go over and sit on her terrace, drink a glass of sauvignon blanc and watch the boats slide past on the Thames, as we used to.

I recognize this for what it is: a natural nostalgia for the days when our children were small, when life seemed so uncomplicated, when so much still lay ahead.

But if this is just about my own, unrequited longing, then — Mike might ask — who exactly is the ghost? Could this be a case of the living haunting the dead, rather than vice versa?

I’m not a churchgoer or even strictly a believer, but realizing that I’ve allowed no possibility of a religious context for these experiences, I email my friend Giles Goddard, who is an Anglican vicar. He tells me he’s certain that “strange and inexplicable things” are regularly “perceived by the subconscious often with no obvious cause.” Like Dr. Ruths, he suggests it’s a normal part of grieving. He sends me a verse by Gerard Manley Hopkins:

All things counter, original, spare, strange;
Whatever is fickle, freckled (who knows how?)
With swift, slow; sweet, sour; adazzle, dim;
He fathers-forth whose beauty is past change:
Praise him.

Original, spare and strange, I like that. But I still find it hard to believe that this is a response to grief. Why would it suddenly come back at me like this?

“Maybe grief is the wrong word, then,” he counters. “Maybe loss?”

Loss. Isn’t that the hardest lesson of human existence? The finality of losing someone you love, of having them fall right out of your life forever: the cold and terrible permanence of it.

Intellectually, I comprehend that Helen is dead. But even after all this time, I’m still not sure I believe it.

It’s been weeks since I smelled the scent. Whenever I haven’t smelled it for a while, I begin to think it won’t come again. And I don’t know what I feel about that.

The other day, killing time on a rainy autumn afternoon on Oxford Street, I walked into a department store and, on a whim, went to the Estée Lauder counter. The sales assistant asked if I’d like to try the new perfume. I smiled and shook my head, picking up one bottle after another — with names like Beautiful, Youth-Dew, Pleasures — and sniffing at them.

I sprayed White Linen onto a card. It wasn’t far off: clean and citrusy.

“Is it a gift for someone?” the girl asked.

I hesitated. “I’m trying to find the one my mother-in-law wears.”

Sensing a sale, her eyes brightened.

“You don’t remember?”

“No.”

“You can’t ask her?”

“Not really.”

“It’s a surprise, then?”

I smiled. “Kind of.”

“Do you think that’s the one?”

“I don’t know,” I said. “It’s possible.”

Complete Article HERE!

The Four Stages of Life

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Life is a bitch. Then you die. So while staring at my navel the other day, I decided that that bitch happens in four stages. Here they are.

Stage One: Mimicry

We are born helpless. We can’t walk, can’t talk, can’t feed ourselves, can’t even do our own damn taxes.

As children, the way we’re wired to learn is by watching and mimicking others. First we learn to do physical skills like walk and talk. Then we develop social skills by watching and mimicking our peers around us. Then, finally, in late childhood, we learn to adapt to our culture by observing the rules and norms around us and trying to behave in such a way that is generally considered acceptable by society.

The goal of Stage One is to teach us how to function within society so that we can be autonomous, self-sufficient adults. The idea is that the adults in the community around us help us to reach this point through supporting our ability to make decisions and take action ourselves.

But some adults and community members around us suck.1 They punish us for our independence. They don’t support our decisions. And therefore we don’t develop autonomy. We get stuck in Stage One, endlessly mimicking those around us, endlessly attempting to please all so that we might not be judged.2

In a “normal” healthy individual, Stage One will last until late adolescence and early adulthood.3 For some people, it may last further into adulthood. A select few wake up one day at age 45 realizing they’ve never actually lived for themselves and wonder where the hell the years went.

This is Stage One. The mimicry. The constant search for approval and validation. The absence of independent thought and personal values.

We must be aware of the standards and expectations of those around us. But we must also become strong enough to act in spite of those standards and expectations when we feel it is necessary. We must develop the ability to act by ourselves and for ourselves.

Stage Two: Self-Discovery

In Stage One, we learn to fit in with the people and culture around us. Stage Two is about learning what makes us different from the people and culture around us. Stage Two requires us to begin making decisions for ourselves, to test ourselves, and to understand ourselves and what makes us unique.

Stage Two involves a lot of trial-and-error and experimentation. We experiment with living in new places, hanging out with new people, imbibing new substances, and playing with new people’s orifices.

In my Stage Two, I ran off and visited fifty-something countries. My brother’s Stage Two was diving headfirst into the political system in Washington DC. Everyone’s Stage Two is slightly different because every one of us is slightly different.

Stage Two is a process of self-discovery. We try things. Some of them go well. Some of them don’t. The goal is to stick with the ones that go well and move on.

Stage Two is a process of self-discovery. We try things. Some of them go well. Some of them don’t. The goal is to stick with the ones that go well and move on.

Man sitting on cliff looking out over clouds

Stage Two lasts until we begin to run up against our own limitations. This doesn’t sit well with many people. But despite what Oprah and Deepak Chopra may tell you, discovering your own limitations is a good and healthy thing.

You’re just going to be bad at some things, no matter how hard you try. And you need to know what they are. I am not genetically inclined to ever excel at anything athletic whatsoever. It sucked for me to learn that, but I did. I’m also about as capable of feeding myself as an infant drooling applesauce all over the floor. That was important to find out as well. We all must learn what we suck at. And the earlier in our life that we learn it, the better.

So we’re just bad at some things. Then there are other things that are great for a while, but begin to have diminishing returns after a few years. Traveling the world is one example. Sexing a ton of people is another. Drinking on a Tuesday night is a third. There are many more. Trust me.

Your limitations are important because you must eventually come to the realization that your time on this planet is limited and you should therefore spend it on things that matter most. That means realizing that just because you can do something, doesn’t mean you should do it. That means realizing that just because you like certain people doesn’t mean you should be with them. That means realizing that there are opportunity costs to everything and that you can’t have it all.

There are some people who never allow themselves to feel limitations — either because they refuse to admit their failures, or because they delude themselves into believing that their limitations don’t exist. These people get stuck in Stage Two.

These are the “serial entrepreneurs” who are 38 and living with mom and still haven’t made any money after 15 years of trying. These are the “aspiring actors” who are still waiting tables and haven’t done an audition in two years. These are the people who can’t settle into a long-term relationship because they always have a gnawing feeling that there’s someone better around the corner. These are the people who brush all of their failings aside as “releasing” negativity into the universe or “purging” their baggage from their lives.

At some point we all must admit the inevitable: life is short, not all of our dreams can come true, so we should carefully pick and choose what we have the best shot at and commit to it.

But people stuck in Stage Two spend most of their time convincing themselves of the opposite. That they are limitless. That they can overcome all. That their life is that of non-stop growth and ascendance in the world, while everyone else can clearly see that they are merely running in place.

In healthy individuals, Stage Two begins in mid- to late-adolescence and lasts into a person’s mid-20s to mid-30s.4 People who stay in Stage Two beyond that are popularly referred to as those with “Peter Pan Syndrome” — the eternal adolescents, always discovering themselves, but finding nothing.

Stage Three: Commitment

Once you’ve pushed your own boundaries and either found your limitations (i.e., athletics, the culinary arts) or found the diminishing returns of certain activities (i.e., partying, video games, masturbation) then you are left with what’s both a) actually important to you, and b) what you’re not terrible at. Now it’s time to make your dent in the world.

Stage Three is the great consolidation of one’s life. Out go the friends who are draining you and holding you back. Out go the activities and hobbies that are a mindless waste of time. Out go the old dreams that are clearly not coming true anytime soon.

Then you double down on what you’re best at and what is best to you. You double down on the most important relationships in your life. You double down on a single mission in life, whether that’s to work on the world’s energy crisis or to be a bitching digital artist or to become an expert in brains or have a bunch of snotty, drooling children. Whatever it is, Stage Three is when you get it done.

Tattooed man with baby

Stage Three is all about maximizing your own potential in this life. It’s all about building your legacy. What will you leave behind when you’re gone? What will people remember you by? Whether that’s a breakthrough study or an amazing new product or an adoring family, Stage Three is about leaving the world a little bit different than the way you found it.

Stage Three ends when a combination of two things happen: 1) you feel as though there’s not much else you are able to accomplish, and 2) you get old and tired and find that you would rather sip martinis and do crossword puzzles all day.

In “normal” individuals, Stage Three generally lasts from around 30-ish-years-old until one reaches retirement age.

People who get lodged in Stage Three often do so because they don’t know how to let go of their ambition and constant desire for more. This inability to let go of the power and influence they crave counteracts the natural calming effects of time and they will often remain driven and hungry well into their 70s and 80s.5

Stage Four: Legacy

People arrive into Stage Four having spent somewhere around half a century investing themselves in what they believed was meaningful and important. They did great things, worked hard, earned everything they have, maybe started a family or a charity or a political or cultural revolution or two, and now they’re done. They’ve reached the age where their energy and circumstances no longer allow them to pursue their purpose any further.

The goal of Stage Four then becomes not to create a legacy as much as simply making sure that legacy lasts beyond one’s death.

This could be something as simple as supporting and advising their (now grown) children and living vicariously through them. It could mean passing on their projects and work to a protégé or apprentice. It could also mean becoming more politically active to maintain their values in a society that they no longer recognize.

Old Woman Praying

Stage Four is important psychologically because it makes the ever-growing reality of one’s own mortality more bearable. As humans, we have a deep need to feel as though our lives mean something. This meaning we constantly search for is literally our only psychological defense against the incomprehensibility of this life and the inevitability of our own death.6 To lose that meaning, or to watch it slip away, or to slowly feel as though the world has left you behind, is to stare oblivion in the face and let it consume you willingly.

What’s the Point?

Developing through each subsequent stage of life grants us greater control over our happiness and well-being.7

In Stage One, a person is wholly dependent on other people’s actions and approval to be happy. This is a horrible strategy because other people are unpredictable and unreliable.

In Stage Two, one becomes reliant on oneself, but they’re still reliant on external success to be happy — making money, accolades, victory, conquests, etc. These are more controllable than other people, but they are still mostly unpredictable in the long-run.

Stage Three relies on a handful of relationships and endeavors that proved themselves resilient and worthwhile through Stage Two. These are more reliable. And finally, Stage Four requires we only hold on to what we’ve already accomplished as long as possible.

At each subsequent stage, happiness becomes based more on internal, controllable values and less on the externalities of the ever-changing outside world.

Inter-Stage Conflict

Later stages don’t replace previous stages. They transcend them. Stage Two people still care about social approval. They just care about something more than social approval. Stage 3

people still care about testing their limits. They just care more about the commitments they’ve made.

Each stage represents a reshuffling of one’s life priorities. It’s for this reason that when one transitions from one stage to another, one will often experience a fallout in one’s friendships and relationships. If you were Stage Two and all of your friends were Stage Two, and suddenly you settle down, commit and get to work on Stage Three, yet your friends are still Stage Two, there will be a fundamental disconnect between your values and theirs that will be difficult to overcome.

Generally speaking, people project their own stage onto everyone else around them. People at Stage One will judge others by their ability to achieve social approval. People at Stage Two will judge others by their ability to push their own boundaries and try new things. People at Stage Three will judge others based on their commitments and what they’re able to achieve. People at Stage Four judge others based on what they stand for and what they’ve chosen to live for.

The Value of Trauma

Self-development is often portrayed as a rosy, flowery progression from dumbass to enlightenment that involves a lot of joy, prancing in fields of daisies, and high-fiving two thousand people at a seminar you paid way too much to be at.

Street graffiti showing abstract human portrait

But the truth is that transitions between the life stages are usually triggered by trauma or an extreme negative event in one’s life. A near-death experience. A divorce. A failed friendship or a death of a loved one.

Trauma causes us to step back and re-evaluate our deepest motivations and decisions. It allows us to reflect on whether our strategies to pursue happiness are actually working well or not.

What Gets Us Stuck

The same thing gets us stuck at every stage: a sense of personal inadequacy.

People get stuck at Stage One because they always feel as though they are somehow flawed and different from others, so they put all of their effort into conforming into what those around them would like to see. No matter how much they do, they feel as though it is never enough.

Stage Two people get stuck because they feel as though they should always be doing more, doing something better, doing something new and exciting, improving at something. But no matter how much they do, they feel as though it is never enough.

Stage Three people get stuck because they feel as though they have not generated enough meaningful influence in the world, that they make a greater impact in the specific areas that they have committed themselves to. But no matter how much they do, they feel as though it is never enough.8

One could even argue that Stage Four people feel stuck because they feel insecure that their legacy will not last or make any significant impact on the future generations. They cling to it and hold onto it and promote it with every last gasping breath. But they never feel as though it is enough.

The solution at each stage is then backwards. To move beyond Stage One, you must accept that you will never be enough for everybody all the time, and therefore you must make decisions for yourself.

To move beyond Stage Two, you must accept that you will never be capable of accomplishing everything you can dream and desire, and therefore you must zero in on what matters most and commit to it.

To move beyond Stage Three, you must realize that time and energy are limited, and therefore you must refocus your attention to helping others take over the meaningful projects you began.

To move beyond Stage Four, you must realize that change is inevitable, and that the influence of one person, no matter how great, no matter how powerful, no matter how meaningful, will eventually dissipate too.

And life will go on.

Footnotes

  1. Often this occurs because the adults/community themselves are still stuck in Stage One.
  2. Some people who get stuck in Stage One get stuck because they come to believe that they will never be able to fit in. These people usually succumb to some form of distraction, depression or addiction.
  3. I put normal in quotes because, really, what the fuck is normal?
  4. Stages can overlap to a certain extent. Transitioning between them is never black/white. It happens gradually. And often with some emotional stress and major lifestyle changes.
  5. This applies to the rare individuals who are talented and capable enough to still remain highly influential and relevant into their 70s and 80s as well. Stage Three doesn’t end until the desire for some peace and quiet outweighs one’s ability to affect change in the world. Some people die without ever leaving Stage Three.
  6. For more on this, see The Denial of Death by Ernest Becker.
  7. Research shows that generally people become happier and more satisfied as their lives go on.
  8. One way to think about it is that people who are stuck at Stage Two always feel as though they need more breadth of experience, whereas Stage Three people get stuck because they always feel as though they need more depth.

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