Category: The Dying Process

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Scientists Monitored 631 People As They Died.

This Is What They Found

The largest international study of the physiology of death to date shows that death is “more of a continuum than the flipping of a switch.”

By Eleanor Cummins

The living have always worried about the dead coming back to life. It’s the plot of the New Testament, the reason 19th century families installed bells in their loved one’s coffins, and a source of tension in end-of-life care today.

While doctors work to reassure families holding vigil in intensive care units and hospice facilities that the end has indeed come, death remains something of a mystery—even among medical researchers. 

These unresolved questions around things like brain death, cardiac death, and more have led to the proliferation of “myths and misinformation,” said Sonny Dhanani, chief of pediatric intensive care at the Children’s Hospital of Eastern Ontario. 

“We felt [stories about the dead coming back to life] might have been impacting people’s motivation to consent for their loved one to be a donor, and for the medical community to offer, donations,” he said. “We wanted to provide scientific evidence to inform the medical understanding of dying.”

In a new study, published Thursday in the New England Journal of Medicine, Dhanani and his team report the results of the largest international study into the physiology of dying to date. It suggests the living can rest easy, kind of.

Between 2014 and 2018, the researchers observed the heart function of 631 patients in 20 adult intensive care units in Canada, the Czech Republic, and the Netherlands after they were taken off life support. The scientists found that 14 percent of the dead showed some flicker of cardiac activity—measured by the electrical activity of the heart and blood pressure—after a period of pulselessness.

But the doctors at the patient’s bedside never got a determination of death wrong. “No one lived. Everyone died. No one actually came back to life,” Dhanani said.

The sputtering was short-lived—the furthest cardiac activity came just 4 minutes and 20 seconds after their heart initially stopped beating—and not strong enough to support other organs, like the brain. 

The data “help us understand how to medically define death, which is more of a continuum than the flipping of a switch,” according to Joanna Lee Hart, a pulmonary and critical care physician and assistant professor at the University of Pennsylvania’s Perelman School of Medicine.

“Our bodies are physiologically designed to stay alive… As our bodies try to keep us alive, they will pump out natural chemicals to sustain life as long as possible,” Hart wrote in an email to Motherboard. But, she added, “Once the dying process starts, it is very hard to return a person’s body back to a condition where the person can survive.”

This should be comforting to families and medical providers. Among other things, the research affirms that current practices, which typically tell doctors to wait 5 minutes after the pulse stops to name a time of death, are working. At that point, things like organ retrieval are safe to start.

While there are still plenty of questions about death, dying, and the afterlife, this study—which is unlikely ever to be repeated, given its scope—is something close to the definitive word on the question of the post-mortem cardiac activity.

“Determining death is so emotional to everyone,” Dhanani said. “We hope that rigorously studying death and dying, not being afraid of that conversation, will help.”

Complete Article ↪HERE↩!

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What Is It Like to Be Dying?

In “Documenting Death,” a couple who work in palliative care take to social media to share their experiences after one of them receives a terminal diagnosis.

Complete Article And Video ↪HERE↩!

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End-of-life care: people should have the option of general anaesthesia as they die

By and

Dying patients who are in pain are usually given an analgesic, such as morphine, to ease their final hours and days. And if an analgesic isn’t enough, they can be given a sedative – something to make them more relaxed and less distressed at the end of life. We have recently written about a third approach: using a general anaesthetic to ensure that the dying patient is completely unconscious. This has been described previously, but largely overlooked.

There are two situations when a general anaesthetic might be used in dying patients. The first is when other drugs have not worked and the patient is still distressed or in pain. The second is when a patient has only a short time to live and expresses a clear wish to be unconscious. Some dying patients just want to sleep.

But what type of anaesthesia are we talking about? If you need surgery or a medical procedure, there are three options. First, being fully awake, but having local anaesthesia to block the pain. Second, you could be partly sedated: you would be less stressed or worried about it, but you might remember some of the procedure afterwards. Finally, you could have a general anaesthetic and be out cold, with no memory of the procedure afterwards.

Any of these might be appropriate, depending on the procedure and depending on the person. But the option with the highest chance that you won’t feel anything is, of course, general anaesthesia.

These same three options could be offered to a dying patient. Some people might want to be as awake as possible. (Like the poet Dylan Thomas, they might not wish to “go gentle into that good night”.) Some might want to be sedated, if necessary. Others might want to be completely asleep.

The choice of general anaesthesia at the end of life is potentially popular. Last year, we surveyed more than 500 people in the UK about end-of-life options. Nearly 90% said they would like the option of a general anaesthetic if they were dying.

You might wonder, is this not just euthanasia by another name? Giving someone medicines to ensure that they are unconscious as they die naturally is different from giving someone medicine to end their life. General anaesthesia is legal, whereas in many countries, including the UK, euthanasia is illegal. This means that the option of anaesthesia could be available now for dying patients in the UK without changing the law. France has recently recognised the right for dying patients to be unconscious.

Wouldn’t it be too risky?

There are side-effects with all medicines, but recent advances mean that it is possible to give anaesthetic medicines to patients close to death without affecting their breathing. The medicine is given slowly, and the patient made unconscious gradually over 15 to 20 minutes. The medicine can be slowed or stopped at any point.

Tray of anaesthetic drugs.
Tray of anaesthetic drugs.

Previous studies that have used anaesthesia at the end of life, have continued the medicines for one to 14 days until the patient died naturally.

This will not be for everyone. It may not be possible for those who are dying in their own home. And some people will not want it. But we have the means to offer dying patients a gentle alternative end to their days. We believe that there is a strong ethical case to make the option of general anaesthesia at the end of life more widely available.

Complete Article ↪HERE↩!

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When is ‘dead’ really dead?

What happens after a person ‘flatlines’

By and

How long should doctors wait after a “flatline” appears before they can declare a person dead? How can they be sure that heartbeat and circulation will not return?

The most common way that people die is after their heart stops beating. However, there is limited evidence for how long to wait to determine death once the heart stops. This missing information has repercussions for clinical practice and for organ donation.

A fundamental principle of organ donation is the dead donor rule: donors must be dead prior to recovery of organs, and organ recovery must not be the cause of death. A lack of evidence about how long to wait before declaring death creates a tension: if doctors wait too long after the heart stops, the quality of organs begins to decline.

On the other hand, not waiting long enough introduces the risk of going ahead with organ recovery before death has actually occurred.

Our interdisciplinary team of doctors, bio-engineers and experienced clinical researchers has spent the past decade studying what happens when a person dies after their heart stops. We focused on patients in the intensive care unit who died after life support was withdrawn, since these patients may also be eligible for organ donation.

In particular, we were interested in understanding whether it is possible for the heart to restart on its own, without any interventions like cardiopulmonary resuscitation (CPR) or medication.

A closer look at end-of-life flatline

Our recent study, published in the New England Journal of Medicine, presents observations of the dying process of 631 patients across Canada, the Czech Republic and the Netherlands who died in an intensive care unit. All patients’ families consented to participate in the research.

In addition to collecting medical information about each patient, we built a computer program to capture and review heart rate, blood pressure, blood oxygenation level and respiratory patterns directly from bedside monitors. As a result, we were able to analyze end-of-life flatline patterns for 480 out of 631 patients — including looking at whether and when any circulation or heart activity returned after stopping for at least one minute.

As it turns out, the classic flatline of death is not so straightforward. We found that human heart activity often stops and restarts a number of times during a normal dying process.

Out of 480 “flatline” signals reviewed, we found a stop-and-start pattern in 67 (14 per cent). The longest that the heart stopped before restarting on its own was four minutes and 20 seconds. The longest time that heart activity continued after restarting was 27 minutes, but most restarts lasted just one to two seconds. None of the patients we observed survived or regained consciousness.

We also found it was common for the heart to continue to show electrical activity long after blood flow or pulse stopped. The human heart functions as a result of an electrical stimulation of nerves that causes the heart muscle to contract and contribute to blood flow — the pulse you can feel in your arteries and veins.

We found that the heart rate (electrical stimulation leading to movement of the heart muscle) and pulse (movement of blood in the veins) only stopped together in 19 per cent of patients. In some cases, electrical activity of the heart continued for over 30 minutes without resulting in any circulation of blood.

Why understanding death matters

The results of our study are important for a few reasons.

First, the observation that stops and restarts of heart activity and circulation are often part of the natural process of dying will be reassuring to doctors, nurses and family members at the bedside. Intermittent signals on bedside monitors can sometimes be alarming if observers interpret them as signs that life is unexpectedly returning. Our study provides evidence that stops and starts are to be expected during a normal dying process without CPR, and that they do not lead to regained consciousness or survival.

Second, our finding that the longest pause before heart activity restarted on its own was four minutes and 20 seconds supports the current practice of waiting five minutes after circulation stops before declaring death and proceeding to organ recovery. This helps to reassure organ donation organizations that practices of determination of death are safe and appropriate.

Our results will be used to better inform policy and guidelines for the practice of organ donation internationally. For donation systems to work, when someone is declared dead, there must be trust that the declaration is really true. Trust allows families to choose donation in a time of grief and allows the medical community to ensure safe and consistent end of life care.

This study is also important for improving our broader understanding of the natural history of death. We have shown that figuring out when dead is really dead is perhaps not so simple. It requires careful observation and close physiologic monitoring of the patient. In addition, it requires an understanding that, just as in life, there are many patterns that the dying process can take.

Our work is a step towards appreciating the complexity of dying and suggests we must move beyond the idea of a straightforward flatline to indicate when death has occurred.

Complete Article ↪HERE↩!

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Headlines Don’t Capture the Horror We Saw

I chronicled what COVID-19 did to a hospital. America must not let down its guard.

By Kasey Grewe

You likely know that the number of patients hospitalized with COVID-19 is surging across the country. But headlines from distant states do not capture the horror of a hospital without enough intensive-care beds. I was an anesthesiology resident in a large academic medical center at the peak of the pandemic in New York City this spring.

During a time when journalists had little access to what was happening inside New York hospitals, I wrote regular email updates to friends and family. These messages—edited for length and clarity below—showcase the frightening reality of what care looks like in an overwhelmed hospital. (Where I describe individual cases in significant detail, I’ve obtained the consent of the patient or family in question.) The emails relate the experiences of health-care workers, and young doctors in particular: the anxiety, the fear, the overwhelming responsibility, and the ethical burden of hard decisions. Even after the pandemic is over, the weight of these experiences will remain with us for a lifetime.

These messages form a chronicle of what COVID-19 has already done in America and a reminder of what it could do again this winter.

Thursday, March 26

A senior anesthesiology resident holds the stat intubation pager, which goes off when a patient anywhere in the hospital needs a breathing tube right away. My co-residents and I first noticed that things were changing when the pager started to go off every few hours, and then every hour. When the hospital ran out of ICU beds, my department swiftly converted our operating rooms into a giant ICU. A co-resident and I spent Tuesday pushing beds and anesthesia machines around to plan how to fit up to four beds in an operating room. The “OR-ICU” fits multiple COVID-19 patients into one operating room, ventilated via the anesthesia machine’s ventilators. Their daytime doctor, an anesthesia resident in PPE, doesn’t leave their side until their nighttime doctor—another anesthesia resident in PPE—comes to take over.

On Tuesday night, one of my co-residents did 17 emergency intubations. Upon running to respond to yet another intubation page, she was horrified to see that the patient was one of our supervising physicians. Today, one of our surgeons was intubated. Off duty in my Upper West Side apartment, I hear an ambulance go by every 10 minutes. It’s hard to sleep. My colleagues wonder out loud: Is this chest pain from the virus, or just intense anxiety?

Wednesday, April 8

I spent the past few days and nights working in the OR-ICU. It is truly a scene from a science-fiction movie. When I put on my PPE (N95 mask, goggles, face shield, hair cover, gown, and two pairs of gloves) to enter the operating room, it almost feels as though the goggles are a virtual-reality headset. Upon entering the OR, I am confronted with the sight of four patients, all deeply sedated, each intubated and connected to an anesthesia-machine ventilator and many, many pumps for IV medications. Some—the lucky ones—are also connected to machines that perform dialysis. It’s loud. Huge fans filter viral particles from the air, and there are hundreds of overlapping beeps from the monitors, ventilators, and pumps. And it’s a mess. For days I wondered about some patient belongings in the corner: a pile topped with a pair of dark jeans and a cotton polo shirt. I inspected it more closely and saw the name tag of a patient who had passed away several days earlier. Yesterday I noticed a loose paper on the ground and picked it up. “Body Bag Instructions,” it read.

My team is responsible for the care of 12 ventilated patients. Of the 12, six are age 50 or under. Most are showing no signs of progress. One is a relatively young person who has been intubated for more than 10 days. We became optimistic that this patient, who had been breathing well with little support from the ventilator, could be disconnected from the machine. On Monday morning we removed the breathing tube, but the patient quickly deteriorated, and we had to re-intubate.

End-of-life care has always been the work of intensivists. It’s hard but profoundly rewarding to feel that you can help families through some of the most vulnerable moments in their lives. It’s part of the reason I chose to become a critical-care doctor. Pre-COVID, we were used to seeing patients pass away with at least one family member at their side. ICU doctors are desensitized to death, but even for us, the fact that people are dying alone is devastating to watch.

We have a team of doctors—who because of their age or other conditions are at high risk for the coronavirus—working from home as “family liaisons.” They call the family members of every ICU patient to give updates and help make decisions about care. When I arrived at work in the morning, our family liaison informed me that a family wanted to withdraw care from their father. He asked me to call into a Zoom meeting so they could see their dad and make a final decision.

Normally, we meet families in the ICU, but in this case I had never met the family. I called in wearing my full PPE, and was met with the faces of the patient’s children, who looked to be about my age. I introduced myself and asked what their understanding of the situation was. They explained that they understood their dad was very sick and that they didn’t want to keep treating him so aggressively. I expressed that I agreed with their assessment of his condition, and that we would support whatever decision they made. I explained that what they were about to see would likely be disturbing—that their dad might be unrecognizable to them—and asked again if they were sure they wanted to see. They insisted that they did. I slowly went to his bedside and flipped the camera so they could see his face. They immediately started to cry. I cannot imagine how jarring it must have been to see him for the first and last time with a breathing tube, deeply sedated, and in shades of yellow and purple. “That’s not Dad anymore,” one of the children said. I showed them the many machines and IV medications he was connected to. They agreed that he wouldn’t have wanted all this, and said they wanted to proceed with the withdrawal.

I asked if they wanted to say anything to him. I put my phone up to his ear, and one of them said, “I love you, Dad.” I asked if there was any music he liked that they wanted me to play. They said that he didn’t really like music. I offered to call a chaplain to pray with him and they said he would like that. I said, “I’m really sorry. This isn’t fair. I wish things were different.” They said, “Thank you, Doctor. Please let us know when it is done.”

I left the room and wiped my phone aggressively with bleach wipes. I called the chaplains’ office, only to learn that in-person visits were not being made to COVID-19 patients. The family accepted this. I asked a nurse to turn off the patient’s dialysis machine. I turned off the medications supporting his blood pressure, turned down his ventilator, and turned up all his sedative medications to make him more comfortable. I watched him die from outside the room on a vitals monitor while looking over data for other patients. I came back to do the official death exam and pronounce him dead. The nurse was overwhelmed, so I took out all his lines and bandaged him myself. I cleaned the grime off his face.

I called his son and told him that he’d passed away peacefully. His son confided that he was unsure whether they’d made the right decision. Their dad was very sick, and his chances of recovering to his baseline were definitely slim. But there is so much we don’t know about the disease. This man was in his 60s, a little younger than my father. If he were my dad, would I have withdrawn care? What would I have wanted to hear from a doctor on the other end of the line? “There is no right decision,” I said. “The best answer is just what you think he would have wanted. When we turned everything off, he passed away very quickly without the support. Maybe that was his way of telling us.” The son seemed to take solace in that.

During sign-out I told the overnight ICU supervising physician that I had withdrawn care on this patient. She marked on her map that we would have another open bed. “Oh, was he on dialysis?” she asked. “You freed up a machine. Maybe I can salvage this guy downstairs whose potassium is 8”—a level typically considered incompatible with life.

My lesson so far is that this disease, for the subset of patients who become critically ill to the point of requiring mechanical ventilation, is far worse than we ever imagined. It is certainly not pure respiratory failure. At the moment, we still have enough ventilators, but more and more I feel that this won’t save us. Our patients’ kidneys are failing, they remain febrile for weeks with no bacterial infection, they form blood clots in all their lines and likely their pulmonary vasculature, and, most strikingly, even the ones who look entirely ready to breathe on their own often fail when we remove mechanical support. The public conception that one ventilator means one life saved is evidently false.

Two of our own physicians remain intubated in the medical ICU.

Even when speaking to other doctors, my colleagues struggle to explain our situation. While we scramble to stay afloat, doctors from fancy hospitals in other states go on TV in makeup. Frankly, I’m not interested in what’s happening at Massachusetts General Hospital, or Stanford, or the Mayo Clinic. When people academically pontificate on possible treatments from afar, I feel frustrated by their lack of understanding of the issue. We have tried virtually every drug and none of them has worked. We are struggling to provide basic ICU supportive care. None of the experimental drugs will be of any utility in an environment where there are not enough hospital beds, doctors, and nurses.

Wednesday, April 22

I’ve been really shaken by the emergency intubations this week. The patients have been terrified. By the time I’m called, they are gasping for air. Because no visitors are allowed, they are alone. These encounters are emergencies and can be chaotic. We are all wearing PPE, so they can’t see our faces. I try to be kind and reassuring. I ask if they have any questions. But so often, as a result of the patient’s respiratory distress and the oxygen mask over their face, I can’t make out what they are trying to say. I have to say, “I’m sorry, I can’t really understand. We are going to put you to sleep now and put in a breathing tube.” I push medications to sedate and paralyze them, and then put a tube through their vocal cords. Looking down at them as they go to sleep, I’m the last person they see. And for the ones who don’t survive, I will have been the only one to hear—or rather, not hear—their last words.

The main resources we lack are respiratory therapists and ICU nurses. Our department has organized a huge operation in which doctors explicitly fill the roles of nurses and respiratory therapists outside of our regular physician shifts. This week, I’m working two overnight shifts as a respiratory therapist. The chair of my department is walking from room to room suctioning breathing tubes. Senior physicians are brushing patients’ teeth.

In the ICU, patients become voiceless and personless. We take care of their bodies for weeks: examining them, adjusting their ventilators, titrating their sedation, and carefully considering their medical management. But in the absence of family contact, we have no idea who they truly are. Last week, when we were rounding in the OR-ICU, I noticed my intern perusing a colorful website rather than the medical record. A note from a family-liaison doctor had pointed him to a support site for one of our patients. We saw for the first time that this patient was a teacher. The website had hundreds of comments from students and parents: “We are thinking of you every day!” and “We are praying that you make it through this!” There were dozens of photos of a middle-aged man with his students—in the classroom, at school sporting events, wearing different silly costumes. He had a huge, toothy grin. My intern stared at the website, stunned. It took my breath away. My attending physician said, “I can’t look at this. Please close it.” We get through our day in the OR-ICU by compartmentalizing—by ignoring the fact that our patients are people who are deeply suffering. When reality cuts through our fantasy, the job can be unbearable.

I’ve been asked when I think this will be over. There is a human impulse to believe that something this horrible will inevitably improve. But we cannot mistake fewer sirens for organic progress. If the curve has flattened, it is only through the deliberate work of millions of people who have accepted the reality of homeschooling their children, missing their friends and relatives, and forgoing their income. I think we have to trust the scientists who argue that reopening in the absence of a robust testing program or a vaccine will fail. Thank you for all of the sacrifices you have made, and continue to make, in the name of protecting those who are the most vulnerable.

Complete Article ↪HERE↩!

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More than 40% of GPs have accompanied terminal fasting

Most respondents said accompanying someone during terminal fasting was compatible with their professional ethics

Four out of ten family doctors in Switzerland have dealt with at least one patient who refuses all solid or liquid food in order to die, according to a study. Most doctors have a positive approach to the issue.

The Zurich University of Applied Sciences (ZHAW), in collaboration with the Swiss Medical Association, conducted a representative survey of 750 practising family doctors in Switzerland on the voluntary stopping of eating and drinking (VSED), also called ante-mortem or terminal fasting.

VSED is the act of a person who consciously refuses to eat or drink with the intention of dying. Healthcare professionals are therefore not charged with providing a lethal drug to the patient but rather with caring for and accompanying the patient from the beginning of VSED until her or his death.

The survey found that 81.9% of family physicians knew about VSED and 42.8% had accompanied at least one patient during the process. On average, doctors with experience of VSED had dealt with 11 such cases.

“We didn’t expect such a high number,” says Sabrina Stängle, co-author of the research at ZHAW. She pointed out that Switzerland still lacks a unified practice in this area.

“Family physicians lack sufficient in-depth knowledge to address patients and their relatives in an appropriate manner during the process,” the researchers concluded. “Further training and development of practice recommendations are needed to achieve more standardised accompaniment of VSED”.

Stressful

In any case, 59% of the doctors questioned saw VSED as a natural death process when overseen by a healthcare professional; 32% defined it as equivalent to passive euthanasia, 5% regarded it as suicide, 2% considered it a self-determined end-of-life decision and 1% as an alternative form of dying. One per cent of physicians said they would classify VSED differently depending on the case, which would also be based on the patients’ motives and physical health.

Almost three-quarters of respondents (73%) said this assistance was compatible with their worldview or religion, 58% with their professional ethics; 24% said it contradicted their ethics and 18% were neutral. Those who have already been confronted with it are generally more favourable.

That said, more than half of the respondents said accompanying a person during VSED was stressful.

Complete Article ↪HERE↩!

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Hospice Workers Share What They Wish Everyone Knew About Death

By Emily Laurence

When Daniel Lynn tells people he’s a hospice volunteer, he says they usually respond by asking him a question: Why? American culture tends to be put off by anything related to death; it certainly isn’t a welcome topic at a party or around the dinner table. “People ask me why I would want to spend my time doing something so sad, but I find it incredibly rewarding and meaningful,” Lynn says.

Palliative care physician Christopher Kerr, MD, PhD, has gotten similar responses when he tells people about his occupation. Dr. Kerr started working in hospice care—a type of health care focusing on managing a terminally ill patient’s pain and symptoms, as well as their emotional and spiritual needs at the end of life—to supplement his income as a doctor. Up until that time, Dr. Kerr’s job only focused on one outcome—saving patient’s lives—so he admits that he wasn’t quite sure where he would fit into a health-care space where death was imminent. “When I first started, to be honest, I didn’t think there would be much for me to do,” he says. “As a doctor, you’re taught that death is the one thing to avoid.”

The years Dr. Kerr has worked in hospice care, treating thousands of people who are dying, have made him see the dying process in a whole new way. “Death is not a sad experience for everyone,” Dr. Kerr says. His book Death Is But a Dream shares stories of patients he has cared for in hospice, showing that dying is much more than suffering. It can be a time when many become emotionally awakened, and there can be levels of comfort and peace that can’t be explained by science.

This year, of course, death has been on our collective minds more than ever due to the pandemic. It’s devastating to lose a loved one—to COVID-19 or otherwise. But hospice workers offer special insight into what’s often overlooked when we talked about dying. And with their observations comes something we all collectively need right now: healing.

How relationships can change when death is imminent

Lynn became a hospice volunteer in 1985, after both his wife and father died of lung cancer. “My current wife and I are both hospice volunteers in Williamsburg, Virginia,” he says. “And we have two Bernese mountain dogs who work as therapy dogs with us in the hospitals and nursing homes.”

Lynn doesn’t deny that losing a loved one is extremely heartbreaking. “When my first wife was dying of lung cancer, I grieved deeply,” he says. Experiencing the need for comfort during this difficult time in his life was part of what inspired him to be there for others.

Just as people live in different ways, people die in different ways. But something Lynn has noticed in his work is that dying patients often prioritize relationships in a way they didn’t earlier in their lives. “Something I often see is that many people want to make amends and improve relationships that have been damaged,” he says. Family members who haven’t talked in years may start communicating regularly. Grudges are dismissed, replaced by forgiveness and peace.

Angela Shook works as a death doula, a trained professional who supports someone at the end of their life. She’s also seen how important relationships become at the end of life. “Many of the people I’ve worked with have a fear that they’ll be forgotten, so something we often do is a legacy project, which is a way of helping friends and family remember them [after they die],” she says. “One woman I worked with was known in her family as this amazing cook. Everyone loved her food. So for her legacy project, we made a cookbook of her recipes that all her children could have. And we used her old clothes to make an apron for her daughter. It was extremely meaningful to her, and also to them.” In these ways, a death doula can help make saying goodbye easier for both the dying and the living.

Experiencing comfort unexplained by science

While many people equate death with suffering, Dr. Kerr says something that has surprised him the most about working in hospice is the peaceful visions that often come in a person’s final hours. He says 88 percent of his hospice patients report seeing visions as they die. Often these visions—vividly real to the person experiencing them—are of people who have died before them, and they provide a great sense of comfort, peace, and even joy.

Dr. Kerr adds that dying children often see pets who have passed away. “Children don’t have the same language that we do to talk about death, but the visions they describe give them a sense that they are loved and that what is happening to them is okay,” Dr. Kerr says.

He cannot offer a scientific explanation for these phenomena. “There’s this assumption that people have these visions because their brains are changing, becoming deoxygenated, or they are medicated and confused, but that’s not the case,” he says. “We know that by looking at the brain; it’s not changing biologically or functionally. I think people are changing very much spiritually.”

“To me, visions like these show that we really don’t die alone. And there can be comfort and even joy in dying.” —Angela Shook, death doula

Shook says many of her clients have also had visions. She and Dr. Kerr say it’s something that happens regardless of religious or spiritual beliefs; even those who don’t believe in a higher power or an afterlife can experience visions. “I would estimate visions are part of about 90 percent of the deaths I’ve been apart of,” Shook says. “One 83-year-old woman I worked with had been feeling very agitated for the three days. But when I walked into her room one day, she had a peaceful smile on her face. I looked over at her and she was rocking her arms, as if she was holding a baby.” The patient died shortly after that, and Shook shared what she saw with the patient’s son. “He told me that his mom’s first daughter had been a stillborn and she had often said that she couldn’t wait to see her daughter in heaven one day,” Shook says. “To me, visions like these show that we really don’t die alone. And there can be comfort and even joy in dying.”

Not everyone, though, has happy visions. In his book, Dr. Kerr says his research has found that in 18 percent of his patients who have visions, they are more like nightmares. “There seems to be a correlation between people who have had very traumatic experiences in life or a lot of regret [and experiencing negative visions],” he says.

Of course, it would be unfair to paint everyone’s end of life experience as peaceful and uplifting. The truth is, death is sometimes accompanied by pain and suffering, both physical and emotional. “Often, people have a question of ‘why me?’” Lynn says, adding that some are angered by what’s happening to them. It seems death, like other stages of life, isn’t all good or bad. Still, few people talk about the moments of peace—and even joy—in the process, and that’s what Lynn, Shook, and Dr. Kerr hope to shed light on.

“Becoming a death doula and spending time with the dying has been the greatest, most beautiful gift of my life,” Shook says. “It’s strengthened my belief that there’s more beyond what we can see.”

What hospice care has looked like during COVID-19

Both Dr. Kerr and Shook say their jobs have changed tremendously during the pandemic, and have caused them to think even more about the importance of end-of-life care. “Our work in hospice and palliative care has become invaluable during the pandemic,” Dr. Kerr says. He adds that, for him, working during the pandemic has been a struggle as the way he works has changed tremendously. “Personally, I feel a bit lost,” he says. “My work is most meaningful when defined by direct interpersonal relationships with patients, families, and colleagues.” But as hospitals and care facilities tightly restrict visitors to reduce the spread of COVID-19, cultivating those relationships is extremely difficult.

Shook says she feels her work has become more vital than ever in helping loved ones find avenues of closure. “Many have lost loved ones and been unable to mourn at a service or traditional funeral because of social distancing restrictions,” she says. “It is so important to take the time to grieve and realize that grief looks different for everyone.” Since, for many, attending a funeral isn’t a possibility right now, it can make finding other ways to say goodbye—such as through a legacy project—especially meaningful right now.

“Those of us who work at the bedside of the dying can attest that patients, in the face of what may look to most like a lonely death, do experience love, meaning, and even grace.” —Christopher Kerr, MD, PhD

Shook says she has still been providing her services as a death doula virtually, as meeting in person with families is not currently possible. “Many facilities and hospices in which many doulas work have restrictions on visitors. During this time, doulas [like myself] have been offering virtual support through web conferencing, calls, letters, FaceTime, and more,” she says. “With so many being isolated, doulas are more important than ever and can still support the dying and their loved ones from a distance.”

Dr. Kerr says that many family members of his patients have expressed devastation and sadness at not being able to be physically present for their loved one’s final moments. He sympathizes with this sentiment, but offers up some words of comfort. “The dying process includes altering levels of alertness and progressively deeper sleep, and include vivid pre-death dreams,” he says. “[In their final days], the majority of patients see not tubes or monitors but the faces of predeceased loved ones. They revisit the memories of being held and cherished, the apotheosis of a life rather than its demise. They teach us that the best parts of having lived are never truly lost.”

This, he says, reveals something important about the dying process, whether it’s during a pandemic or not: “The totality of our human experience can never be defined by or reduced to its last moments,” he says. “Those of us who work at the bedside of the dying can attest that patients, in the face of what may look to most like a lonely death, do experience love, meaning, and even grace. The dying often experience a summation of their life’s best moments and they leave us feeling more connected than alone.”

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