How California doctors are fixing how we die

Doctors change life-ending drugs to ease the final hours

Dr. Lonny Shavelson

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Modern medicine excels in ways to save a beating heart.

Yet hardly anything is known about how to humanely stop one.

Frustrated by the dearth of information about how to aid dying, Berkeley’s Dr. Lonny Shavelson is gathering data to guide other physicians through this new, important and sorrowful clinical frontier. Legalized in 2015, California’s End of Life Option Act allows doctors to prescribe life-ending drugs to terminally ill patients.

“We’re doing a medical procedure. And whatever is done in medicine should be done well, and consistently,” said Shavelson, 68, a UC San Francisco-educated former Emergency Room physician.

“Now we can tell patients: ‘We’re giving you the best protocol we have,’ ” said Shavelson, whose Bay Area End of Life Options medical practice has overseen 232 deaths. “And we’re getting better and better.”

When Californians passed the medical aid-in-dying law – inspired by Oakland’s Brittany Maynard, San Mateo’s Jennifer Glass and others who sought to end their suffering from cancer – voters assumed it promised them a neat Shakespearean-styled ending, like Romeo’s quick poisoning in Verona. That was the goal, but it didn’t always happen.

A little-known secret, not publicized by advocates of aid-in-dying, was that while most deaths were speedy, others were very slow. Some patients lingered for six or nine hours; a few, more than three days. No one knew why, or what needed to change.

“The public thinks that you take a pill and you’re done,” said Dr. Gary Pasternak, chief medical officer of Mission Hospice in San Mateo. “But it’s more complicated than that.”

So Shavelson, in collaboration with Washington-based retired anesthesiologist Dr. Carol Parrot, set out to compile data to help doctors help their patients. At a UC Berkeley-based conference last February, they co-founded the American Clinicians Academy on Medical Aid in Dying. The Academy’s 240 clinicians are now contributing and sharing their own experiences.

Dr. Lonny Shavelson, of Bay Area End of Life Options, looks over data at his home office in Berkeley, Calif., on Tuesday, Feb. 18, 2020. Shavelson is leading a data collection project to learn what medications most quickly and gently bring the person to their requested death under the 2016 End of Life Options Act.

To each deathbed, seated with grieving family members, Shavelson brings a clipboard with drug names and dosage levels.

As minutes tick by, he measures falling oxygen levels, slowing cardiac rhythms and fading respiration. He tracks outcomes while providing care.

The pharmacologic findings, shared with clinicians nationwide, are dramatically reducing the incidence of long, lingering and wrenching deaths.

“It’s really helpful to have someone actually studying the utility of what it is we’re doing,” said Pasternak. “So much of what we’re doing has arisen empirically. He’s collected such great data.”

“Patients want a medication that is effective. They want a swift, peaceful death,” he said.

Using the initial drug regimen in place when the law was passed, 34% of all patients took longer than two hours to die; one man died after 11 hours. A second regimen reduced that to 20%. With the current protocol, fewer than 10% of patients take longer than two hours to die, and most patients die in 1.1 hours, on average.

The protracted deaths didn’t create suffering for patients; they are in a deep coma. But the lengthy vigils can be agonizing for loved ones.

“After two hours, people were starting to get concerned, and restless,” Shavelson said. They wonder what’s happening. People start walking around the room, going into the kitchen. It disrupts the meditative mood. Between two and four hours – that’s not ideal. Anything over four hours we consider to be problematic.”

“I was looking at what was happening and thinking: ‘This isn’t as good as it’s been hyped up to be,’ ” he said.

There’s no repository of information to help doctors in states that have passed aid-in-dying laws, representing 22% of the U.S. population. The U.S. National Institutes of Health won’t fund the research. Medical schools don’t teach it. Hospitals don’t oversee it. Without that official support, medical journals won’t publish any findings.

Traditional medical research is conducted at universities and medical schools, “and they won’t touch the topic,” said Shavelson. “They’ve completely abrogated their responsibility to patients who are dying … bowing out of their traditional role of teaching, research and providing quality care. It’s taboo. There’s still a stigma.”

When aid-in-dying was first passed in Oregon in 1997, patients were given secobarbital, sold under the brand name Seconal. It induces deep sleep, then a coma that is so deep that the brain no longer drives respiration.

But that drug wasn’t consistently quick. Then it became prohibitively expensive, finally unavailable.

To replace Seconal, the doctors invented a three-drug cocktail — a painkiller, sedative and a heart-slowing agent — based on their experiences with overdose deaths. They later added another cardiac drug. But problems remained.

While sitting at the bedsides of several six-hour deaths, Shavelson pondered what was going wrong. He speculated that one cardiac drug was rendered ineffective by the large quantities of the other drugs. So he separated that out and gave it earlier, so it had time to act.

When some delays persisted, he replaced one of the heart-slowing drugs for a heart-damaging drug.

Based on newly compiled data from Academy clinicians, the formula is about to be improved again, pending confirmation of results.

Shavelson and Parrot have identified which patients are more likely to linger, and can recommend adjustments. People with gastrointestinal cancer, for example, don’t absorb the drugs as well. Former opiate users often have resistance to some of the drugs. Young people and athletes tend to have stronger hearts and can survive longer with low respiration rates.

“We’re learning. Hypothesis, data and confirmation. This is what science is,” he said. “Our job is to stop the heart; that’s what they want us to do.

“We haven’t made it less sad. It’s still death. There’s tears and crying,” he said. “But it’s a better ending.”

Complete Article HERE!

At 31, I have just weeks to live. Here’s what I want to pass on

Now that there’s no longer any way to treat my cancer, I’ve been reflecting on what I want others to know about life and death

‘I have come to see growing old as a privilege. Nobody should lament getting one year older, another grey hair or a wrinkle. Be pleased that you’ve made it.’

By

At the beginning of April I wrote a piece for the Guardian. If you haven’t read it, the headline pretty much sums it up: “Terminal cancer means I won’t see the other side of lockdown”. Given the pandemic and the announcement of shielding for vulnerable people, I thought I wouldn’t be able to live out my last few months in the way I’d imagined. It seemed like I would be stuck alone, with no light at the end of the tunnel, and without the comfort of friends or family.

Five months on, I’m still here, but much has changed. Thankfully, the experience wasn’t as bleak as you might think. During the first few weeks of lockdown I found I was floating nicely through the time by staying occupied and upbeat. In many ways, you can’t beat the liberation of being able to wake up when you feel like it, having few plans set in stone and being able to do whatever you want with the time you have.

Over the past couple of months, though, my energy levels have dropped, and I have started doing less. I look drastically different. I have lost a lot of weight. A 20-minute coughing fit is now part of my morning routine while my chest tries to settle itself. It’s nothing that some steroids, morphine, an iced drink to settle my throat and time spent dry-heaving in front of a bucket won’t eventually sort out, but it can get really distressing – like an intrinsic panic response.

At points I was really struggling. The loneliness of Covid was making me miserable, and I needed company. But my sister came to the rescue at just the right moment. She moved back into our shared flat at the end of June. It made a huge difference, and I don’t know where I would be without her. After months of isolation, having a family member close by changed everything.

At the same time, out of the blue, I was told I was finally suitable for a drug trial that had been dangled in front of me for more than a year. The oncologists made it very clear that this would not be a “magic bullet”, and the goal would be to extend life by a few months. The aim of the treatment would be to stop the cancer stealing all the nutrients and energy my body needs.

But I was not in the same good shape I had been in at the beginning of other treatments; I was extremely short of breath, unable to exercise and felt lethargic. And after pinning my hopes on the idea of a drug trial for so long, it took just over a week for it to batter me. My days involved moving from my room to the sofa, feeling like I had flu and struggling with mental fog. Almost immediately I realised I just couldn’t do it. Life for me is about living, not just clocking up the years. And this drug made living almost impossible.

I realised I had to finally accept the inevitable: that there was no treatment. I thought this mindset would leave me feeling completely liberated. I was wrong. With nothing left to fight, it really was just a question of waiting. The battle became emotional and mental. It has forced me to reflect.

The first three decades of my life were pretty standard. Well, actually they were awesome, and everything was going pretty perfectly with regards to work, health, relationships and friends. I had plans for the future, too: learn some Spanish, see more of central America, and get a bit more out of it with some volunteering too.

Elliot with his sister at Lulworth Cove, Dorset.

I imagined settling down in my 30s or 40s with kids, a mortgage and so on. Or maybe I wouldn’t. Maybe my friends’ children would call me Uncle Elliot as their parents gathered in the kitchen looking slightly concerned about their single 45-year-old friend about to set off travelling around Mongolia. Either way, growing older with my mates and living my life to the full was always my ambition.

Of course, the second part of this storyline won’t be written now. It’s a shame I don’t get to see what happens. But everybody dies, and there will always be places and experiences missing from anyone’s life – the world has too much beauty and adventure for one person to see. I will miss marriage or children, blossoming careers and lives moving on. But I’m not alone in my life being cut short, and I think my time has been pretty good.

At this point I should say a word to my friends. Being this ill complicates all relationships. The rut I found myself in a few weeks back hasn’t lifted. I’ve definitely been “feeling the victim” a lot more than usual. My acceptance that my time and energy is now limited comes with the knowledge that I won’t be able to catch you all properly to give our relationships the time and appreciation they deserve. I get so many messages from you all, which often exceed the energy I have to reply. Where I am able to see people, I’d just say keeping me company and being positive is helpful. I want fun, laughter, happiness, joy. I think it’s very possible to have this kind of death – there is likely to be a shadow of sadness hanging over proceedings, but for the most part I want everyone relaxed and to be able to feel the love.

Because I know that that moment isn’t too far away. I haven’t asked for a specific prognosis, as I don’t believe there’s much to gain from doing so, but I think it’s a matter of weeks. Medicine has luckily turned this into quite a gentle process. That really does take a lot of the fear away. And I’m hoping impending death now grants me the licence to sound prematurely wise and overly grandiose. Because I’ve had time to think about the things that are really important to me, and I want to share what I’ve discovered.

First, the importance of gratitude. During my worst moments – the shock of cancer diagnosis, the mental lows and debilitating symptoms of chemotherapy – it was difficult to picture any future moments of joy, closeness or love. Even so, at those times I found comfort in remembering what I have: an amazing family, the friends I’ve made and times I’ve shared with them, the privilege of the life I’ve had.

Second, a life, if lived well, is long enough. This can mean different things to different people. It might mean travel. I’ve had the good fortune to be able do this, and can confirm that the world is a wonderful place full of moments of awe and amazement – soak up as much as you can. It may mean staying active, as much as possible – the human body is a wonderful thing. You only appreciate this when it starts to fail you. So when you find yourself slipping into autopilot, catch yourself, and take simple pleasure in movement, if you can. Look after your body because it’s the only one you have, and it’s bloody brilliant. Knowing that my life was going to be cut short has also changed my perspective on ageing. Most people assume they will live into old age. I have come to see growing old as a privilege. Nobody should lament getting one year older, another grey hair or a wrinkle. Instead, be pleased that you’ve made it. If you feel like you haven’t made the most of your last year, try to use your next one better.

Third, it’s important to let yourself be vulnerable and connect to others. We live in a society that prizes capability and independence, two things that cancer often slowly strips away from you. This was naturally a very difficult pill to swallow for a healthy, able late-twentysomething male, but having to allow myself to be vulnerable and accept help has given me the best two years of my life, which was pretty inconceivable at the time of diagnosis. Vulnerability has shown me what phenomenal people my sister and parents are – words can’t do justice to how much they have done for me. The same applies to my friends – what better way is there to spend two years than being surrounded regularly and closely by these people?

Fourth, do something for others. Against the backdrop of Covid-19, Black Lives Matter and the desperate attempts of migrants to cross the Channel, my thoughts really turned to those who have not had my privilege – whether that’s by virtue of socioeconomics, ethnicity or the country I was born in. I always try to remind myself of this.
Fifth, protect the planet – I can’t leave this off because it’s so important. I’ll be gone soon, but humanity will still be faced with the huge challenge of reducing carbon emissions and saving habitats from destruction. In my time here, I’ve been lucky enough to see some natural wonders and understand how precious they are. Hopefully future generations will be able to say the same. But it will take a massive collective effort.

If you asked me what I’d want to leave behind, it would be a new awareness of these things among my friends – and anyone who’ll listen, really. I was astonished by the number of people that responded to my article in April. I now find myself in a position where people are asking me how they can help or what they can do that would make me happy. Apart from the obvious – looking after each other once I’ve gone – I’m going to push for people to give, be that money or time. I’ve already had so many people ask which causes I recommend, and there are loads, but I’d say any that align with the values I’ve sketched out above would have my blessing. Among friends and family there is talk of setting up a small charity in my memory.

Despite some very low times, it’s worth repeating that the period since being diagnosed has been made not just bearable but actually fantastic. I’ve had new experiences that haven’t seemed tainted by cancer – and those experiences were, as always, much better shared. In a situation that is pretty new for most of my loved ones and friends (I am yet to meet anyone I grew up with who has had to deal with cancer or a similar chronic illness at my age), it has been amazing watching them all rise to the challenge. I’m not sure if it’s just that I know a high proportion of amazing people (possible) or if most human beings have this capacity for connecting and recognising what’s truly important (very likely).

After the gut-punch of cancer diagnosis, I’ve really struggled to define a purpose for my own life. I found in time this came naturally. Life is for enjoyment. Make of it what you can.

Complete Article HERE!

Patients with COVID-19 shouldn’t have to die alone.

Here’s how a loved one could be there at the end

By &

While the number of new COVID-19 cases in Victoria continues to trend downwards, we’re still seeing a significant number of deaths from the disease.

The ongoing outbreaks in aged care, and the fact community transmission is continuing to occur, mean it’s likely there will be many more deaths to come.

As a result of strict infection control measures restricting hospital visitors, tragically, many people who have died from COVID-19 have died alone. Family members have missed out on the opportunity to provide comfort to the dying person, to sit with them at their bedside, and to say goodbye.

But it doesn’t have to be this way. We have cause to consider whether perhaps we could do more to preserve the patient-family connection at the end of life.

Who can visit?

There’s some variation between Victorian health-care facilities in how visitor restrictions are applied. Some allow visitors to enter hospitals for compassionate reasons, such as when a person is dying. But visitors are not permitted for patients with suspected or confirmed COVID-19.

The latest figures show 20 Victorians are in an intensive care unit (ICU) with 13 on a ventilator. This indicates their situation is critical.

Despite hospitals, and particularly ICUs, being adequately prepared and resourced to provide high-level care for people diagnosed with COVID-19, patients will still die.

Family-centred care at the end of life in intensive care is a core feature of nursing care. So in the face of this unprecedented global pandemic, we realised we needed to navigate the rules and restrictions associated with infection prevention and control and find a way to allow families to say goodbye.

Our recommendations

We’ve published a set of practice recommendations to guide critical care nurses in facilitating next-of-kin visits to patients dying from COVID-19 in ICUs. The Australian College of Critical Care Nurses and the Australasian College for Infection Prevention and Control have jointly endorsed this position statement.

The recommendations are evidence-based, reflecting current infection prevention and control directives, and provide step-by-step instructions for facilitating a family visit.

Some of the key recommendations include:

  • family visits should be limited to one person — the next-of-kin — and that person should be well
  • the visitor must be able to drive directly to and from the hospital to limit exposure to others
  • they should dress in single-layer clothing suitable for hot machine wash after the visit, remove jewellery, and carry as few valuables as possible
  • on arrival, staff should prepare the visitor for what they will see when they enter, what they may do, and what they may not do (for example, it would be OK to touch your loved one with a gloved hand)
  • a staff member trained in the use of personal protective equipment (PPE) should assist the visitor to put on PPE (a gown, surgical mask, goggles and gloves) and after the visit, to take it off, dispose of it safely and wash their hands
  • where possible, the visitor should be given time alone with their loved one, with instructions on how to seek staff assistance if necessary.

We also highlight the importance of intensive care staff ensuring emotional support is provided to the family member during and immediately after the visit.

Tailoring the guidance

It’s too early to know the full impact a loved one’s isolated death during COVID-19 may have on next-of-kin and extended family. But the effect is likely to be profound, extending beyond the immediate grief and complicating the bereavement process.

These recommendations are not meant to be prescriptive, nor can they be applied in every circumstance or intensive care setting.

We encourage intensive care teams to consider what will work for their unit and team. This may include considerations such as:

  • whether there are adequate facilities in which the visitor can be briefed and don PPE
  • whether social distancing is possible with current unit occupancy and staffing
  • whether an appropriately skilled clinician is available to coordinate and manage the family visit
  • each patient’s unique clinical and social situation.

Rather than just using a risk-minimisation approach to managing COVID-19, there’s scope for some flexibility and creativity in addressing family needs at the end of life.

Complete Article HERE!

5 Ways To Make Your Dog’s Last Days Their Best Days – DogTime

By Maggie Clancy

Grieving over the loss of a pet is traumatic. But sometimes, it can be even harder when we know that our dogs don’t have much time left. Anticipatory grief is real, and it’s a completely normal emotion to feel.

Dogs are very intuitive, and your grief may be contagious to your ailing pet. Perhaps instead of spending your remaining time with your canine companion in a state of grieving and sadness, you can make the rest of your dog’s life as comfortable and wonderful as possible.

Here are some tips on how to make your dog’s last days the best that they possibly can be.

Create A Bucket List

Dog parent Riina Cooke made the decision to make a bucket list for her terminally ill Boxer, and it helped her with the grieving process tremendously. From a cheeseburger to a pedicure, she filled her dog’s remaining time with fun and happiness.

What makes your dog ecstatic? Is it taking luxurious car rides? Hanging out with some of their favorite friends?

Create a list of what your dog loves to do best, and cross off as many as you can as long as your dog’s health and safety permits.

There’s nothing better than seeing your pup at their happiest, and there’s no better way to remember them than in that state, as well.

Go All Out With The Food

If your dog’s vet agrees that certain people foods are okay for your dog to ingest, give your pup the tastiest, most decadent food possible.

When my childhood dog, a nine-year-old Cocker Spaniel, was suffering from a myriad of ailments, we gave her steamed rice and steak every night for dinner. Some nights, her dinner was fancier than what the humans of the household were eating.

Ask your vet which foods are appropriate, and start making Fido gourmet meals.

Indulge In All Forms Of Pampering

Go buck wild with any and all forms of pampering, especially anything that will relax and soothe your dog.

Have a dog masseuse come to your house. Go to a dog bakery and get them the most outrageous dog cake you can find.

You can even go a little less traditional route and do things like take your dog to a pet communicator or psychic to hear what they’re really feeling. You may not be a believer, but it will probably be a fun experience and a fond memory.

Get Educated On Pain Management

This may not be the most fun part of the list, but it’s crucial. If your dog is suffering, it may not always be apparent that he or she is in pain. Educate yourself on the signs of pain in dogs.

If your dog hits a point of extreme pain or a point where you cannot take care of your pup yourself, it may be time to consider dog hospice care. Much like human hospice care, dog hospice care is from the comfort of your own home.

You can work with your vet on things like administering medications and deciding if and when it’s the right time for euthanasia.

Allow Your Friends And Family To Help You

In order for you to be in the right state of mind for when your dog is nearing the end of their life, you should have a solid support group. Talk to friends who know your dog well, family, and a veterinarian you can trust.

Many animal hospitals also offer support groups. By having this ring of support for yourself, you will be able to effectively and lovingly support your pooch through this painful time.

Letting go of a dog is never easy, but you can make it as positive of an experience as possible for both you and your dog.

If you’ve gone through the grieving process of a dog passing away, what did you do to make your dog’s last days their best? Do any fond memories bring you comfort? Let us know in the comments below!

Complete Article HERE!

Pa’s Smile

Jaimal Yogis’s dad explained his final wishes: “I’ve gotten so much from Buddhism for good living, I’m not going to pass up their tips for good dying.”

by

The first and only time I bought dry ice, the grocery store clerk asked if I was going camping. “No,” I muttered, then managed to stop myself from saying it was for a body. The ice really was to lay my father’s corpse on.

An air force colonel who was skeptical of organized religion, my father, who we call Pa, wasn’t sure the Tibetan Buddhist tradition of leaving the dead undisturbed for three days was necessary. But, as he said after being diagnosed with late stage lung cancer, “I’ve gotten so much from Buddhism for good living, I’m not going to pass up their tips for good dying.”

As if summarizing Socrates in his famous pre-execution speech, Pa often said he had no idea where he was going. ‘If the lights go out, it’ll be a good rest,’ he’d say. ‘And if there’s more, it’ll be a great adventure.’

These three days are not unique to Tibetan, or more accurately, Vajrayana Buddhism. Irish wakes often last two or three days while a soul departs, and Jewish Midrashic texts say a soul hovers over the body for three days (or seven) until the body is buried. The idea behind the three days in Vajrayana Buddhism is that as the breath and heart stop, our gross level of consciousness dissolves but more subtle levels of consciousness remain in the body for up to about seventy-two hours. During that time the subtlest stream of consciousness is said to leave, a transition known to go more smoothly if the body can chill—in Pa’s case literally since under California law dead bodies have to be kept on ice.

“Otherwise they tend to smell like dead bodies,” our hospice nurse informed us.

“Right,” I nodded. “And where do we get the ice?”

“Grocery store.”

“Of course.”

As if summarizing Socrates in his famous pre-execution speech, Pa often said he had no idea where he was going. “If the lights go out, it’ll be a good rest,” he’d say. “And if there’s more, it’ll be a great adventure.” Still, he’d reasoned his way toward the three-day death plan. In addition to reading up on how Vajrayana Buddhists use strict tests to prove they’ve found reincarnations of former teachers, he’d read the work of doctors like Sam Parnia of NYU Langone Health. Dr. Parnia has meticulously catalogued data on people who’ve died clinically, sometimes for hours, before being resuscitated. These briefly dead folks often report vivid dreams after waking, sometimes ones in which they correctly recount what doctors had been saying—“Going to the game later?”—when the patients had no heartbeat. “That’s enough evidence for me,” Pa said. “Don’t poke or prod me for a few days.”

As the actual death part of the three-day death plan approached, we—his family—wondered if having Pa’s cold body steaming on carbon dioxide in the bedroom might intensify our grief. And might it be a little creepy? It turned out to be just the opposite.

Death leaves you in a dreamy shock. You don’t know if you should wail or drive all night to Mexico or finally get to writing your own will. When Pa stopped breathing on a warm summer evening, dressing him in his aloha shirt and favorite Christmas socks, then adorning his room with flowers, was just the beautiful busy work our reeling minds needed. Reading Jane Hirshfield’s “It Was Like This: You Were Happy,” a special request from Pa, while he was actually there in the room felt more heart opening than reading it again while scattering his ashes. And as we sat with Pa each of the three mornings while reading him The Tibetan Book of The Dead—a text meant to help us navigate the space between lives—it felt as if we were on a kind of spiritual tour bus with him, visiting the realms where awakened beings are born from lotuses and truths are whispered on the breeze.

Perhaps most surprising was how much the three-day death plan helped before death. As Pa was starting to show signs of getting close to the end, my sister Ciel and I asked if he would like to hear a Medicine Buddha ceremony that is often done for the sick and dying. “You don’t have to bother with that,” Pa said, continuing his usual stubborn quest to keep us from doting. But we argued that the ceremony would be a good warm-up for when he was down for the count and we were reading The Tibetan Book of the Dead, which Tibetans actually call The Great Liberation for Hearing in the Bardo. Since this made it sound like the reading was for us, Pa agreed.

We sat around his bed, switching back and forth between botching the Tibetan chanting and reading the English translation. The ceremony took about an hour, and we thought ­­Pa had slept through it. But at the end, he sat up with tears in his eyes. “I am so honored you did that for me,” he said. “And now I’m going to get up and see the sky one more time.”

“We’ll get the wheelchair,” Pa’s wife, Margaret, said reasonably.

“No,” he said, “I’m going to walk.”

Pa had already fallen behind the toilet in such a precarious position we’d needed the fire department to come dislodge him, and he’d been bedridden for days now. But charged up by the chanting, Pa managed to lumber slowly to the back porch, rasping with every breath.

We opened the door. Pa turned his face up bracingly to the blue. He looked so pale, I half expected him to croak right there. Instead, he then looked down at a few small stairs he would have to navigate in order to be fully outside. “Take me back,” he whispered. “I want an easy death. Not to fall off the damn steps.”

We laughed. Finding humor in the face of hardship was one of Pa’s great gifts. But we hadn’t heard zingers with gusto like this for a few weeks. And I think, in addition to the power of the ceremony itself, knowing that his family would be there for three full days—botching more Tibetan chants around him—was a great comfort, a lightening.

Philosophical aspects of the plan were helpful too. In hospice Pa occasionally felt unsure of where—even who—he was. One day he called himself King Henry and my aunt the queen. “You wouldn’t believe what’s happening,” he told me. “It’s like I’m disappearing.” This was scary, but Buddhist wisdom for conscious dying gave Pa a place to put his fears.

According to Vajrayana Buddhists, our gross consciousness is where we construct our version of reality through our senses. This construction is like a video game in our heads in which we are the most important character, the one whose suffering matters most, the one who should win all the gold coins because, as our senses (falsely) tell us, we exist separately from the rest of reality. The more we let go of this illusory separation from others, the more room there is to experience our true blissful and compassionate nature. Vajrayana Buddhist teachers say this true nature is most easily accessible at death because, as opposed to meditative glimpses beyond the veil, in death the gross levels of consciousness drop away automatically. So, when Pa was scared or disoriented, we could remind him that losing a mere idea of himself was not just natural, it was part of spiritual awakening.

In his last hours, Pa’s brow was furrowed and his body appeared tense. He looked like he was trying desperately to remember something. Ciel, Margaret, and I were taking turns sitting with him, and fittingly it was just when Margaret was singing him Nat King Cole’s, “When I Fall in Love,” a song they’d danced to on West Cliff Drive above the sea, that Pa finally let go. As he did, his brow smoothed completely, making him look instantly younger. A distinct half-smile appeared on his lips. A Buddha smile. And whether it was Pa’s newfound bliss, rigor mortis, or some combination of both, that smile remained perfectly serene for all three days.

Complete Article HERE!

The surprising benefits of contemplating your death

Now is the perfect time to face your fear of mortality. Here’s how.

By

Nikki Mirghafori has a fantastically unusual career. After getting a PhD in computer science, she’s spent three decades as an artificial intelligence researcher and scientific advisor to tech startups in Silicon Valley. She’s also spent a bunch of time in Myanmar, training with a Buddhist meditation master in the Theravada tradition. Now she teaches Buddhist meditation internationally, alongside her work as a scientist.

One of Mirghafori’s specialties is maranasati, which means mindfulness of death. Mortality might seem like a scary thing to contemplate — in fact, maybe you’re tempted to stop reading this right now — but that’s exactly why I’d say you should keep reading. Death is something we really don’t like to think or talk about, especially in the West. Yet our fear of mortality is what’s driving so much of our anxiety, especially during this pandemic.

Maybe it’s the prospect of your own mortality that scares you. Or maybe you’re like me, and thinking about the mortality of the people you love is really what’s hard to wrestle with.

Either way, I think now is actually a great time to face that fear, to get on intimate terms with it, so that we can learn how to reduce the suffering it brings into our lives.

I recently spoke with Mirghafori for Future Perfect’s limited-series podcast The Way Through, which is all about mining the world’s rich philosophical and spiritual traditions for guidance that can help us through these challenging times.

In our conversation, Mirghafori outlined the benefits of contemplating our mortality. She then walked me through some specific practices for developing mindfulness of death and working through the fear that can come up around that. Some of them are simple, like reciting a few key sentences each morning, and some of them are more … shall we say… intense.

I think they’re all fascinating ways that Buddhists have generated over the centuries to come to terms with the prospect of death rather than trying to escape it.

You can hear our full conversation in the podcast here. A partial transcript, edited for length and clarity, follows.

Sigal Samuel

You’ve worked in Silicon Valley and you still live near there, so I’m sure you’ve encountered the desire in certain tech circles to live forever. There are biohackers who are taking dozens of supplements every day. Some are getting young blood transfusions, trying to put young people’s blood in their veins to live longer. Some are having their bodies or brains preserved in liquid nitrogen, doing cryopreservation so they can be brought back to life one day. What is your feeling about all these efforts?

Nikki Mirghafori

It’s the quest for immortality and the denial of death. Part of it is natural. Human beings have done this for as long as we have been conscious of the fact that we are mortal.

A person who really put this well was Ernest Becker, the author of the seminal book The Denial of Death. I’d like to offer this quote from him:

This is the paradox. A human is out of nature and hopelessly in it. We are dual. Up in the stars and yet housed in a heart-pumping, breath-gasping body that once belonged to a fish and still carries the gill marks to prove it. A human is literally split in two. We have an awareness of our own splendid uniqueness in that we stick out of nature with a towering majesty, and yet we go back into the ground a few feet in order to blindly and dumbly rot and disappear forever. It is a terrifying dilemma to be in and to have to live with.

There is a whole field of research in psychology called terror management theory, which started from the work of Ernest Becker. This theory says that there’s a basic psychological conflict that arises from having, on the one hand, a self-preservation instinct, and on the other hand, that realization that death is inevitable.

This psychological conflict produces terror. And how human beings manage this terror is either by embracing cultural beliefs or symbolic systems as ways to counter this biological reality, or doing these various things — cryogenics, trying to find elixirs of life, taking lots of supplements or whatnot.

It’s nothing new. The ancient Egyptians almost 4,000 years ago, and ancient Chinese almost 2,000 years ago, both believed that death-defying technology was right around the corner. The zeitgeist is not so different. We think we are more advanced, but it comes from the same fear, same denial of death.

Sigal Samuel

It seems like in the West, we really have a bad case of that denial. I think we rarely talk about death or are willing to face up to the reality that we’re going to die. We seem to be wanting to always distract ourselves from it.

You are a Buddhist practitioner and you have a practice that is very much the opposite of that, which is mindfulness of death, or maranasati. You’ve done trainings and led retreats around this subject. But some people might say this is too morbid and depressing to think about. So before we actually delve into the mindfulness of death practices, could you entice us by telling us a few of the benefits of doing them?

Nikki Mirghafori

First and foremost, what I found for many people, myself included, is that facing the fact that I am not going to live forever really aligns my life with my values.

Most people suffer what’s called the misalignment problem, which is that we don’t quite live according to our values. There was a study that really highlighted this, by a team of scientists, including Nobel Prize winner Daniel Kahneman. They surveyed a group of women and compared how much satisfaction they derived from their daily activities. Among voluntary activities, you’d probably expect that people’s choices would roughly correlate to their satisfaction. You’re choosing to do it, so you’d think that you actually enjoy it.

Guess what? That wasn’t the case. The women reported deriving more satisfaction from prayer, worship, and meditation than from watching television. But the average respondent spent more than five times as long watching television than engaging in spiritual activities that they actually said they enjoyed more.

This is a misalignment problem. There’s a way we want to spend our time, but we don’t do that because we don’t have the sense that time is short, time is precious. And the way to systematically raise the sense of urgency — Buddhism calls it samvega, spiritual urgency — is to bring the scarcity of time front and center in one’s consciousness: I am going to die. This show is not going to go on forever. This is a party on death row.

Sigal Samuel

So the approach here is to bring to the forefront of our consciousness how precious our time is, by impressing upon our minds how scarce it is. And that helps align our life with our values.

Are there other benefits to practicing mindfulness of death?

Nikki Mirghafori

The second benefit is to live without fear of death for our own sake. That way, we don’t engage in typical escape activities. And it frees up a lot of psychic energy. We have more peace, more ease in our lives.

The third benefit is to live without fear of death for the sake of our loved ones. We can support others in their dying process. Usually the challenge of supporting a loved one is that we have a sense of grief for losing them, but a lot of that grief is actually that it’s bringing up fear of our own mortality. So if we have made peace with our own mortality, we can be fully present and support them in their process, which can be a huge gift.

My mom passed away two years ago. And for me, having done all of these practices, I could be with her by her deathbed, holding her hand and supporting her so that she could have a peaceful transition. She didn’t have to take care of me so much and console me. She could be at peace and take delight in this mysterious process that we just don’t know what it’s like. It might be beautiful, might be graceful. We don’t know — there might be nothing; there might be something.

Sigal Samuel

Now I feel sufficiently enticed to learn about the actual practices of mindfulness of death. Let’s start with one that seems simple: the Five Daily Reflections, sometimes called the Five Remembrances, that are often recited in Buddhist circles. Would you mind reciting those?

Nikki Mirghafori

Happy to. These are the Five Daily Reflections that the Buddha suggested people recite every day.

Just like everyone, I am of the nature to age. I have not gone beyond aging.

Just like everyone, I am of the nature to sicken. I have not gone beyond sickness.

Just like everyone, I am subjected to the results of my own actions. I am not free from these karmic effects.

Just like everyone, I am of the nature to die. I have not gone beyond dying.

Just like everyone, all that is mine, beloved and pleasing, will change, will become otherwise, will become separated from me.

Allow whatever arises to come up. It’s okay. These contemplations can bring a lot up. So just be with them as much as possible.

Sigal Samuel

I’ve done these reflections before, but every time I do them, I notice that some are much harder for me to absorb than others. The fourth one — I’m of the nature to die — does not terrify me. Maybe that’s weird, but that’s not the one that really scares me. The one that I find impossibly hard is the fifth one. Everyone that I love and everything that I love is of the nature to change and be separated from me.

It’s really the death or the separation from the people I love that I find much harder to face than the death of myself. Because if I’m going to die, you know, then I’ll be gone. There won’t be any me to miss things.

Nikki Mirghafori

Yes. So appreciate and make space for the one that really touches you.

Also I would say that with the fourth one, making peace with our own death, I’ve done the practice and sometimes I’m like yeah, sure, whatever. And then I’ve really stayed with it, and thought, “This could be my last breath.” When the practice really takes hold and becomes alight with fire, it’s like, “Oh, my God, I am going to die!” It really hits home.

Sigal Samuel

Just to clarify, this is a separate mindfulness of death practice, where you contemplate with every breath, “This could be my last inhale. This could be my last exhale.”

Nikki Mirghafori

Yes. And to bring the historical context into it: This particular teaching is what’s called maranasati. Marana is death in Pali, the language of the Buddha. Sati is mindfulness. The mindfulness of death sutra, that’s where the Buddha taught it, and it’s actually quite a lovely teaching.

The Buddha comes and asks the monks, “How are you practicing mindfulness of death?” And one of them says, “Well, I think I could die in a fortnight, in a couple weeks.” Another one of them says, “Well, I think I could die in 24 hours.” Or “Well, I could die at the end of this meal.” Or “Well, I could die at the end of this bite of food I’m eating.” And another one says, “Well, I could die at the end of this very breath.”

And the Buddha says, “Those of you who said, two weeks, 24 hours, whatever — you are practicing heedlessly. Those who said right at this breath, you are practicing heedfully, correctly. That is the practice.”

There are ways to really bring the sense of immediacy and urgency to all this. It’s not out of the question that there could be an aneurysm or that a meteor could just hit the Earth in this moment. Use visualizations; be creative.

Sigal Samuel

Another thing I find really helpful is remembering the idea of impermanence. Which, of course, is the theme of our whole conversation — that our whole life is impermanent — and that’s a very central Buddhist teaching. But also any emotion that I’m feeling is impermanent. So if I’m feeling an intense surge of fear as I do a practice, that’s impermanent, too.

Nikki Mirghafori

Yeah, I love that. When I teach impermanence, there are little impermanences that come and go, and then there is the big impermanence, which is your life! I’m chuckling because this is a case where impermanence is on your side. Impermanence is just a rule of how things run in this world. It’s impersonal. It’s just the way things are. But in our perspective, it’s either working for us or against us.

Sigal Samuel

Can you tell me about another kind of contemplation — the “corpse contemplation” or “charnel ground contemplation”? Charnel grounds are these places where, after people have died, their bodies are left to decay above ground, to rot in the open air. And Buddhist monks would go and observe them up close, right?

Nikki Mirghafori

Many monks do that, especially in Asia. In order to become more intimate with a sense of mortality, the practice is to go to the charnel ground and to actually see a corpse. And the contemplation is: My body, this alive body, is just like this body that is decaying. It’s in different stages of being a body, of decomposing.

A specific practice in the Buddhist canon is to contemplate a corpse in different stages of decay. This particular practice requires a sense of stability of mind. Do the other ones first. I only teach it on a retreat when there’s a container of safety, holding people and supporting them through it.

Sigal Samuel

I definitely have not yet worked myself up to doing corpse contemplation by looking at images of actual human corpses. But when I go for a walk, whenever I see a dead bird or squirrel or mouse that’s been run over in the road, I actually pause and take a minute to look at it. I’m trying to ease my way into this practice.

Nikki Mirghafori

Brilliant. Similarly, another informal practice I wanted to share is having a memento mori. Like a little skull, or those bracelets that are all skulls. I just drew on a little Post-It a skull and bones, and posted it on my computer monitor, so I would remember: Life is short. I’m going to die.

I’ve had various memento moris on my desk throughout the years, and I invite people to have them. They don’t have to be sophisticated. On a piece of paper, just write out, “Life is short” or “You are going to die” or “Traveler, tread lightly.” Whatever works for you to keep death in your perspective. And I think it’s good to switch memento moris around so that your mind doesn’t get used to seeing the same thing all the time.

Sigal Samuel

I’m glad you brought this up because I was going to say the corpse contemplation reminds me a lot of that memento mori tradition, which is a centuries-long tradition in Christianity. So many different religious traditions have emphasized the importance of meditating on our death and have devised ways like the memento mori to try to keep forcing the ego to recognize its looming demise.

Nikki Mirghafori

Yes. And I know that for me, I feel most alive and I feel happiest and I feel most connected with myself, when I’m aware of my death. If it happens for a day or two that it’s not in the forefront for whatever reason, I’m not as bright, as sharp, as alive. So I just love bringing it back. It enlivens me. It supports me to live more fully and hopefully die with more delight and joy and curiosity.

Sigal Samuel

I’m wondering if you can help me with something else. I mentioned earlier that I’m not really scared of my own death so much, but I am scared of the death of the people I love. And especially during the pandemic, I think that’s causing a lot of anxiety for me and probably a lot of others. We’re scared about the potential death of our grandparents, our parents, our friends. Is there a way to free ourselves of the overwhelming fear of their death?

Grief is a natural part of the process. However, it is complicated by our own seen and unseen fear of death. So I invite you to actually work with the practice of making peace with your own death. That’s what’s underlying it. Even if you think you’re not afraid of your own death, you probably are.

When people are really at peace with their own passing, there is a different perspective. There’s a different way of being with the fear or sadness of losing others. There is still a pain of loss, but it shifts.

Complete Article HERE!

Dying in Your Mother’s Arms

A palliative care doctor on finding a “good death” for children in the worst situations.

A palliative care doctor on finding a “good death” for children in the worst situations.

by John Beder

If losing a child to an illness is one of the worst things that can happen to a family, Dr. Nadia Tremonti has made it her mission to make it better.

It’s not easy. But as a pediatric palliative care physician, she works to ensure that terminally ill children receive quality end-of-life care. Palliative care is sometimes misunderstood to shorten life expectancy, but it’s a method that increases quality of life, improves symptom burden and decreases medical costs. We follow Dr. Tremonti in the short documentary above as she works to make death less medical and more human. In the process she asks a critical question: When a child is terminally ill, how can we make the end of life a better one?

Complete Article HERE!