Month: October 2020

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Caring For The Caregivers

By Nekee Pandya

When the United States recorded 100,000 deaths from the novel coronavirus, the New York Times (NYT) commemorated the lives lost by filling their front page with a list of the names of those who died, accompanied by descriptive phrases that gave small glimpses into their lives. Titled “An Incalculable Loss,” the piece helped remind us that those who perished from the virus were people, beloved members of our communities. Like many New Yorkers, I scrolled through the names on the list, trying to understand the scope of loss our city was experiencing. Like many New Yorkers, I came across a name I recognized. This name, however, wasn’t of a friend or family member, it was of one of the patients that I took care of when they got sick with COVID-19.

I work as a hospitalist at a large hospital in Manhattan. During the COVID-19 peak, I was redeployed to co-lead one of the pop-up intensive care units (ICUs) created to expand our ability to care for our sickest patients during the surge. It may not seem surprising that I came across the name of one of my patients on the NYT list, but the odds are actually exceedingly small. Although the article depicted an unimaginable amount of deaths over a few short months, the names represented only 1 percent of the total lives lost in the United States at that time. And while New York City has been the epicenter of the pandemic, Manhattan was relatively spared compared to the other NYC boroughs. And yet, we did not feel spared.

Within three weeks of admitting our first COVID-19 patient, we had filled all our existing ICUs with coronavirus cases and had started construction to create new ICUs to keep up with the number of critically ill patients. As one colleague described, it felt like we were imitating Wile E. Coyote as he frantically tried to lay down new train tracks before an oncoming train; as soon as a new ICU opened, it was filled within hours.

The name I came across in the article was one of my first patients in the newly created COVID-19 ICU where I was asked to work. As a hospitalist, I am trained as a doctor of internal medicine who cares for acutely ill hospitalized patients. Although I have worked in ICUs before, I am not critically care trained. Determined to provide my patients with the best care possible, I spent time training with our critical care colleagues, practicing procedures on mannequins, and watching countless videos aimed at brushing up on my ventilation management skills. I was partnered with an anesthesia attending and pulmonary critical care fellow to create a team that brought together different skills to ensure we could handle all aspects of the patients’ care.

Our 12-bed ICU was completely filled within 36 hours of its existence. The patient on the NYT list was one of five new patients with severe COVID-19 who came to us within four hours. We quickly realized that caring for these patients was a hospitalwide team effort. We had daily phone conferences to share our experiences, exchange ideas, and create new standards of care. We all became COVID-19-ists, united in treating just one disease. Yet, in other ways, the care of these patients was also incredibly lonely. I spent my days standing alone in the room of intubated and sedated patients, in layers of personal protective equipment, listening to the beeping of monitors and the hum of the negative pressure system, hoping that we had learned enough about this disease to help our patients survive. I often found my gloved hands holding theirs, knowing that they didn’t know I was there but hoping that my touch might make them, and me, feel less alone. 

I can remember every patient in our unit those first few weeks. The 40-year-old man whose old college friends sent us daily meals for three weeks; the 80-year-old man who had a wife dying of COVID-19 in another hospital; the man who survived discharge from the COVID-19 ICU only to die in a general medicine unit a few days later from a massive bleed; the sole woman being treated in the COVID-19 unit, who used to be a nurse. Some of them passed. Some of them stayed in our unit for weeks, went to our in-house rehabilitation unit, and were eventually discharged home. Some of them are still hospitalized today. And while the stories of all those patients stay with me, the patient whose name I came across in the article is especially meaningful. He was my first patient that died of COVID-19.

The day he died was also the day that my first patient with COVID-19 improved enough to be taken off a ventilator. Our whole team stood in a mass outside of the glass doors, watching as the respiratory therapist prepped to take the breathing tube out. It would be our first time seeing someone with such severe disease survive this infection. As soon as he was extubated, the resident on our team rushed into the room with an iPad to FaceTime the patient’s family. We could hear the cries and cheers of his family from outside. My resident, wanting the family to see the team that took care of their loved one, swung the iPad around and there we were 10 masked faces cheering from just outside the room. Six feet, a glass door, and an iPad apart, we all celebrated that moment together.

But within 10 minutes of this first success, I was standing in the room of my other patient, to be with him when he died. Up until a few days before his death, his story sounded exactly the same as the patient’s we had just extubated. He was a man in his fifties, with a few well-controlled medical problems, who came in with a dry cough and shortness of breath. Both men had been on the medical floor for a few days before they were intubated. Both spent the first few days on our unit deeply sedated, paralyzed, on high ventilatory settings. But for reasons unknown to me, or to the rest of the medical community, one of them was recovering, and the other was progressing to multi-organ failure.

I stood at his bedside in disbelief that we weren’t able to help him survive. He was young, too young. He still looked robust, as if he was about to wake up and tell us to take the tube out. Like all hospitalists, I’ve taken care of many dying patients, but this death felt different. I was not used to seeing a young healthy person die of pneumonia. I was left feeling like I failed him and struggled to give him any semblance of a “good death” in the sterile, lonely ICU room.

My patient’s partner saw him for the last time over FaceTime. Family and friends texted the patient’s phone so we could read their messages aloud before he passed. I was struck by the contrast of his current situation to his last texts where he told people he was feeling fine but the doctors told him he needed to be intubated. We read him messages of love, thanks, and sadness from his family and friends, knowing that it was a poor substitute for their presence but trying to do whatever we could to imitate what a good death would look like in any other situation. I stood in the room with the nurse in silence, not knowing how long it would take for him to pass but not wanting to leave him alone. The nurse suggested it might be nice to play him some music. My goggles fogged up while I tried to find his most played list on Spotify. The music that played was upbeat and electric, completely at odds with his current situation. It made me imagine the type of person he was before he got sick, before COVID-19 took his life. An hour after his death, a new COVID-19 patient on the edge of death rolled into his now disinfected room, forcing us to quickly shift our attention to try to help this new patient survive.

When I saw the deceased patient’s name on the NYT list, feelings of hopelessness and guilt resurfaced once again. There were no proven treatments for COVID-19, so most of the time it felt like everything we were doing was just buying patients time. Buying them time to let their bodies either recover or succumb. We saved a lot of lives by buying them time, but we lost a lot, too. I clicked on his name in the article, and it led me to his obituary. I learned about his life and his passions and got a glimpse into the man who listened to that upbeat playlist. I hoped that our farewell was the good death he deserved.

A few weeks later, I was sent a video of our first extubated patient going home. He was walking out of a car, down the sidewalk, and up the stairs, all with an oxygen canister in tow. He had a big grin on his face as he looked at all his neighbors out on the doorsteps cheering him on. He probably wouldn’t recognize me if we met. He left our ICU almost immediately after he was extubated to make room for the next patient, and he never saw me without my mask and goggles. But seeing him take those steps brought me to tears. I shared the video with my team as a reminder of the meaning behind our work.

It is my colleagues that I worry about now. Every doctor in my hospital has stories like mine: stories of soaring highs and extreme lows. Doctors speak of being unable to do right by patients due to resource limitations or institutional policies. They tell stories of distress over equity in patient care and stories of rage about the societal and governmental response to this crisis. And now, with the rates of COVID-19 rising in the rest of the country, many more doctors will be dealing with these scars and collective trauma. Studies all over the world are finding higher than usual rates of burnout and depressive symptoms amongst doctors caring for COVID-19 patients. In New York, where we are just past the first wave of COVID-19, we are starting to think about how we can heal the healers. 

We have learned that we need to move beyond the impromptu office debriefing with colleagues and create formalized space and time for hospitalists to share and reflect on experiences. Our hospitalist group has started the process by allowing doctors to choose the format in which they would like to debrief. Everyone had the opportunity to meet in dyads, small groups, or large groups, to swap stories, cry through losses, celebrate victories, and vent about the things we had no control over and things that we could have done better. It has let many of us explore emotions that we did not have time to deal with in the moment and may not have even recognized that we were having. It also helped us lean on the people in our lives who truly understood our experience: each other.

Part of this process also included sessions with the hospitalist section chief to reflect as a group on the response to the crisis. Hospitalists were encouraged to have honest and open discussions about what did not work well organizationally, as well as to brainstorm and exchange ideas on how the group could do things differently moving forward. Having a leader at the table who was committed to listening and enacting change was key in combating the helplessness and isolation felt by individual practitioners.

Hospitals must start prioritizing—and devoting time and resources to—the well-being of their providers during the pandemic. Given the degree of trauma experienced by providers, if we don’t address the post-COVID-19 care of physicians now, we will find the consequences of burnout rippling through the medical field. Our community has already seen its first physician suicide amidst this crisis. Beyond the negative impact of burnout on providers, we know that patients’ care will also suffer. As we prepare for a potential second surge of COVID-19 infections, it is imperative that we invest in helping our physicians recover, so they can be prepared to provide the best care possible when they are asked to lead the fight once again.

Complete Article ↪HERE↩!

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Social Isolation a Threat to Hospice Patients During COVID-19

By Holly Vossel

The threat of COVID-19 has forced many providers to keep high-risk seriously and terminally ill patients isolated to limit the virus’s exposure and spread. As families become disconnected from loved ones approaching the end of life, hospice providers have sought new ways to offer mental health support during the pandemic.

Social isolation during the coronavirus emergency has substantially impacted the hospice population, as well as seniors in general. Research has identified significant links between social isolation and increased risk of early mortality among older and seriously ill patients.

According to a recent report from health insurance marketplace company GoHealth, the pandemic has been driving a mental health decline among isolated aging populations as they practice social distancing from family and friends. In a nationwide study of 1,000 Medicare beneficiaries, 25% percent reported a decline in their mental wellness since the pandemic’s onset, and more than 90% felt lonelier now than before it began.

“Social isolation from friends, families and even their hospice providers visits, has impacted the mental health of hospice patients,” said Shelley Cartwright, executive director of Illinois-based Apex Hospice and Palliative Care. “Social isolation contributes to a decline in mental health. Depression, anxiety, and delirium in those who are terminally ill are frequent and currently most likely under-diagnosed as hospice frontline personnel are not being allowed to make in-person visits as frequently as they normally would as patients, families, hospitals and skilled nursing facilities are in COVID-19 precautions.”

Hospices have struggled to find a balance between technology and the human touch while offering telehealth visits and online virtual support. With families often connected only virtually in the last moments of life, disenfranchised grief has added to concerns of ramping up mental health support.

“Dying is inherently lonely and isolating and made worse when people are actually removed from their loved ones,” said Christopher Kerr, CEO and chief medical officer of Hospice & Palliative Care Buffalo in New York. “It’s ultimately a closing of a life, not just a medical phenomena, and that life is defined by relationships. The pandemic has taken a difficult situation and made it multiple times worse. It’s in moments of crisis and need that we need to connect ourselves to those people that give our life meaning. The opposite happened that when we most needed to be reconnected to those we love, we were removed.”

The sweeping effects of isolation has drawn heightened focus from hospice providers on the need for greater communication and deeper integration of psychiatric care. Research from 2018 projected that the number of seniors with mental health conditions will triple over the next three decades. An estimated 5 to 8 million aging Americans currently suffer from mental illness. Providers have been working on improving hospice access for these patients.

With facilities and hospitals limiting interactions, social isolation has exacerbated mental health concerns as hospices face barriers to reaching patients during the pandemic. One strategy being employed is increased collaboration with referring facilities, psychiatric disciplines and primary physicians as hospice work to support isolated patients and their families.

“We believe that no one should have to face serious illness or death alone,” Carla Davis, CEO of Heart of Hospice, told Hospice News. “Holistic, person-centered care delivered by hospice care teams plays a critical role in protecting and improving the mental health of vulnerable populations who would otherwise be left in isolation. The more we are able to work diligently alongside our facility partners to continue providing quality care, the better equipped we will be to prevent negative mental health outcomes in individuals facing serious mental illnesses.”

As COVID-19 cases and fatalities continue to climb, so does growing concern among hospice providers over the effects of isolation on the quality and experience of end-of-life care.

“Patients, even though imminent, often fight death until they are at peace and have said their good-byes or receive permission from their family to ‘let go,’” Cartwright told Hospice News. “Quality end-of-life experience and death for patients and their families is, and will be, jeopardized with the continued isolation of dying patients from their families.”

Complete Article ↪HERE↩!

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My Dying Uncle Talks Life, Death, and Australia’s First Year of Legal Euthanasia

“It’s very surreal locking in a date to die. But I haven’t had any doubts, because it’s just a question of timing.”

by Chris Shearer

Australia has a complex relationship with euthanasia, or voluntary assisted dying (VAD) as it’s now often called. The states of New South Wales, Tasmania and South Australia have all debated VAD bills and rejected them. But the mood is beginning to shift. In June 2019, Victoria became the first state in the country to legalise VAD, while a similar scheme will come into effect in Western Australia sometime in mid-2021.

Australia is one of just a handful of countries and US states where the option exists. In the first 12 months since it was legalised in Victoria, 124 people have ended their lives through VAD. And in a few weeks’ time, my uncle, Don, will also die this way.

In mid-2018, Don was diagnosed with motor neurone disease, also known as ALS or Lou Gehrig’s disease, a condition that causes the muscles to weaken and waste away. His condition has deteriorated significantly in the last few months, and today he struggles to move. As his symptoms began to rapidly progress and his neurologist gave him between six and 12 months to live, Don began the formal process of applying for VAD and is now in the final stages of that process.

I spoke with him about what it’s like to face your own mortality, and prepare for an exit that’s still illegal in most of the world.

VICE: Hey Don, can you tell me a little about your condition?
Don: I’ve got what they’d call typical motor neurone disease, which basically mean your limbs start to stop working and you have muscle deterioration. The thing that actually kills you is your lungs because you either get pneumonia or you just stop breathing. I would say that my deterioration wasn’t too bad until about December 2019. If you recall we got together and I probably wasn’t too bad at Christmas.

Yes, you weren’t too bad then. But that was the last time I saw you in person.
What happened, as we moved into 2020, around February, March, that’s when everything fell off a cliff. All of a sudden, I knew I was sort of getting to the business end of the disease.

So how long have you been thinking about VAD as an option for you?
Euthanasia and assisted dying has always been in the back in of my mind, in the sense that I always thought it was a person’s right to choose the manner in which they die. So I had always thought to myself, if I ever got sick and it was going to be a horrible death and I had the opportunity to avail myself of any legal option that would end my life, I would.

How are you feeling about the decision? Is it something you have to prepare yourself for emotionally as that date approaches?
Once I became aware that I was diagnosed with MND, it was sort of tough, but then I became more accepting of my death and I began preparing for it. And the way you prepare for it is to almost see yourself dying and letting go, because you’ve got to prepare yourself to let go, and not be attached to things. Everything that you own, everything that you know, everything that you were, will go. And that’s a journey that you will take on your own.

The most important thing that I’ve always said to people is there is a difference to being alive and living. So at the moment, I’m alive. But my world for the last four or five months has been a 10 metre radius from this chair. I’ve got the bathroom, my bedroom, and the backyard. And that’s only going to get worse until I’m unable to move at all. And if you compare that to the type of person I was—an avid golfer, I loved the surf, I loved to get out and have a beer and basically live life to its fullest—unfortunately this disease doesn’t allow you to do that.

How do you have this conversation with your family? How do they feel about it all?
Once I was diagnosed, or not too long afterwards, I just put it on the table. At first I didn’t look sick, I didn’t feel sick. But then, slowly, slowly the physical aspects started to kick in, and then I thought “well shit, this is no joke, this is really going to happen”. It was always my intention and I’ve always made that quite clear to the kids and to [my wife] Vicki. And they were supportive, but it was out of sight, out of mind, you know what I mean? But from about March, it was clear to them that I was getting worse. In the last two months it became very evident that this was the pathway I was going to take. And now, they’re facing into it along with me.

How’s your wife handling it?
Yeah look, it’s hard. I think Vicki is probably more prepared than what the kids are. I’ve tried to prepare them as much as possible. They’re sort of stoic in their own way. I think obviously now they are aware that this is going to happen. Are they prepared for it? I don’t know. And I think they’re going to have to be, because it’s going to happen. As Vicki said to me, “from your perspective, you’re prepared for it. But we’re the ones that have to actually live on after you’ve gone. We’re the ones that have to mourn you and grieve you. You’ll be gone”. And I understand that. So there’s this whole thing: I’m only looking at the end game, whereas they’re looking at my death and the journey that they have to take after that.

Knowing you have this certain amount of time left, has it changed how live?
Not really. I cherish each day and I cherish the time that I have here with Vicki and the kids, but for me it’s probably more the end game and just getting there. It hasn’t really changed the way that I think, because my thinking about death has been set for a long while. And if I look back, I am the luckiest guy in the world. I would love to have another 20 years, 25 years, but it doesn’t work like that.

Since you’ve begun the process of applying for VAD, have you had any doubts?
It’s very surreal locking in a date to die. You sometimes take a step back and think “what the fuck?” but I haven’t had any doubts, because it’s just a question of timing. I’m going to end up dead either way. If I didn’t take the VAD path, I would then deteriorate further. So I’ve never had any doubt, because the end game is the same, it’s just the manner that I get there is going to be a little bit quicker, and certainly far more comfortable than a prolonged death that would certainly have a more harrowing impact on my family.

Once you’ve made this decision, how do you go about telling people? Do you have a playbook for letting people know?
The short answer is no, and I’m still trying to come to grips with that. This is a pretty unique situation. Often you don’t have time to consider the way that you’re going to leave this world. Generally it’s thrust upon you. But with this situation, what do you do? I think what I’ll end up doing is as I become more aware of the timing I’ll just let it out there.

When you get crook, you feel pretty useless, right. Then all of a sudden, I thought to myself that I’m not useless. If anything I’m opening up people’s eyes to, I guess, a cycle of life and death, and the death that they’ll invariably face. So maybe that’s my contribution to this whole game.

Is it in some ways daunting to think about that groundswell of morning that might come in before you’re even dead? The letters, the calls, that sort of thing?
What I don’t want to happen is I don’t want a line of people out the front door saying “we’ve come to say goodbye” and all that. To some extent Covid-19 has been a godsend because I haven’t had people coming and knocking on the door. One of my mates, my close mates, who I haven’t really seen since the end of February because of the lockdown, he said “mate, I want to come and see you” and I said to him “look, I’d rather you remember me physically the way that I actually was, rather than the way that I check out, because I’m not the same person”. He understood that.

What I don’t want is all of a sudden this wave of sympathy and people ringing up, “I’ve just heard, I think you’re brave”. Ugh, that shits me, “I think you’re brave”. It’s got nothing to do with fucking bravery. It’s just a decision that you’ve made. What’s unusual about it is you have the time to consider and think about it. Quite often today, you have a heart attack, a car accident, you’re sick for three months and then you just die. It’s really quick. I’ve had two and a half years to think about this. I can understand people feeling sad, I get that. There’s going to be an element of grieving and sorrow, and that’s fine, I accept that. I’m comfortable so I hope other people are too.

This is probably the last time you and I will speak face to face. Do you have an idea of how that last goodbye will go with people?
For me the so-called last goodbye is pretty simple really: thank the person, and wish them nothing but the best.

Some people are still against VAD, with the argument that “no matter how hard life may be, every life is worth living”. What would you say to those people?
Look, I could be short and sweet and say “fuck off, this is my life”. But I understand what they may be thinking about. It’s great to be an advocate for someone, but unless you are the one who is actually going through it, you don’t actually know what that person is going through. From my perspective, my body has shut down, and I feel like I can no longer contribute to society. I understand when people say every life is precious. I’m not denying that. But I think the person living that life has the right to choose how they end that.

You haven’t settled on a date yet, but you do want to do it at home. What’s the process?
I will select a date and then, because my arms don’t work, I’ll have to have it administered by a physician. Now, I’m not going to have a cast of thousands here. It’s going to be very, very small. I suspect it will be immediate family. It will be a question of me saying, OK, I feel it’s now time. I’ll make my way to wherever it’s going to be done. I’d say for me, comfort-wise, the best place will be to lie on the bed. I’ll be given a relaxing shot, just to calm things down, and then I’ll be given an anaesthetic, which will put me to sleep. After that, the medications will be administered to stop my breathing and create death. I’ve been told it’s fairly quick.

Do you have an idea of how you want to spend that last morning?
Nah mate. There’s nothing I want to do, apart from maybe sitting outside in the backyard. I’m not going to go down the street in a wheelchair. Truth is I’ve been locked up here so long, so this is my next adventure really. This is the adventure that I take on my own. I just feel I’ll wake up and do it.

Complete Article ↪HERE↩!

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Study finds room for improvement when hospital patients transition to hospice care

by Steve Lundeberg

Terminally ill patients referred to hospice care from a hospital setting tend to be on hospice for shorter periods than those who enter hospice while living at home or in a residential care facility.

The findings by Oregon State University College of Pharmacy researchers are an important step toward improving the care experiences of dying patients and their loved ones.

Hospice care refers to treatments whose goal is to maximize comfort and as opposed to prolonging life. In general, more time on is better for patients than less time, research has shown.

“It’s well established that hospice care reduces symptom burden and improves quality of life for patients nearing the end of life and for their caregivers,” said the study’s lead author, Jon Furuno, an associate professor and the interim chair of the Department of Pharmacy Practice. “Patients receiving hospice care also have their discomfort controlled better and experience more satisfaction with their care compared to patients who die without receiving hospice care.”

But Furuno’s recent research, published in the journal Medical Care, points out some key variations in hospice transitions and experiences, opening the door to changes that could make important, positive differences for patients and families.

Patients can be referred to hospice care from any location, Furuno explains, but little is known about differences between referrals from different care settings; i.e. hospitals, nursing homes, assisted living facilities or the someone’s .

“Are the patients enrolling in hospice at an appropriate time or later than ideal? Are they making the transition to hospice care with the right prescriptions from their providers? How do things differ among referral locations? Those are all key questions to explore to help ensure optimal patient care,” Furuno said.

The study looked at data from nearly 80,000 adult hospice patients from 19 states over a five-year period. Their average age was 79, and one-third were receiving hospice care because of a terminal cancer diagnosis.

Just over half of the decedents had been referred to hospice from a , and about one in five had been living at home at the time of their referral. Nursing homes (17%) and assisted living facilities (9%) rounded out the sample.

The results showed that hospital-referred patients were much less likely to receive hospice care before the final seven days of their life than patients referred from elsewhere; 56% of those referred from a hospital spent less than a week on hospice, compared to 30% from nursing homes, 29% from their own home, and 19% from assisted living.

“Obviously every case is unique, but generally speaking, more time in hospice care is associated with better patient and family outcomes,” Furuno said. “In our study, the median length of time on hospice was nine days.”

Another key finding involved drug prescriptions, particularly the absence or presence of a constipation-alleviating drug along with the opioids often used during hospice care. Opioids relieve pain but can cause other discomfort in the form of infrequent bowel movements.

“Hospital-referred patients had the lowest frequency of co-prescribed opioids and a bowel regimen,” Furuno said, noting co-prescription of these medications is an important indicator in the Centers for Medicare and Medicaid Services’ Hospice Quality Reporting Program.

Among hospital-referred hospice patients, fewer than 60% received that co-prescription compared to 72% of patients referred from nursing homes, nearly 70% from assisted living facilities and 63% from home.

“The study’s results suggest an opportunity for interventions that will improve the transition to hospice care and benefit patients and families,” Furuno said. “Patients transitioning from the hospital to may be the most vulnerable group because of the magnitude of the transition from actively fighting a chronic illness for months or maybe years to palliative care.”

Also, health care providers in a hospital setting may not always be sufficiently trained in preparing patients and families to make that transition, he said, adding that further research should look for explanations behind the hospice transition differences uncovered by this study.

“The end goal is policies and practices that consider these differences and trigger specialized interventions when necessary so patients can get the best care possible,” Furuno said.

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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How ‘I Am Dead’ Uses Death to Illuminate Life

Developer Ricky Haggett and designer Richard Hogg talk about how the puzzle adventure game is “not spooky or sinister,” but is instead a story about people and relationships.

by Trilby Beresford

Welcome to October, a time that, depending on which social circles you frequent, may be dominated by conversations about the next-gen Xbox Series X/S and PlayStation 5 consoles set to release in just a few weeks; and their respective launch titles.

While for many players this month may also contain video games that indulge in creepy vibes or costumed assailants (Resident Evil, anyone?), this week’s column features an interview with two of the creatives behind Annapurna Interactive’s puzzle adventure I Am Dead, a game that one might assume involves terror and tragedy, but actually, that couldn’t be further from reality.

Hollow Ponds developer Ricky Haggett and designer Richard Hogg, both who are U.K.-based, describe the truth and meaning behind their latest offering, which just dropped on consoles.

I Am Dead is a Colorful Game About Living

As the title suggests, I Am Dead does involve a dead person, but it’s not explicitly about death or dying. As developer Ricky Haggett recalls on the phone with The Hollywood Reporter, “It’s not really a spooky or sinister game. It really is a game about people’s lives.”

Artist and designer Richard Hogg chimes in with the irony that the game, which features bright colors and an inviting sense of warmth, is releasing in October, the month of Halloween. “It suddenly occurred to me, wow, we’re launching a game called I Am Dead, about ghosts, kind of during Halloween season, and that’s so duplicitous because our game isn’t at all scary,” he says.

The story of the puzzle adventure game follows a deceased museum curator named Morris who sets about to explore the afterlife, a world filled with learning and discovery. The idea came to the developers years ago when they were working on another, entirely different game, where the central idea was “somebody dead in a grave — somebody from like the Bronze age, who was thousands of years old, with all of their tools, clothing and equipment that they would have had with them,” explains Haggett. “Occasionally people turn up in a bog or in the ice where it’s like, oh this person is this many years old and we can learn about their lives from these objects that they had with them.” He goes on to say, “We never ended up making that game, [but] then when we came to make I Am Dead, the first thing that we had was the idea of this mechanic.”

“I remember being really into the idea of it being a game about a dead person, but not about them dying — one benchmark idea was that you wouldn’t know how they died,” says Hogg, “instead the game is about how they lived.” He adds that death is a common theme of video games, but the stories are often about that moment when someone dies and how it happened. “We liked the idea of using death as a way of illuminating life.”

I Am Dead is set in present day in a location similar to the seaside town of Hastings, where Hogg resides. “It’s full of anecdotes and mini-stories about people’s lives and people’s relationships with each other that I think work a lot better [than the game that was set in the Bronze Age] because they’re things we can understand and that we can relate to.”

Morris is loosely based on Haggett’s geography teacher from back at school, a man who used to walk with his fingers tucked into the waistband of his trousers. “He was quite an elderly, fairly eccentric guy,” Haggett recalls. “He’s the sort of person that you see, if you go to the supermarket in the U.K. quite early in the morning,” adds Hogg. “The only people who do their shopping early in the morning are maybe people who’ve retired. Sort of non-descript, middle class guy in his 60s, probably quite cheerful, probably quite a fun granddad, quite an interesting guy, but at the same time doesn’t choose his own clothes, his wife chooses his clothes for him.”

While developing I Am Dead, Haggett and Hogg drew upon their shared enthusiasm for the literary works of Patrick O’Brian, scribe of the Master and Commander books about historical naval warfare. “They’re the sort of books that someone like Morris would read,” says Hogg. And then there’s libraries and museums, which Hogg and Haggett frequently meet at. “This game is kind of like a love letter to small, provincial British museums that we’re massive fans of,” Hogg concludes.

I Am Dead is currently available on Nintendo Switch, PC via Steam and the Epic Games Store.

Complete Article ↪HERE↩!

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Are Animals Capable of Grief?

When animals lose a member of their species, they often show behaviors that look like human grief. Does this mean they are mourning the dead?

By Leslie Nemo

In August of 2018, millions of people watched a video of an Orca in the Pacific Northwest and felt their hearts break. The new mother named Tahlequah had lost her calf, but persisted in pushing the corpse around for 17 days. It was almost impossible not to feel, deep down, that the mom was grieving.

Scientists are tempted to draw those conclusions, too. But even if researchers feel that an animal’s behaviors mean it is mourning, that’s not how their job works. “We need documented evidence that this is indeed an analogue to grief,” says Elizabeth Lonsdorf, a primatologist at Franklin and Marshall College in Lancaster, Pennsylvania. Unfortunately, that proof is hard to get. “In terms of emotion, animal cognition is tricky,” she says. “It would be a lot nicer if you could ask them what they’re feeling.”

Since that option is off the table, scientists resort to observations, analysis and testing hypotheses to figure out why animals interact with their dead, and whether those interactions count as grief. And it’s going to take a lot more than just observations in the wild to get an answer. “The short answer is this is one of these great scientific problems that will take people working from all areas to sort out,” Lonsdorf says.

Rare Sightings

To begin with, it’s important to understand how rarely researchers see animals interact with the dead. Even if observations make headlines, those are single incidents. Scientists need a large dataset of interactions to reach any conclusions about why animals do what they do.

For many animals with documented behaviors toward deceased individuals, the field notebooks don’t have many entries. When Lonsdorf and her colleagues analyzed incidents of chimpanzee mothers carrying infant corpses for a study published in July, there were 33 total cases to work with — and that was after 60 years of research in the same chimp communities in Tanzania. Data is scarce for cetaceans, too. Between 1970 and 2016, there were only 78 recorded incidents of different dolphins and whales showing interest in a dead individual. 

Observing these interactions in the wild is somewhat serendipitous. Unlike other animal behaviors, it’s not possible for researchers to head out into the field intent on observing interactions with the dead. “You can’t go out and wait for animals to die,” Lonsdorf says.

There’s also a chance that the incidents that do end up in studies are only the ones that intrigue us humans the most. As behavioral ecologist Shifra Goldenberg and her colleagues point out in their 2019 analysis of elephant behaviors, “There is probably a bias within this body of anecdotes that favors the recording of interesting or more obvious behaviors.” Even when compiling all recorded instances, finding a pattern of behavior can be hard if not all research groups know or document the exact same details every time. These details might include how long the interactions were, who showed up, or the exact nature of the relationships between the living and deceased.

Using Context Clues

Researchers can still take a close look at the ways in which different animals interact with the dead to try and suss out their motivations. For example, some scientists have proposed that maybe a given species nudges, touches or carries a corpse because they don’t yet know their child or friend is, well, dead. When it comes to cetaceans, like dolphins and whales, many biologists think that within a few days of interaction, the living individual would have figured it out. After all, their motionless companion starts to reek of decay. But there’s still no concrete evidence that the aquatic mammals are aware that the individual won’t be revived. “Though research into this realm started over fifty years ago,” wrote zoologist Giovanni Bearzi and his colleagues in their 2018 analysis of these cases, “there has been little direct research on this topic and the matter is still open to investigation and debate.”

With chimpanzees, it’s a different story. In their study, Lonsdorf and her team analyzed the same possibility — that mothers didn’t realize their child had died — but found evidence to suggest otherwise. The moms sometimes dragged the infants, something they’d never do while their child was alive. In some cases, they cannibalized their young, a pretty clear indicator that they knew something had changed. Other theories about why these mothers interacted with their deceased kids didn’t fit the evidence, either. One idea was that mothers are so overwhelmed with the postpartum hormones influencing their maternal instincts that they can’t bring themselves to let go of their child. If that was the case, then the research team would have seen mothers who lost older kids let go faster, as they’d be well past the wave of hormonal attachment. But there wasn’t any relationship between infant age and how long the mother carried the body around.

When their analysis was done, Lonsdorf and her colleagues were left with the impression that chimp mothers know their child has died, but still can’t let go — even grooming their baby as if it were still alive. But that doesn’t mean the team concluded that these primates were feeling grief. “Our conclusion was, ‘Okay, at least for chimps, the simple solutions don’t work.’ We need to think more creatively.”

Understanding Grief

To better understand why chimps — or elephants or cetaceans or any number of animals — interact with their dead, more nuanced research needs to happen. When it comes to chimpanzees, maybe experiments with captive individuals could show how they react to, say, photos of deceased friends. After a death, primatologists could look for changes that mirror some common human grief behaviors, like withdrawing from others or losing interest in food, Lonsdorf says. For cetaceans, Bearzi and his colleagues think that it might be worth trying to record the sounds the marine mammals make after a death, as many species are famous for intricate echolocations.

A better understanding of animal behavior could use some introspection, too. Grief is a vague, variant concept and process for humans, and even death itself comes with a learning curve. Lonsdorf, for example, remembers watching Star Wars as a kid and believing the actor who played Obi-Wan Kenobi actually died on screen. “I was shocked when he showed up in another movie,” she says. Death and grief can still seem strange and unfamiliar to us. Naturally, a more nuanced understanding of those concepts in people might help us recognize them in other creatures, too.

Complete Article ↪HERE↩!