[M]y cat, Osiris, is lying at my feet as I type this article. That’s his normal nook while I’m in my office, which doubles as our guest room—the futon behind me is also a suitable sleeping option. Celebrating his eighteenth birthday soon, I’m thankful he’s stayed healthy and vibrant for this long. The same was not the case for his namesake.
On Sunday many Christian faithful celebrated the resurrection of their savior. Yet the story of Christ is an oft-repeated motif in mythological literature. Resurrection tales abound across the planet. This was first brought to broader attention thanks to James Frazer’s The Golden Bough, an exhaustive survey on world mythologies that was originally written to show their inadequacies by a skeptical Frazer, yet turned out to influence entire academic departments in the comparative mythology and comparative religion fields that grew from his work.
While much speculation has been offered as to why resurrection cycles persisted, the annual birth, death, and rebirth of the soil provide an important clue. The plants that grow, wither, and die seasonally only to return to nourish us once again makes for a convenient segue to the concept of souls. Frazer consciously linked this fact with the cults of Persephone, Adonis, Attis, Osiris, and Dionysus. As he writes,
It remains to see whether the conception the annual death and resurrection of a god, which figures so prominently in these great Greek and Oriental worships, has not also its origin or its analogy in the rustic rites observed by reapers and vine-dressers amongst the corn-shocks and the vines.
Easter Sunday, known as Resurrection Sunday to the faithful, marks the third day of Christ’s burial after his death on the crucifix. Missionary Christianity spread Christ’s story across the planet; over the course of centuries those other resurrected gods were discredited, rewritten, or forgotten. The uniqueness of Christ’s story has been challenged by modern scholarship, notably by tablets such as Gabriel’s Revelation. Frazer just brought that reality to the forefront.
Unlike many older stories, the Christ motif was unlinked at some point from sexuality and regeneration to focus on the soul. This speaks in part to the establishment of Christian ethics, yet the desexualization of Christ did a disservice to our understanding of ecology and the environment. The below figures are all in some way connected to fertility and nutritional sustenance, two necessities for the continuation of life. The Christ story is mainly metaphysical, unchained from the earthly cycles even though those annual renewals provide the foundation upon which the Christian mythology was founded.
Beyond the cited figure in each historical mythology is the theme, which is essentially more relevant to the living than the dead. Sure, we discover emotional comfort by the notion of life beyond the grave, but what really matters is picking ourselves up after deaths during lifetime—divorce; the death of relatives and loved ones; losing a job; watching a child leave the nest. Our character is defined by our response to tragedy and suffering.
As the characters below demonstrate, some achieve greater glory after the tragedy while others are trapped in an unforgiving underworld for eternity. What unites them is the human imagination that dreamed up each figure to communicate a primal idea about how to navigate life.
The Egyptian deity of the afterlife, underworld, and dead is the classic tale of regeneration. There are many variations on his theme, but each poem centers around his love for his sister-wife Isis, a jealous brother that murders him, Set, and his son, Horus, who avenges his father’s death. In every variation, Isis copulates with Osiris’s briefly resurrected body before he once again perishes. In one telling, his body parts are scattered across the planet, which Isis has to collect before stitching him back together. The agricultural connection is clear: Osiris was associated with the annual flooding of the Nile River and the crops dependent upon its rising. He was also linked to the positioning of the stars, Orion and Sirius, at the beginning of each new year, another resurrection motif.
The Greeks offer the most famous mythological motifs in the West, unsurprisingly as they’re the basis of our culture. Maybe the drunken god of grape harvest, wine, fertility, religious ecstasy, and ritual madness waking up the morning after was enough of an impetus to make him a resurrected being—sulfites pack a punch. Dionysus was never crucified, but torn to bits by cannibalistic titans; he was somehow reshaped from the remaining heart, which flies in the face of anthropological data that our ancestors were organ eaters. Regardless, mythology is not about facts. Rituals celebrating his prowess remain beloved to this day.
In one of the world’s oldest pieces of literature, The Epic of Gilgamesh, the Sumerian king references Tammuz, an ancient Mesopotamian lord of shepherds, as an ex-lover of Ishtar who was turned into a bird with a broken wing. The scorching Mesopotamian summers needed a hero to resurrect the fertile soil every year—the link between sex/fertility and vegetation, noted above with Dionysus, is another common motif—and that duty fell onto Tammuz, who was also known as Dumuzid. A midsummer month was even named in his honor. Tammuz’s legacy lived behind himself, as gods do. He was incorporated into myths in the Levant and Greece, where he became known as Adonis.
Being the mortal lover of Aphrodite is no small task. As his harbinger, Tammuz, was already firmly secure in his sexual prowess, Adonis has echoed through the generations as the ideal lover. Born from a myrrh tree and raised by Persephone, whose own myth centers on the regeneration powers of vegetation, Adonis’s good looks created a feud between Aphrodite and Persephone. Zeus declared that the boy would spend one-third of each year with each of them, then choose where to spend his final third term. He must not have been a fan of Hades, as he chose Aphrodite. Then he was gored by a wild boar, dying in Aphrodite’s arms. Adonis is reborn with gardens planted in his honor each summer, the result of his dying blood mixing with Aphrodite’s tears to form an anemone flower.
This Geek deity’s story went down over a millennia before the Christ figure appears. His first cult was linked to a Phrygian trading outpost, Pessinos, whose great mountain was thought to be a daemon. Attis’s mother, Nana, became pregnant by laying an almond from a mystical tree on her bosom. She had second thoughts about this motherhood job, though, as upon his birth she abandoned him. Attis was subsequently raised by a he-goat. He fell in love with Cybele, but his foster parents sent him to Pessinos, where he was forced into an arranged marriage to King Midas’s daughter. Eventually, he went mad and cut off his genitals, so that he would not betray Cybele. He too died and was reborn, concurrent with the spring planting and autumn harvest the locals experienced every season.
[I]n the Halloween season, American culture briefly participates in an ancient tradition of making the world of the dead visible to the living: Children dress as skeletons, teens go to horror movies and adults play the part of ghosts in haunted houses.
But what if the dead played a more active, more participatory role in our daily lives?
It might appear to be a strange question, but as a scholar of late medieval literature and art, I have found compelling evidence from our past that shows how the dead were well-integrated into people’s sense of community.
Families offered commemorative prayers to their ancestors, whose names were written in “Books of Hours,” prayer books that guided daily devotion at home. These books included a prayer cycle known as the “Office of the Dead,” which family members could perform to limit the suffering of loved ones after death.
Medieval culture also had its ghosts, which were closely linked with the theological debate concerning purgatory, the space between heaven and hell, where the dead suffered but could be relieved by the prayers of the living. Folk traditions of the dead visiting the living as ghosts were thus explained as souls pleading for the prayerful devotion of the living.
When, how practices changed
The Reformation in Europe radically changed this cultural interface with the dead. In particular, the idea of a purgatory was rejected by Protestant theologians.
While ghosts persisted in folk stories and literature, the dead were pushed from the center of religious life. In England, these changes were intensified in the period after Henry VIII broke with the Catholic Church in the 1530s. Thereafter, the veneration of saints and commemorative prayers associated with purgatory were banned.
The dead were also removed from view in more literal ways: Reformation iconoclasts, who wished to purge churches of any association with Catholic practices, “whitewashed” hundreds of church interiors to cover the bold, colorful murals that decorated the medieval parish churches.
One of the more popular mural subjects that I have studied for many years was the Dance of Death: over 100 mural paintings of the theme, as well as dozens of manuscript illuminations, have been identified in England, Estonia, France, Germany, Italy, Spain and Switzerland.
A powerful metaphor
Dance of Death murals typically depicted decaying corpses dancing amid representative figures of late medieval society, ranked highest to lowest: a pope, an emperor, a bishop, a king, a cardinal, a knight and down to a beggar, all ambling diffidently toward their mortal end while the corpses frolic with lithe movements and gestures.
When modern viewers see images like the Dance of Death, they might associate them with certain well-known but frequently misunderstood cataclysms of the European Middle Ages, like the terrible plague that swept through England and came to be known as Black Death.
My research on these images, however, reveals a more subtle and nuanced attitude toward death, beginning with the evident beauty of the murals themselves, which endow the theme with color and vitality.
The image of group dance powerfully evokes the grace and fluidity of a community’s cohesion, symbolized by the linking of hands and bodies in a chain that crosses the barrier between life and death. Dance was a powerful metaphor in medieval culture. The Dance of Death may be responding to medieval folk practices, when people came at night to dance in churchyards, and perhaps to the “dancing mania” recorded in the late 14th century, when people danced furiously until they fell to the ground. But images of dance also provoked a viewer to participate in a “virtual” experience of a community. It depicted a society collectively facing up to human mortality.
A healthy community
In analyzing the murals in their broader social context, I found that for medieval cultures, dying was a “transition,” not a rupture, that moved people from the community of the living to the dead in stages.
After death, groups prepared the corpse, sewed its shroud and transported the body to a church and then to a cemetery, where the broader community would participate in the rituals. These activities required a high degree of social cohesion to function properly. They were the metaphorical equivalent of dancing with the dead.
The Dance of Death murals thus depicted not a morbid or sick culture but a healthy community collectively facing their common destiny, even as they faced the challenge to renew by replacing the dead with the living.
Many of the murals are irretrievably lost. However, modern restoration work has managed to recover some of them. Perhaps this conservation work can serve as inspiration to recover an older model of death, dying and grief.
Acknowledging the work of the dead
In the modern era entire industries have emerged to whisk the dead from view and alter them to look more like the living. Once buried or cremated, the dead play a much smaller role in our social lives.
Could bringing the dead back into a central role in the community offer a healthier perspective on death for contemporary Western cultures?
That process might begin with acknowledging the dead as an ongoing part of our image of community, which is built on the work of the dead who have come before us.
[I]t was a surprise to enter the Abbey of Gethsemani’s church and see a body lying on a bier. Br. Harold was dressed in a white cowl and his face bore no signs of being made up by a mortician. He did not look like he was sleeping. He looked like what he was: dead.
He was not alone. The community had kept vigil with Br. Harold all night, each monk taking turns at the bier, praying the psalms with him one last time, prayers he knew so well from decades of saying the Divine Office.
As the funeral Mass began, Br. Harold’s bier was carried directly in front of the altar. There was no casket and his face was not covered. He simply lay there, a monk among his brother monks, albeit a now silent and unmoving participant in the Eucharistic feast.
After the Mass, his bier was carried out the doors of the church to the cemetery, filled with hundreds of identical white crosses. Here are buried monks from more than 160 years of monastic life at the Abbey. Among them is Thomas Merton, known in the community as Fr. Louis, buried beside Dom James Fox, the abbot with whom he so often clashed.
Along with the monks and members of Br. Harold’s family, I processed to a freshly dug grave. Although I’ve come to know quite a few of the monks of the abbey, I didn’t know Br. Harold. He was already in the infirmary with Alzheimer’s when I moved to Kentucky. I learned, though, that I missed out on a beautiful and simple man who breathed God in deeply, particularly when looking at a flower in bloom.
To allow Br. Harold’s brother monks, family members, and friends to be near the graveside, I found a spot on an outlook near the church that stood above his final resting place. Cistercians dig their graves very deep and they bury their dead without caskets. From my perch I could see that a pillow had been placed in the grave, on which had been placed a flower. There was also a ladder leading into the grave.
After graveside prayers, one of the monks descended the ladder while others lifted Br. Harold from the bier. The sheet he was on had six long straps attached by which he was lowered into the ground. As his brothers lowered Br. Harold down, the monk standing in the grave gingerly held Br. Harold’s head.
There was love and gentleness in the way the monk did this. I was reminded of the care with which my wife and I would put each of our newborn sons into the crib, doing all we could to make sure that his sleep wasn’t disturbed. When Br. Harold reached the bottom of the grave, I could see his brother monk almost tuck him in for his rest. He carefully laid Br. Harold’s head on the pillow, placed a white shroud over his face, and then ascended out of the grave, pulling up the ladder behind him.
From my vantage point I could see Br. Harold at the bottom of the grave, and then, shovel by shovel, being covered in dirt. Truth be told, it was disconcerting to see a human body—not a body in a casket, but simply a body—be buried. But never before had the words Christians recite on Ash Wednesday—remember you are dust—been as real to me as they were at that moment.
More importantly, I had never experienced death as something beautiful before this funeral. What I witnessed was the care and love of a community for one of their brothers, a care that extended to the very depths of the grave.
On Ash Wednesday we are reminded once again of our mortality; some of us need this reminder more than others. However, there’s something about my experience at Br. Harold’s funeral that leads me to contemplate my mortality not as something to be feared, but as an invitation to give more completely of myself to those in my community—to my wife, to my sons, to my students and colleagues, to those in my parish, and to those in my neighborhood and city.
Br. Harold lived a life of prayer and devotion in the context of a community, staking his own existence to the existences of others. In his life, he gave himself to his community. In his illness and death, the monks in the community gave themselves to him. At his funeral I learned that to confront our mortality is to come face to face with the reality of how deeply and truly we need one another.
The Buddha said the greatest of all teachings is impermanence. Its final expression is death. Buddhist teacher Judy Lief explains why our awareness of death is the secret of life. It’s the ultimate twist.
[W]hether we fight it, deny it, or accept it, we all have a relationship with death. Some people have few encounters with death as they are growing up, and it becomes personal for them only as they age and funerals begin to outnumber weddings. Others grow up in violent surroundings where sudden death is common, or see a family member die of a fatal illness. Many of us have never seen a person die, while people who work in hospitals and hospices see the realities of death and dying every day. But whether death is something distant for us or we are in the thick of it, it haunts and challenges us.
Death is a strong message, a demanding teacher. In response to death’s message, we could shut down and become more hardened. Or we could open up, and become more free and loving. We could try to avoid its message altogether, but that would take a lot of effort, because death is a persistent teacher.
Teacher death met up with us the minute we were born, and is by our side every moment of our life. What death has to teach us is direct and to the point. It is profound but intimate. Death is a full stop. It interrupts the delusions and habits of thought that entrap us in small-mindedness. It is an affront to ego.
Death is a fact. Our challenge is to figure out how to deal with it, because it is never a good plan to struggle against or deny reality. The more we struggle against death, the more resentment we have and the more we suffer. We take a painful situation and through our struggles add a whole new layer of pain to it.
We cannot avoid death, but we can change how we relate to it. We can take death as a teacher and see what we can learn from it.
Facts are facts: everyone is going to die sooner or later. No magic trick or spiritual gimmick will make it go away. Distancing ourselves from death or putting off thinking about it does not work.
I have noticed that the more distant we are from death, the more fear arises. Death becomes alien, other, scary, mysterious. People who work regularly with the dying, who are closer to death, seem to have less fear.
We each have our own unique relationship with death, our own particular history and circumstances, but one way or another we all relate to death. The question is: how do we relate with this reality and how does this color our lives? It is possible to come to terms with the fact of death in a way that enriches our lives, but to learn from death we must be willing to take a dispassionate look at our experiences and preconceptions.
Reflecting on our own mortality and the reality of death is practiced in many contemplative traditions. In the Buddhist tradition, the contemplation of death is said to be the “supreme contemplation.” It encompasses reflecting not only on physical mortality, but on impermanence in all its dimensions.
By means of meditation and by developing an ongoing awareness of death, we can change our relationship with death and thereby change our relationship with life. We can see that death is not just something that pops up at the end of life, but is inseparably linked with our life moment to moment, from the beginning to the end. We can see that death is not just a final teacher. It is available to teach us here and now.
When we contemplate in this way, our many schemes for getting around the reality of death, such as coming up with interpretations to make it more palatable, are exposed one by one and demolished. Death is the great interrupter, unreasonable and nonnegotiable. No amount of cleverness will make it otherwise.
Contemplating death is not an easy practice. It is not merely conceptual. It stirs things up. It evokes emotions of love, sorrow, fear, and longing. It brings up anger, disappointment, regret, and groundlessness. How tender it is to reflect on the many losses we have experienced and will experience in the future. How poignant it is to reflect on life’s fleeting quality.
How we think about death matters. It affects how we live our life and how we relate to one another.
In this practice, we deliberately bring our attention back again and again to our relationship with death. We examine what we mean by death and what it brings up for us. We reflect on our experiences and reactions to it.
It is a bit like going for marriage counseling. “When did you two first meet? Tell me a little about your history. Do you spend much time together? What is it about him or her that has offended you? How do you see your relationship moving forward?” You could say that death is your most intimate partner. It is with you all the time, completely interwoven into your daily activities. Since that is the case, wouldn’t it be worthwhile to make a relationship with it?
But our relationship with death is not that simple. In order to understand it, we need to slow down and systematically examine our ideas about it, what it brings up for us, and what it means to us. Death stirs up all kinds of thoughts. And hidden within those clouds of thoughts is a small, unspoken, deep-rooted, yet persistent notion—that we will come through it intact, as though we could come to our own funeral.
The more closely you look into all these ideas, the more you see how inadequate the conceptual mind is in the face of death. Nonetheless, how we think about death matters. It affects how we live our life and how we relate to one another.
Contemplative practice challenges us to look deeply into our thoughts and beliefs, our fantasies and presumptions, and our hopes and fears. It challenges us to separate what we have been told from what we ourselves think and experience. We have all kinds of thoughts about what happens when we die and how we and others should relate with death, but through meditation we learn to recognize thoughts as thoughts. We learn not to mistake these thoughts and ideas about death for direct knowledge or experience. We learn not to believe everything we think or everything we have been told.
We are in a dance with death at all levels, and each level influences and is influenced by the others. We are influenced by what we have been told about death and dying, by our personal history, by our cultural biases, and by what we have observed. We are also influenced by inner habits of thought and conditioned responses. Our most subtle views and reactions to impermanence may be quite hidden, but they touch on our view of life altogether, and on our personal identity.
If we want to understand our relationship with death, we need to explore its broader as well as its more subtle dimensions. If we are willing to take an honest look at how we personally deal with this reality, we can develop a deeper understanding of impermanence and even befriend it.
One way to begin is by reflecting on your personal history with death. What have you been told about death? What are some of your earliest experiences of it?
In my case, when I was about five, I was told my babysitter had died, and that was it. For me, she just disappeared, and children did not go to funerals. A bit later, when my aunt died, I was told that she would go to heaven, a very beautiful place. But I didn’t think people really believed that, because all I saw were people upset and crying. When pets died, I was told they “went to sleep.” It didn’t look like sleep to me.
As a child, I observed that dead animals did not breathe or move about like live ones. I saw that they shriveled up and began to smell funny, or were squashed beyond recognition. I saw that dogs hit by cars screamed in pain and that animals looked sick before they died. I saw that people became old and frail. I saw that when you killed a bug, you could not make it come back to life, even if you felt sorry. My friends and I thought it was funny to sing ditties, like “The worms crawl in, the worms crawl out…” Death was not that real to us; we made it into a joke.
I observed many such things on an outer level, but on an inner level, I did not have a clue as to what death was about or what it all meant. I did not know how to make sense of it, or to link it to other experiences in my life.
Death is the texture out of which we grow our identity, the stage on which we enact our story.
In our encounter with mortality, it is this inner dimension, the relationship dimension, that we need to explore. It becomes obvious that to get to a more uncluttered relationship with death, we first need to plow through a surprising number of ideas, presumptions, and speculations, some of which are very deep-rooted. Through this process, we can become aware of the many concepts that are floating around in us, and try to figure out where they come from and what effect they have on us.
When we look into where all this comes from, we encounter a paradox. We usually consider death to be the end, but it begins to seem that death is in fact the beginning. It is the texture out of which we grow our identity, the stage on which we enact our story.
We can begin our exploration right where we are. We have already been born, we are alive, and we have not yet died. Now what? We might connect to our life in terms of a story or a history. For instance, we were born in such and such a time and place, we did this and that, and we have a particular label and identity. But that story is always changing and in process; it is not all that reliable. However, when our story is combined with a physical body, we seem to have something more solid, a complete package. We have something to hang onto and defend. We have something that can be taken away.
But what do we have to hang onto, really? Our story is not that solid. It is always being revised and rewritten. Likewise, our body is not one solid continuous thing. It too is always changing. If you look for the one body that is you, you cannot find it.
The closer you look, the less solid this whole thing seems. When we investigate our actual experience, here and now, moment by moment, we see how fleeting and dynamic it is. As soon as we notice a thought, feeling, or sensation, it has already happened. Poof! It is the same with the act of noticing. Poof! Gone! And the noticer, the one who is noticing, is nowhere to be found. Poof! When we contemplate in this way, we begin to suspect that this life is not all that solid—that we are not all that solid.
This may seem like bad news, but in fact this discovery is of supreme importance. As we begin to see through our mythical solidity, we also begin to notice all sorts of little gaps in our conceptual schemes. We notice little tastes of freedom and ease in which our struggle to be someone dissolves, and we just are. In such moments, at least briefly, we are not being propelled by either hope or fear. We see that continually holding onto life and warding off death as a future threat is not our only option. There is an alternative to our tight-jawed habit of holding on and defending.
After each little insight or pause, there is a regrouping, and we find ourselves reconstructing our world. Each time we put it back together, we are also putting together the threat that it cannot be maintained. We do this over and over again. We are repetitively and continuously fueling the pretense of solidity and the fear of death that comes with it.
To undo this harmful habit, we need to see it more clearly. We need to recognize that we ourselves are responsible for perpetuating it, and therefore we have the power to stop.
In looking at the seeds of our relationship to life and death at a subtle inner level, we uncover how we set ourselves up for a struggle with death from the beginning—at the very personal level of identity and self-definition.
The more solidly we construct ourselves, and the more rigidly we identify with this construct, the more we have to defend and the more we have to fear. Looking at death in terms of such subtle underlying patterns may seem inconsequential, but it is not.
When we drop the battlefield approach—that life and death are enemies—we become open to an entirely new way of viewing things. Instead of this vs. that, us vs. them, something much more inspiring can take place. Experiences can arise freshly because they are immediately let go. Because they are dropped as soon as they arise, there is nothing to hold onto and nothing to lose. There is no battlefield, no winner and loser, no good guy and bad guy.
Simple formless meditation is a very powerful tool for relaxing this pattern of holding and defending. Working with death through our awareness of momentary arisings and dissolvings is a profound practice. It shows us that the life–death boundary is an ongoing and quite ordinary experience, and that this unsettling meeting point colors all that we do. If we can become more grounded at this level, we can become more open to what death has to teach us altogether.
Although death is an ongoing reality, there are times when it hits us particularly hard. It may be when we have a health scare or a near accident. At such times, we really wake up to the presence of death, and its teachings come through loud and clear. The heart pounds, the senses are heightened, and we feel extra alive. There is a stillness, as though time had stopped.
When we become complacent and take things for granted, death steps in.
Times like this are so simple and straightforward, so immediate. “This is it,” we think. “It’s actually happening.” In such moments, the heightening of our awareness of death simultaneously heightens our feeling of being alive.
In fact, in the face of death, we feel more fully alive than ever. We are shocked into thinking more seriously about what to do with the time that we have. Usually, though, we don’t maintain that awareness, and the feeling of heightened aliveness fades away. We revert to the default pattern of avoiding death, and, along with that, our dulled down approach to life.
Maintaining an awareness of death makes life more vivid. In the light of death, petty concerns fall away and our usual preoccupations become meaningless. It is as though clouds of dust that have covered over something shiny and vivid have been blown away, and we are left with something raw, immediate, and beautiful. We have insight into what matters and what does not.
Awareness of death—hearing its teaching—cuts through the subtle clinging at the core of our experience. It cuts through our self-clinging and our clinging to others. This may sound harsh, but all that clinging has not really helped us or anyone else. Our clinging to others may have the appearance of real caring, but it is based on fear and an attempt to freeze and control life. It is a way of tuning out death and pulling back from the intensity of life. But if we develop more ease with our own impermanence and struggles with death, we can be more understanding of others and their struggles. We can connect with one another with greater genuineness and warmth.
Death turns out to be the teacher who releases us from fear. It’s the teacher that opens our hearts to a more free-flowing love and appreciation for life and one another. When we get stuck in self-importance and earnestness, death steps in. When we get caught in self-pity, death steps in. When we become complacent and take things for granted, death steps in.
Death spurs us forward with a sense of urgency and puts our preoccupations in perspective. Death lightens our clinging and mocks our pretensions. Death wakes us up. It is our most reliable teacher and most constant companion.
[D]ecisions about diabetes care can become harder as people age, and that may be especially true for those needing hospice care.
A new study has found that, among people getting hospice care in a nursing home, diabetes care may lead to higher rates of dangerous low blood sugar episodes, known as hypoglycemia.
That finding came from the researchers’ analysis of data on nearly 20,000 people with type 2 diabetes, all in nursing homes and receiving hospice care.
In 180 days, the time period covered by the study, about one in nine people experienced low blood sugar episodes. But, among those treated with insulin, about one in three had low blood sugar episodes, according to the study’s lead author, Dr. Laura Petrillo, an instructor in medicine at Harvard Medical School.
Low blood sugar can cause weakness, sweating, confusion, shakiness and dizziness, which can cause suffering and reduced quality of life. The researchers defined low blood sugar episodes as blood sugar levels under 70 milligrams per deciliter (mg/dL).
“Hospice is care focused on maximizing comfort at the end-of-life, and usually includes stopping treatments that are unlikely to have short-term benefits,” Petrillo said. “Patients with type 2 diabetes were experiencing hypoglycemia, which would be an indication that there was room for improvement in their diabetes care.”
The study also looked at high blood sugar episodes, defined as blood sugar levels over 400 mg/dL. High blood sugar — hyperglycemia — can cause excessive thirst and a need to urinate more frequently. During the 180 days, 38 percent of patients treated with insulin had low blood sugar, 18 percent had severe low blood sugar and 35 percent had high blood sugar.
Blood sugar levels were checked an average of 1.7 times a day for people on insulin and 0.6 times a day for those who weren’t given insulin, according to the report.
People in the study were receiving end-of-life care at Veterans Affairs nursing homes between 2006 and 2015. All were 65 or older, and nearly all — 98 percent — were men. About 83 percent died before 100 days.
The study findings bring up an important issue — the need for more specific guidelines for diabetes management in nursing home and hospice patients, according to Dr. Joel Zonszein, director of the Clinical Diabetes Center at Montefiore Medical Center in New York City.
Those institutions often “export guidelines for hospitalized patients, and end up continuing to use a lot of medications that cause hypoglycemia,” he said.
Zonszein noted that insulin isn’t the only medication that can cause low blood sugar levels. Some oral diabetes medications also can cause blood sugar levels to drop too low.
In addition to causing people to feel terrible, low blood sugar levels can also increase the likelihood of falls — a concern in hospice facilities and in nursing homes, he explained.
“If medications are not improving quality of life in hospice, it doesn’t make sense to use them,” Zonszein said. “There are many newer medications that don’t cause lows and control the highs. They cost more, but you don’t have to monitor patients as much,” so ultimately they’re likely cost-saving, he suggested.
Matt Petersen, managing director of medical information for the American Diabetes Association, said that the study adds to the understanding of end-of-life care for people with diabetes.
“Hypoglycemia is to be avoided for safety and quality of life, but severe hyperglycemia is also to be avoided for the same reasons — left to go too high, glucose levels can lead to catastrophic (and very unpleasant) metabolic crisis,” Petersen said. “In patients that may not be eating well, estimating insulin dosing to match food intake can be challenging.”
Petersen said it appears from the information provided that patients in the study were receiving individualized care based on their health condition, which is what the American Diabetes Association recommends for care.
“Care should involve a comprehensive consideration of what will ensure the best circumstances for the patient,” he noted.
The study authors pointed out that about one-quarter of people in the United States die in a nursing home, making this a problem many people might face.
What, then, can people do to ensure they or a loved one receives the right care for them in a nursing home, particularly as they near the end-of-life?
“Advocate for your loved ones,” Petrillo advised. “Ask for a medication review, and make sure that medications are geared toward providing comfort and that they’re not receiving anything that doesn’t have a short-term benefit.”
The study was published as a research letter in the Dec. 26 online edition of JAMA Internal Medicine.
“Are you willing to pretend something for a minute?” asks Greg Lathrop, a local end-of-life activist. “So, let’s pretend this. March 27 will be your last day here. In this game, we know that you’re going to die March 27th. Now, how’s your life? See, it’s a simple perspective shift. Perspective is just a choice. You shift the perspective just that much, and it opens a door. We’re getting somewhere. Now it’s like, ‘I hate my job,’ or ‘I’m in debt up to my eyeballs.’ What would it look like, in these last three months, to live the best three months of your life? It gives us an opportunity. It’s more than a bucket list. What’s your life’s purpose — why are you even here?”
Lathrop, a registered nurse, holds a certification as a Sacred Passage doula — caring for people who are in the process of dying — and is co-founder of Asheville’s Third Messenger, a community of Asheville death-issues activists who have created a forum for conversations about death at the so-called Death Cafe. Lathrop is also part of a growing national community that works in “the death trade” — people dedicated, he notes, to broaching the conversation of death and dying within a culture that prefers to speak about virtually any other subject.
Lathrop first began that conversation on the heels of his own significant loss. Synchronistically, the death of Lathrop’s wife and the passing of Third Messenger co-founder Said Osio’s daughter propelled the two men to join forces in end-of-life activism. To Asheville locals and tourists alike, Third Messenger’s work may be most visible in what has become a landmark Biltmore Avenue structure.
Ministered to for years by Earl Lee “Happy” Gray (before his passing in October 2016), the “Before I Die” wall poses passers-by one simple question: What have you left undone? Not surprisingly, responses range from the mundane to the profound, reflecting our culture’s divisive relationship with the end of life. Yet the wall serves as a catalyst, the beginning of what Third Messenger views as a critical and much-needed conversation. “We cultivate the sacred art of being with dying — we use art to engage the conversation,” says Lathrop.
It is precisely this lack offamiliarity with death that engenders the paralyzing fear of the unknown and creates what author and end-of-life activist Stephen Jenkinson, who spoke at Asheville’s Masonic Temple Nov. 6, refers to as a “death-phobic culture.”
Dr. Aditi Seth-Brown, hospice and palliative care physician at CarePartners, agrees: “Many years ago, there were so many intergenerational families and communities, so death was something that young children were around and saw — life happened around death.” As a result of an unfortunate marriage of families living farther apart and a highly individualistic culture, Sethi-Brown now frequently encounters many individuals who have virtually no experience with the process she views as an inextricable part of life.
“People come to us, and oftentimes this is their very first experience with death, and there’s so much fear of the unknown,” says Sethi-Brown,who is also is a local musician, whose work includes playing for people transitioning and at Third Messenger events. “Sometimes, family members come to us and say, ‘We don’t want our loved one to know that they’re dying.’ We don’t practice it. There are some traditions around the world that actually have practices around death, meditations around death — just like if you’re birthing, you go to birth classes, read birth books, but [there’s] nothing to prepare you for death.”
Shining light upon the shadows
“I was 9. That’s the start of it, in my memory.” says Asheville resident Julie Loveless. Beginning in early childhood, Loveless found herself plagued by an inexplicable and inescapable fear of death. One night in particular, Loveless says, “We were at my grandmother’s house. My parents were there, my grandmother, my aunt, and it was time for me to go to bed. I was terrified, because I knew I wasn’t going to wake up the next morning. So I was coming up with all of these tactics to stay up. I had a fever, I had diarrhea, my stomach hurt, I was throwing up, I fell down the stairs — anything I could do to stay up and be the center of attention.” It was as though she needed to be seen in her terror, Loveless says, validated in her very existence. “I needed somebody to know I was alive.”
Loveless’ childhood fear of death is far from uncommon. Recent studies show that children as young as 5 express substantial “death anxiety.” The results of one such study indicated that a mature relationship to dying (understanding death as an inevitable biological event) correlated with a decreased fear of death.
Is it any surprise, when many children are now inoculated from the natural rhythms of life, that they fear, rather than revere, that great unknown? The reality is that “we don’t even have a language for dying,” says Lathrop.
Trish Rux, hospice and palliative care nurse and Sacred Passage doula, agrees. In contrast to her upbringing, she says, the majority of individuals she meets have rarely contemplated death. “I was raised without a death phobia,” Rux says. “I remember my father bringing me to a friend’s funeral when I was pretty young and my not really understanding about the casket, and his explaining it to me. He was just a very practical person. Just knowing that death is a part of life — it was an accepted thing.”
In stark contrast, Rux now regularly witnesses individuals who, in their final days, have scarcely given a thought to the inevitability of their own mortality. “Curiously, I’ve had people that in are in their late 80s, and they’ve not thought about their death. It’s incredible to me — they haven’t thought about what they want, who they want to see. It’s sad for me, and it’s pretty common.”
Dancing with death
Loveless was 30 when she first received a diagnosis of breast cancer and 37 when it returned with a vengeance. After having been in remission from thecancer for seven years, a persistent lymphedema sent her back to the oncologist for a standard biopsy. “I’ve never seen it happen that fast,” Loveless says. “He walked in, did the core needle biopsy and left. I got my clothes back on and am sitting down, and he immediately walked back in and said, ‘It looks like disease.’ The way he was talking about it, he made it clear it had metastasized. I don’t think he said the word, ever — it was just understood.”
Yet Loveless is no longer afraid to fall asleep. Now faced with the stark reality of her worst childhood fears, she finds herself liberated rather than imprisoned. “When I go back to the last time I remember having that really potent fear of death that was crippling, like pulling over to the side of the road and having to breathe into a paper bag, to now — it’s night and day. Before, when something would go wrong and I’d look into the mirror and see a new mark on my skin, I’d think ‘Oh, that might be skin cancer.’ Or, ‘I have a headache — I might have an aneurysm.’ To have those thoughts in my head all the time, to think that way and then to be like ‘Oh my God, I might have cancer — oh wait, I do have cancer.’ I have the worst thing you can have. Nothing else is scary.”
Freed from the fear of dying, Loveless now finds herself preoccupied with living. “[I] wake up in the morning and [think], ‘This may be my last day — how am I going to spend it?’ [Or], this might be my last minute — do I want to spend it brushing my teeth and sitting on the toilet and looking at Facebook? Or, do I want to go make a really yummy smoothie, or do I want to go outside and look at the leaves? So, if you’re thinking that way all the time, you have no idea that it’s even happening until the end of the day and you realize — ‘I didn’t waste my day today.’”
Lathrop questions whether we cheat ourselves of the chance for a more meaningful life if we spend our days running from the inevitability of death. His answer: “Death is my guru. It becomes a real teacher for how to live.” And Sethi-Brown agrees: “The reality is you don’t know when your time is. Don’t be afraid of having the conversation. The fear of the conversation, the discomfort around it — go there, explore that — and you’ll see, it will change your life.”
[T]he Jewish tradition is rich with mourning rituals. We’ve done it as a nation for millennia; mourning the loss of Jerusalem, lamenting the Holocaust, remembering the long lost days of the Holy Temple. As individuals, we do it with bagels and covered mirrors and week-long shiva visits. We can say Kaddish (the mourner’s prayer) for a year. There is plenty of space and opportunity to grieve.
And it’s a good thing. A great thing even. It’s supportive. It’s community showing up at times when someone might be at their lowest low. It’s not leaving people to manage their grief alone. It’s a built-in system of shoulders to cry on, arms to lean on, caretakers, yentas – all of them creating a space for you to mourn and pause before gathering strength to move forward.
But while we offer so much to mourn those who have passed, there is nothing available to support those mourning pregnancy loss. There are no rituals. No one brings bagels. No one even talks about it. Some rabbis will tell you that you are not even permitted to say Kaddish after a stillbirth. It’s like it never happened.
And there’s a logical reason for that. In times long ago, pregnancy loss was incredibly common. It was also often very public. It was rare to find a family that had not lost a child or infant in the course of their family-building. In fact, many parents lost more than one in their lifetimes. So if the custom would have been to stop everything to mourn, people would have been in states of mourning constantly. And one could say that therapeutic value of shiva/mourning rituals would be diluted. The rabbis, in their wisdom, thought it better to not make such a big deal of pregnancy loss – precisely because it was so common.
But what about today? 2017. When pregnancy loss is not something that happens as often in each family? And certainly not in the same public way it did in olden times? What do we do with these feelings of loss that can be so devastating – particularly in the midst of communities that value children so highly?
Where should a couple take their grief when they learn that they will not be able to be parents? How should a mother-to-be mourn the loss of a life that she cherished? What prayer should she say? There is no ritual. No one talks about it openly because of the attached shame and disappointment of not being a “fruit bearer.”
It’s rough. It’s lonely. And it is incredibly sad.
It is ironic that a faith community that is normally so very good at supporting individuals laden with grief, can fail so terribly at addressing this common and natural loss.
I know of more than a few synagogue regulars who stopped attending services and recuse themselves from the ebb and flow of Jewish communal life after a miscarriage or when they continue to fail to conceive. With no “official” way to mourn a pregnancy loss or a fertility struggle, it can be incredibly isolating and “othering” for couples — often pushing people away from their communities during the very time they need support most. They feel not understood, invalidated, wrong for being so heartbroken. The absence of ritual or commemoration of pregnancy loss sends a message loud and clear: “Your loss is not a real loss. It is not worthy of the community’s attention or caring.”
So we wanted to do something about that. We wanted these important community members to feel held and supported and we wanted to validate their loss and let them know that they are not alone in their grief.
This month, we participated in Yesh Tikva/The Red Stone’s “Infertility Awareness Shabbat” in an unusual way. Our goal was to create a space for empathy and understanding about infertility in the very tight-knit, family-focused Jewish community. But, rather than ask our clergy to talk about infertility or pregnancy loss in a sermon as has been traditional, we decided to do something new.
On the Sabbath before Passover, the Agam Center at Ohev Sholom invited the entire community to “Light A Candle For Your Loss.” We circulated an anonymous form and asked our community members to indicate the number of memorial candles they would like illuminated on their behalf and gave them the option to have their candles dedicated or labeled in the manner of their choosing.
The response from the community was overwhelming. We lit forty-seven candles, submitted anonymously by thirty individuals – just from our 300 family congregation alone. We displayed these candles publicly, at the entrance to our sanctuary, in our light-filled atrium. Every community member passed by the memorial display on their way into services, and our clergy, Maharat Ruth Balinsky Friedman, invited the community to pay their respects and honor the (often silent) loss felt deeply among our grieving community members.
The responses from the community came pouring in.
“Thank you for doing this. Don’t really have words right now. Just gratitude to have the opportunity to mark my little boy’s birth, especially so close to the actual date.”
“This is absolutely beautiful. Thank you for giving a voice to so many who are on this journey. All my love and support for your amazing, very necessary work.”
“I thought I’d fill out the form because it was a lovely idea – and then found myself in tears, making a small space for something I mostly push aside. Kudos to you for creating the holy opportunity. Really proud to be a part of this community.”
As far as I know, our decision to publicly anonymously recognize pregnancy loss in the synagogue community is a unique endeavor to validate this loss and create a space for a life-experience that can be so isolating and stigmatized and reframe it as an opportunity for communal support.
As we filed into the sanctuary for Saturday morning services, we stopped to read the inscriptions and dedications next to the memorial candles. They took my breath away. Here is but a sample of what was shared:
“I would have loved to love you.”
“Eternally grateful for the journey you were a part of, as painful as it has been. Your loss made way for those we watch grow, shaping me into a mother who strives for daily patience and gratitude.”
“Mothers Day 2011. You were and then you weren’t. Still wonder why I wasn’t supposed to be your mommy.”
“For the family I thought we’d have and the empty seat at our table that I wish we had filled.”
The Agam Center is working hard to make people feel seen and understand that their community is indeed there for them during their time of sorrow or struggle. We want to help people in the midst of a fertility journey see that they are truly not alone, and that there have been so many others – even right in their very synagogue community – who have walked this path with them. We are creating a space to mourn something that is usually so privately painful – particularly in a tradition that is, ironically, so “good” at supporting mourners in other circumstances. I am hopeful that we can begin to highlight ways that communities can create spaces for these losses and families unrealized.
Rather than staying home and feeling isolated, these mourning couples made a point to come to synagogue that week and watched as others learned about and began to appreciate the magnitude of the loss they were feeling. They came inside from standing on the fringe of the community and felt embraced and found solidarity, all without a word. This heartbreakingly beautiful display was our community’s way to show that all loss is real loss and to remind those still struggling that they are not alone in their grief of hopes for the family of their prayers.