It’s a cold Saturday morning in Melbourne and I am a doctor at work in a palliative care unit. I have just reviewed one of my patients, whose body is beginning to reveal some of the tell-tale signs of dying.
His son stands over him and sadly remarks that “this is a bad time to die”.
With strict visiting restrictions firmly in place across Melbourne, there is a very real chance that his father will die alone and he knows it. This is the new normal.
In a state of disaster, there are a set of rules and visiting restrictions for families and friends of those dying in a hospital setting. These restrictions vary slightly between health services, but the message is the same: as few visitors as possible, for as short a time period as is reasonable.
For months now, hospital staff (myself included) have been chanting the mantra of seemingly arbitrary visiting windows, maximum numbers of visitors per patient and numbers of visitors permitted at the bedside.
In recent times, I have found myself asking questions such as “do all six of your siblings need to visit?” or “could your grandchildren say their goodbyes via FaceTime?”. These conversations are among the hardest I have had as a doctor.
Many find these new rules unacceptable, and with good reason. Few people want to die alone, and even fewer want their loved one to be alone in the final weeks, days and hours of their life.
However, these are not normal times, and a balance must be struck between compassion and safety. Across the world, and now in Victoria, we know that many people with COVID-19 are dying alone; but so are those without COVID-19. Both are tragic realities.
Under normal circumstances, achieving “a good death” is laden with obstacles, let alone in a pandemic. An inherent challenge is that a good death is an individualised experience, reflecting the diversity of the human person.
There are some commonalities across what constitutes a good death, and the company of friends and family features almost universally.
A current patient comes to mind — a woman in her 70s dying of lung cancer — who tells me almost daily that her breathing is bad but the feeling of loneliness even worse. She would like to see her grandchildren, but no children are allowed in the hospital.
Her brother visits, but the allocated two-hour visiting window is not long enough to fill the void created when faced with one’s own mortality. And so on. Her story is not unique.
Dying in a pandemic has brought with it new and more challenging obstacles, ones that make us question what it means to be human. Death is normal, but dying alone is not. So, frankly, when I hear my patients and their relatives say that it is a bad time to die, I can’t help but agree.
Ultimately, how we live and how we die tells us about society as a whole. Today, people die alone to protect society and this at least may be a small source of solace. Their strength and determination to push forward and adapt to this strange new world is a testament to the human spirit.
I hope, though, that those dying in this COVID-19 world know that their sacrifice has not gone unnoticed. Every day, their struggles are seen and felt. Many have had to forgo the so-called good death, and that is the undeniable truth.
Andrea Aycock can only sometimes look at the photos of her hands clasped with her mother’s just before she died in May. But she’ll always cherish the helping hand she got from Anna Adams, an end-of-life doula in San Antonio who preserved that personal moment and so many more for Aycock in her mother’s dying days.
“Anna came and took care of her,” said Aycock, a call center operator in San Antonio. “(She) just mainly comforted me.”
Just as birth doulas help expectant parents bring new life into the world, end-of-life doulas help the dying cope with their next journey. They help the dying and their survivors face death with empowerment and affirmation instead of fear and anxiety.
Also known as death doulas, these trained professionals provide the terminally ill and their families physical and emotional support before, during and after death, the San Antonio Express-News reported. These are nonmedical services that often include relaxation exercises, funeral planning, educating the family on their loved one’s condition and just simple companionship.
Adams sees death awareness becoming more commonplace in the United States in the way that Día de los Muertos (Day of the Dead) celebrations have grown more mainstream and that there are more calls for services of end-of-life doulas.
“Cultures like the Mexican culture that have these beautiful traditions of staying in connection with that (dying) process are so admirable and so beautiful. Doulas want to make sure that is available to all people,” said Shelby Kirillin, an end-of-life doula in Richmond, Va., and program development manager for the International End of Life Doula Association (INELDA) in Jersey City, N.J.
Kirillin sees the rising awareness of death doulas as part of what she calls a “death positive movement,” where more people are getting back to supporting their dying loved ones at home and engaging with their death more up close and personal, much as their ancestors did.
“In the last 100-plus years in our Western culture, that has been taken away from us,” Kirillin said. “How to be with someone who was dying, how to touch them. That was something that we knew how to do.”
INELDA is one of just a handful of death doula organizations in the nation and was launched just five years ago. Co-founder Henry Fersko-Weiss created the first end-of-life doula program in the United States at a New York City hospice in 2003.
Kirillin estimates INELDA has around 40 certified death doulas across the country, yet has trained around 3,000 individuals in death doula care. Many just sign up to learn more about facing death and don’t pursue death doula work, she said, while others branch off to do their own training.
Most death doula services come in three phases.
The first is planning and preparation, which involves getting a terminal patient’s affairs in order and asking some tough questions that call for honest answers. Where does that person want to die? Who do they want present for those final moments? What so they absolutely need to say or do before they’re gone?
Kirillin said that first phase often addresses the dying individual’s regrets and unfinished business, as well as any advance directives, wills, etc. Often referred to as “legacy work,” such planning makes it easier for family to understand and respect the dying person’s wishes.
Fran Morgan is in that early stage with her dying mother Rosalee, who receives hospice care at the private residence of a family friend.
“With Anna in the picture, she will be advocating for all of the things that need to happen,” said Morgan, a retired telecommunications company manager in San Antonio. “It will release me from those responsibilities, and I can just be with my mom and cherish those final moments.”
That second phase is called the vigil, usually the last four or five days of the dying person’s life where end-of-life doulas and family members spend more time at their bedside.
“I call them my angel vigils,” Adams said.
During her doula vigils, Adams, 38, often creates a soothing space for the dying with soft music and dim lighting. Sometimes she’ll add a favorite scent with aromatherapy. Most times, she just gently massages her client’s arms and holds their hands.
And in those final moments as they take their last breaths, Adams comforts them with what they most want to hear, be it Bible verses, soothing music or just someone to say it’s going to be OK.
The final phase of a death doula’s work addresses survivors’ grief. Kirillin said that involves circling back with the family a few weeks after their loved one’s death to check on their emotional well-being.
Kirillin stressed that end-of-life doulas do console families, but are not licensed grief counselors and will refer families to such resources if necessary.
When it came to caring for Aycock’s mother, Adams mostly helped with her bedside care and keeping her visiting nurses on task. Adams also explained to Aycock any of her mother’s diagnoses she didn’t understand.
Then there was that time Adams took those hand photos of Aycock and her mother. Difficult as it is for Aycock to look at those photos, much less share them, she still holds them close.
She holds Adams’s work even closer.
“It is the best help that you can get,” Aycock said. “They provide comfort not only for your loved one that is going through the transition, but for you.”
Morgan expects to experience more of that care from Adams. “I’m looking forward to the relationship that we’re going to have,” said Morgan, who started working with Adams around three weeks ago. “For now my initial experience (and) impression is she certainly has the heart for what she’s doing.”
Adams’s first experience comforting the dying came when she was 16. Fresh from certification as a nursing aid, Adams tended to a best friend’s cousin for several months at her home with bathing and conversation. That care continued when that cousin transferred to hospice care and well up to her death.
“So we just had a bonding moment. I gave her that sacred zone,” Adams said. “That kind of piqued my interest.”
Adams went on to pursue a career in hospice, then for the last four years worked as an EMS manager and dispatcher for a private company. But something pushed her back into working with the dying.
“I told my family, ‘God wants me to do this. God is keeping me in line with this,’ ” Adams said.
At the start of this year, Adams got her end-of-life doula certification. Then over the summer, she partnered with fellow certified doula Sonja Koenig to launch TX Doula Movement, an online training and certification course for death doulas, senior care doulas and doula consultants.
Adams knows of just a handful of death doulas in San Antonio right now, but she expects that number to double later this year when around five of her TX Doula Movement students complete their certification. Adams plans to launch her own doula training service next year.
Adams said the coronavirus has not deterred her from her work, save for having to incorporate more video consultations with families and masks and frequent hand-washings during visits. She has yet to provide end-of-life doula services to someone with COVID-19, but one of the hospice companies she works with takes in COVID-19 patients.
“I don’t have a problem working with COVID patients,” Adams said.
Adams said most hospitals still don’t work with death doulas, but hospice services are slowly warming up to them as adjuncts to their own care.
“It is relatively new, but we’re seeing it more,” said Rachel Hammon, executive director of the Texas Association for Home Care & Hospice in Austin.
Holistic Hospice Care is one of two hospice centers in San Antonio that works with Adams. Administrator Erica Sandoval said Adams has been a welcome bridge between families and clinical teams.
“She can get on (everyone’s) level,” Sandoval said. “And she’s very calm and very patient. And she just wins their trust and they feel very comfortable with her.”
Like Adams, Sandoval, too, sees parallels between death doulas and Día de los Muertos, such as the memory books the doulas make for their clients and the Day of the Dead tribute altars families make for their lost loved ones.
“I definitely think that there’s a good association to that because they are (both about) wanting you to cherish their memories and enjoy the last moments and everything that you can remember of the individual,” Sandoval said.
A deadly worldwide pandemic has helped to expose pitfalls in a broken health care system, drawing increased awareness and attention around the delivery of serious illness and end-of-life care, according to hospice and palliative care experts speaking at End Well’s Take 10 virtual conference.
The virus has claimed more than 1.6 million lives globally since its onset, according to a recent World Health Organization report which stated that the United States continues to bear the brunt of the pandemic’s effects, accounting for 86% of new deaths worldwide in the last week alone. According to a number of health care stakeholders, the government and the health care system itself hasn’t sufficiently adapted to meet patients’ needs during the crisis.
“We’ve been putting our elderly and disabled in solitary confinement for months, and that was understandable during the first few weeks where we didn’t understand anything about the virus or how to keep people safe. We saw entire units where elderly people and disabled people died, but now we know how to keep people safe,” said Atul Gawande, M.D., a surgeon, writer and public health leader, at the End Well event. “I myself have family with serious health issues and they need long term care, but we’re told we have to sign away the possibility that we’d ever see them again, that we’d ever hug them again and that’s just unacceptable. They won’t provide the [personal protective equipment (PPE)] and the training to make such things as possible, and that is outrageous.”
Gawande is founder and chair of Ariadne Labs, a joint center for health systems innovation, and of Lifebox, a nonprofit organization aimed at making surgery safer globally. He is also co-founder of the Massachusetts Serious Illness Care Coalition and serves as board chairman of Haven Healthcare. Gawande is among the providers calling for fundamental changes to the health care system.
A key component of that change would be to promote end-of-life and goals-of-care conversations among patients and families. Gawande cited surveys conducted by the Massachusetts Serious Illness Care Coalition, an organization he founded, which indicated that only about 50% of people who have a serious health condition have discussed their wishes with their loved ones. Only 25% have had such conversations with their clinicians.
“When they have those conversations they’re not at all confident that those wishes will be followed. That should be an outrage,” Gawande said.
COVID-19 has disrupted the health care system as providers faced lack of protective resources, staffing issues and revenue losses. Hospices have been pummeled by the disease’s spread, taking hits to operations and finances and facing difficulty accessing facility- and community-based patients.
Some of the roadblocks to quality end-of-life and serious illness care often stem from social determinants of health, lack of awareness around hospice care, and racial divides in accessible care. While these issues are gradually coming to the forefront of discussions in the end-of-life space among clinical, business and policy leaders, stakeholders are renewing calls to accelerate a reorientation of the health care system towards patient-centered, goal-concordant care.
“We all deserve a system that we’re not just tolerating,” said Mark Ganz, president and CEO of Cambia Health Solutions at the End Well Take 10 event. “Let’s resolve as we accelerate out of this curve called 2020 that we take some of the difficult things we’ve seen and talked about and we turn it into a thing of light. We have the opportunity to invent the systems that allow us to truly see the patients and their loved ones in a new way. We need to act and act now.”
Conceived as an end-of-life option for terminally ill patients, hospices provide palliative care, medications, nursing services and counseling for those diagnosed with six months or less to live.
The number of U.S. hospices has roughly doubled in the last 20 years, as more for-profit providers vie for a share of $19.2 billion a year in Medicare spending that covers hospice care. More than 1.5 million Medicare beneficiaries now receive care from some 5,000 hospices, nearly a quarter of them in California.
While hospice has been a godsend for millions of dying Americans and their families, a Times investigation found that intense competition for new patients has spurred billing fraud and other illegal practices, including falsified diagnoses and kickbacks to unscrupulous doctors and recruiters who target prospective patients at retirement homes and other venues.
The Times also found hundreds of instances in which California hospice patients were harmed, neglected or put at serious risk, their mistreatment sometimes exacerbated by serious gaps in government oversight.
What are the benefits of hospice care?
Hospice is intended to provide comforting, compassionate care and a range of support services for terminally ill patients and their families. In addition to nursing and medical care that includes pain management, prescription drugs and supplies, patients receive spiritual and emotional support, help with personal hygiene and respite care for family caregivers.
Most hospice patients receive care in their homes, including assisted-living settings and nursing facilities.
How do I choose a hospice?
There’s no set formula for choosing a hospice, although experts suggest discussing options with your personal physician and seeking recommendations from friends and relatives whose loved ones have had good experiences.
You should also interview any prospective hospice, asking questions about its licensing, which is required by the California Department of Public Health; whether it is certified by Medicare; when it was last inspected and whether violations were found; the range of available services; the makeup of the hospice care team and the roles of its doctors, nurses and others; and the role the hospice expects family members to play in a patient’s care plan.
Several industry and advocacy groups offer online guidance, including the National Hospice and Palliative Care Organization, which provides a worksheet and a list of questions.
How do I know if a hospice is reliable?
There is no one place where consumers can go to make a comprehensive comparison of local hospices — a gap that patient rights advocates have long criticized.
A variety of online sources provide information about hospice care, but each has limitations. Medicare’s hospice comparison site allows consumers to search for providers by ZIP Code or name, but has scant information about quality-of-care issues and inspections.
The California Department of Public Health has a searchable tool called Cal Health Find Database, which provides users with inspection reports when serious violations are uncovered back to 2017. It also allows consumers to compare quality metrics of up to three hospices at a time, but it doesn’t provide a rating system for providers. The results of inspections by accrediting agencies are not included on the site — a significant problem for consumers in California, where more than 80% of hospices contract with accrediting agencies rather than the state to conduct certification inspections once every three years.
Another resource that is more difficult to navigate is an interactive site maintained by the Centers for Medicare and Medicaid Services. The site includes copies of complaint investigations and a look-up function that allows users to compare the number of serious violations at hospices in California and other states.
What red flags should I look for?
Be on the lookout for any hospices that have been cited in recent years with serious violations. In the language used by Medicare, these include “condition-level” deficiencies or “immediate jeopardy” situations, which are considered the most severe. Also, hospices can be cited for failing to certify that patients are terminally ill, which is an indication of possible fraud.
If you have the name of a hospice administrator, which can be found on the state public health department’s website, you can find out if that person has been excluded from receiving federal healthcare payments on a site run by the U.S. Department of Health and Human Services’ Office of Inspector General.
If I’m not happy about my hospice, where do I complain?
You may also file a complaint about Medicare providers directly with the federal agency or with the California Senior Medicare Patrol, a federally funded statewide hotline to help Medicare beneficiaries prevent, detect and report fraud.
Police officers in Philadelphia gave the Friday after Thanksgiving its dark name in 1966 as zealous shoppers mobbed streets and sidewalks. But it quickly came to mean a day when business owners could expect their accounts to be in the black, as opposed to in the red.
If Black Friday celebrates American consumers spending in order to live well, we could also adopt it as a day to consider what it means to die well. As the ancient Greek philosopher Epicurus ostensibly put it, “The art of living well and the art of dying well are one.”
As a physician, I’ve met countless patients who were ill-prepared for death. The “trajectories of decline” described by geriatrician Joann Lynn make it easy not to prepare. Some people live for years with chronic illnesses but feel no need to ponder their mortality. Hospital tune-ups enable them to live seemingly forever. Others enjoy relative health until being caught off guard by a deadly illness. Still others live good long lives only to succumb to dementia, which robs them of their ability to plan.
We are habituated to living with hope for intervention or cure. To accept the impossibility of treatment is to admit defeat, which most people are loathe to do.
How and where we die underscores how unprepared we are. Most Americans have never had end-of-life conversations or formalized their wishes for medical treatments at the end of life. Despite existing in some form since the 1970s, only 37% of Americans report having formalized their wishes through an advance directive. What’s more, most Americans say they want to die at home, yet roughly 60 percent die in hospitals, nursing homes, and hospices. There’s no question that institutional care can be a lifesaver for families not equipped to care for their loved ones at home.
If we are to realize the ideal of death at home surrounded by family, we’ve got work to do. Making a home death possible requires difficult decisions — in end-of-life conversations with family members and health care professionals — about which treatments and hospitalizations to forgo, whether homes can accommodate hospital beds, and who will do the hard work of caring for the dying.
That’s where taking a new approach to Black Friday comes in. On that day, families could pivot from giving thanks to giving thought to ending well. A simple prompt for starting end-of-life conversations might be, “Mom, Dad, if you become so sick that you can’t speak for yourself, who would you want to make medical decisions on your behalf?” And the natural follow-up would be, “Help me know how to advocate for you. Let’s talk about the benefits and burdens of particular medical interventions.” Conversation can then move to broader community-based issues such as funeral, burial, and religious or existential concerns.
It’s not the easiest conversation to have, but the payoff can be worth the effort. And since Black Friday comes every year, it’s a discussion that can build on itself over time.
A reimagined Black Friday could help Americans formalize their wishes for care at the end of life. Advance care planning documents allow people to identify health care proxies to make medical decisions if they lose decision-making capacity. Living wills specify an individual’s choice to have — or not have — cardiac resuscitation, mechanical ventilation, and other invasive procedures.
To be fair, there are good reasons why some people don’t want to prepare for death. Many of my patients fear that talk of death might “jinx” them. Some are reluctant to put their wishes in writing because they worry that doctors will give up on them. Others are concerned they’ll change their minds down the road but be too sick to say so. These concerns are real, but the potential exists for much greater harm by ignoring finitude entirely.
Reflecting on death has the potential to bring into relief that which matters most, and it can empower us to change how we live for the better. Ask anyone who is fully engaged in the process of dying. When our days are numbered, we value our relationships differently. We spend our time and money differently. We ponder life’s mysteries.
In ordinary times, we fool ourselves into thinking that the preparation for death can wait. But these are not ordinary times. When I was caring for hospitalized Covid patients this past Spring in New York City, they were frequently astonished that they had become so sick. They had not understood, as did Epicurus, that the art of dying is wrapped up in the art of living. But the pandemic has taught us that sickness and death do not happen only to other people. All of us must live with a view to our finitude.
This Black Friday, after the feasting has subsided and before the shopping begins, take a few minutes to talk with those you love about how to die well. Be frank about end-of-life wishes. Complete and sign documents.
At the same time, it also makes sense to talk about living. If Epicurus is right, to die well one must live well. And attending to what it means to live well — in light of the precarity of life — can make all the difference.
— What physician-assisted death is like for a family
Margaret Handley wrote the essay so her children understood their grandmother’s experience and to help others learn about physician-assisted dying.
By Meghan Holohan
It started with weakness and pain when walking. Then Jacqueline Shapiro had a deep lesion on her leg before she broke it, oddly, and doctors struggled to set it. The pain medications caused her to have bad reactions and her energy waned. Eventually doctors learned that the 85-year-old had lymphoma. She underwent three grueling months of surgery, radiation and chemotherapy, but it only left her exhausted and feeling worse.
“It can cause delusions and a sort of psychosis. And it just was horrible, just horrible. And it was really hard for her to get her pain stabilized,” Margaret Handley, her daughter who is an epidemiologist living in the San Fransisco Bay area, told TODAY. “If you looked at those episodes medically, they were going well, but it was just part of an escalating discomfort for her. She increasingly felt like ‘I don’t think this is a good place for me to be.’”
Shapiro worried about spending the rest of her life undergoing painful treatments that might not even cure her cancer.
“She didn’t want to be lying there dwindling while people take care of her,” Handley said.
When a palliative care doctor visited Shapiro to discuss her pain, they started talking about California’s End of Life Act. People with terminal illnesses, who meet a certain criteria, can request drugs to aid dying, according to the California Department of Public Health. Similar legislation exists in eight other states. Compassion & Choices, a nonprofit working to improve patient rights and individual choice at the end of life, recently reported that Brittany Maynard’s advocacy of “death with dignity” inspired the passage of medical aid dying laws in Washington, D.C, Colorado, Hawaii, New Jersey and Maine.
Shapiro met those requirements. Hearing about the option of medically assisted death seemed to lessen her burden.
“She told me right away after the doctor left, ‘That’s what I’m going to do — physician-assisted dying. I don’t want to compete with this disease — that’s not what I want to do with the rest of my life,’” she wrote. “I sat with her and my sadness and then, over the next few days, we set upon the logistics to put her right-to-choose into motion.”
While her oncologist thought there was a possibility that the cancer could go into remission, Shapiro wasn’t sure if she could endure more treatment. Then she spoke with a doctor from the physician-assisted dying group, who described how the process works. He noted that many people request the drugs but don’t ultimately go through with it. Handley felt impressed by how all three doctors acted when advising her mother.
“I don’t think that (the doctors’ input) affected her decision,” Handley said. “But it was also much better that she heard them and witnessed them doing their work and felt like she was part of the narrative, not outside of it.”
Shapiro loved nature and the forest. As a young woman, she spent her summers at Yosemite and lived in the Sierra Nevada mountains until age made a remote living situation a little tougher. She had a garden with plants from the forest and an ornery cat name, Darcy, named after Mr. Darcy from “Pride and Prejudice.” While she was sick, she worried about his well-being. Making the decision for physician-assisted death put her mind at ease about what would happen to her pet, her plants and her life. This allowed Shapiro to say goodbye to her family the way she wanted, watching nature shows and cat videos, enjoying one another’s company.
“We were lucky to know it was coming and to be able to say let’s have these moments together,” Handley said.
Handley and her brother sat with their mother, with Darcy on her lap. As Handley read the poem, “Evening” by Rainer Maria Rilke, her mom passed away.
“It was a really powerful experience to be able to sit with someone who is making this choice,” Handley said. “That was a good experience for us to share.”
Handley said she wrote the essay because she felt there were so few personal stories about what physician-assisted death is really like. She also hoped that by sharing the experience her three children would also better understand her mom’s choice and experience.
“I wanted to write down what happened with my mom’s decision-making so that they would understand,” she said. “I thought this was just adding a little more real personal experience of what (physician-assisted death) looks like in one given situation.”
Arun Shourie is an unflinching seeker. He has an exemplary ability to face the toughest questions. After a bracing meditation on the problem of suffering in Does He Know a Mother’s Heart (2011), Shourie now turns to Preparing for Death. There used to be a joke that the purpose of literature is to prepare you for the good life, while the purpose of philosophy is to prepare you for the good death. But it is hard to understand our own extinction. Broadly speaking, two diametrically opposite views are invoked to reconcile us to death. One is that we don’t really die; in some form, through an incorporeal soul or something, we continue to exist. The other unflinchingly accepts that we just are evanescent matter and nothing else. Both approaches address the question of dying by simply saying “there is nothing to it.” There is something to this strategy, but it cannot make sense of the significance of life. It seems we can either make sense of life or of death, but not of both.
Shourie’s book takes a brilliantly different pathway. The book has three distinct themes. The first, the most powerful and meditative section of the book is not so much about death as the process of dying. He documents with detail, “great souls” experiencing the often painful dissolution of their own body — the Buddha, Ramkrishna Paramhansa, Ramana Maharshi, Mahatma Gandhi, and Vinoba Bhave, and, as a cameo, Kasturba. All of them give lie to Sigmund Freud’s dictum that no one can contemplate their own death. But what emerges from these accounts is not so much the conclusion that they all faced death unflinchingly; most of them have a premonition. It is also not about capturing the moment where the good death is leaving the world calmly. It is rather what the suffering body does to consciousness, all the memories and hard decisions it forces on us.
But the relationship between the body and consciousness goes in two different directions at once. On the one hand this suffering is productive: consciousness works through this pain. On the other hand, even the most exalted soul does not escape the utter abjection of the body. The most poignant moment in this section is not the calm and plenitude with which these exalted souls face death; it is the moments where even the most powerful souls are reduced to abjection by the constraints of the body. The only one rare occasion where Ramana Maharshi ever loses his cool is in his now utter dependence on others for most basic bodily functions. The problem of dying is not that you cannot ignore the body; it is that the body does not ignore you.
The second theme of the book is to take a sharp scalpel to false comforters of all religions and philosophies that promise the everlasting soul, or the preservation of bodies only to subject them to torment in hell. This metaphysical baggage makes dealing with death harder and is a total distraction. This section is less generous in its interpretive sympathies. The third theme of the book, interspersed in various parts, is about the discipline of dealing with your own body as it is in the process of dying. The book impressively marshals a variety of sources, from the Tibetan Book of the Dead, with its incredible imaginative exercises that make you take in the whole of existence, to Jain sources of Sallekhana, and various meditative techniques to inculcate a certain kind of mindfulness. But mostly one gets the sense that the ultimate preparation for death is simply love, something that can endow the evanescent moment with significance.
But this is a seeker’s book. It is in parts profound probing, honest but not dogmatic. Its immense value comes from the fact that the book is both a book and an anthology on death, with extracts from not just the words of those experiencing the process of dying, but an astonishing range of sources: from Fernando Pessoa to Michel de Montaigne, from yoga to the Tibetan Book of the Dead. For the politically inclined, there is an ambivalently revealing account of the Prime Minister’s visit to Shourie while he was in the ICU. All throughout, the book is laced with judiciously selected poetry: the startling moment where Gandhi recites the Urdu couplet to Manu: Hai baha- e-bagh-e duniya chand roz/ Dekh lo iska tamasha chand roz, a register you might associate more with Guru Dutt than Gandhi. There is a lot of Kabir, of Basho poetry and haikus. One stunning one: Circling higher and higher/At last the hawk pulls its shadow/From the world.
This haiku caught my attention because I happened to be reading a stunning essay by Arindam Chakrabarti at the same time, “Dream, Death and Death Within A Dream”, in Imaginations of Death and the Beyond in India and Europe (2018), a volume edited by Sudhir Kakar and Gunter Blamberger, that reads as a great philosophical complement to this one. That volume has a powerful piece by another brilliant philosopher, Jonardan Ganeri, on illusions of immortality that deals with a source Shourie cites at length: Pessoa. Chakrabarti’s essay ends with the insight of Yoga Vashishtha: To be born is to have been dead once and to be due to die again. Shourie is perhaps right: Can we really unravel what it means for the hawk to pull its shadow from the world? Does the shadow reappear if it flies lower?